How specific are venous symptoms for diagnosis of chronic venous disease?
Van der Velden S, Shadid N, Nelemans P, Sommer A.
Phlebology. 2014 Jan 3. (Epub ahead of print).
Reviewed by: Djordje Radak and Srdjan Babic Belgrade, Serbia
Are the symptoms of venous disease specific for chronic venous disease (CVD)? Is the pain or swelling the most important venous symptoms? Does the presence of pain predicti CVD progression? What is the best medical treatment to prevent development of CVD? When should we start with medical treatment, to be more efficient in prevention of CVD progression? Those are the question that should be answer by large prospective multicentric international studies including patients with CVD, analyzed by CEAP classification and presence of ultrasonographic signs of vein reflux or obstruction. This is the design that was used in present study, but it did not have statistical power because of an insufficient number of patients. In any case, the design that was used could be the proposal for future big studies, which are more than necessary.
The authors evaluated which ‘venous’ symptoms are characteristic for patients affected with chronic venous disease (CVD) compared with patients with other diseases of the lower limbs. The study was comprised of 76 patients suffering from CVD compared with 74 patients with other diseases of the legs without reflux. The authors used VEINES-Sym of the VEINES-QOL/Sym questionnaire to evaluate the frequency of symptoms.
The study showed that the differences between groups were small and statistically non-significant; presence of venous symptoms was slightly more often reported in the CVD group. Severity of chronic venous disease as classified by the CEAP classification was not associated with higher proportions of patients reporting symptoms than in non-chronic venous disease patients, except for swelling (P =0 .016) and itching (P =0 .007) in C3-C6 patients. Significant difference was found at the time of the day at which symptoms were most intense; the CVD patients were more likely to experience symptoms at the end of the day.
Identification of subjects with venous-type leg symptoms is a very difficult mission and it seems to be extremely complex especially in groups of patients without clear signs of CVD, who are in the early stages of a visible disease. Signs of CVD may be associated with a whole range of symptoms such as pain, heaviness, restless legs, tingling, aching, burning, night muscle cramps, swelling, sensations of throbbing or itching skin, leg tiredness and/or fatigue.<sup>1</sup> However, this range of symptoms could be part of some other non venous chronic and acute diseases and conditions: obesity, neurological reasons, standing or sitting profession, arterial occlusive disease.<sup>2</sup> Therefore, the very first step in determining the prevalence of lower-limb symptoms related to CVD should be to exclude all patients with symptoms of non venous origin.
Development and implementation of the universal clinical, etiological, anatomical, pathophysiological (CEAP) classification allowed each CVD stage to be precisely defined and the results to be compared between countries and continents.<sup>3</sup> However, there are several disadvantages of the CEAP classification: any assessment of the level of the symptoms is not included; with the classes only categorized as ”symptomatic” or ”asymptomatic.” As a result, symptoms are often underestimated by the physicians and these limitations require additional questionnaires.
It has to be noted, venous pain and other venous-related sensations greatly worsen patients’ quality of life. Even so, lack of the epidemiological studies concerning this issue is frustrating. These types of research are more than necessary, not only to determine which of the symptoms are related to venous origin, but also to incorporate levels of symptoms and their change during the time period, and the proper time for best medical treatment.
1. Eklöf B, Perrin M, Delis K, Rutherford R. Updated terminology of chronic venous disorders: the vein term Transatlantic Interdisciplinary consensus document. J Vasc Surg. 2009;49:498-501.
2. Benigni JP, Bihari I, Rabe E, et al., UIP – Union Internationale de Phlébologie. Venous symptoms in C0 and C1 patients: UIP consensus document. Int Angiol. 2013;32(3):261-265.
3. Beebe HG, Bergan JJ, Bergqvist D, et al. Classification and grading of chronic venous disease in the lower limbs: a consensus statement. Vasc Surg. 1996;30:5-11.