Phlebolymphology 49 – Editorial

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Chronic venous disease: chronic venous disorder or chronic venous insufficiency?

This issue of Phlebolymphology contains some interesting articles, all dealing with chronic venous disturbances, each of them using different terminology.

Michel Perrin’s paper reports on the results of reconstructive surgery for the elimination of deep venous refluxes. There is no question, that these procedures are directed towards normalization of insufficient venous pumping function. The author states that “refluxes related to deep venous insufficiency” are corrected. In this functional context the expression of chronic venous insufficiency (CVI) is certainly justified.
It is also made clear that the clinical signs of potential candidates for deep venous valve repair correspond to edema (CEAP: C3), skin changes (C4), and ulceration (C5 and C6), and not to simple varicose veins. This is exactly the definition of how the term CVI was also understood by Leo Widmer, who differentiated three stages of CVI:
Stage I: edema (and corona phlebectatica paraplantaris), stage II: skin changes, and stage III: open or healed venous ulcer. Thus, the functional term “CVI” describing an abnormality of the venous pump, was used for the clinical description of severe stages of venous disease. Spider veins (C1) should certainly not be classified as CVI, and this is also true for varicose veins (C2).
As Tomasz Urbanek, winner of the Servier-UIP award, correctly states in his basic research article, the “valve failure theory to explain the development of varicose veins is no longer satisfactory.” Refluxes are rather the consequence than the primary cause of varicose veins. This also endorses the concept that varicose veins should not be classified as CVI.

The ischemia/reperfusion experiments of Eliete Bouselka and coworkers present an excellent model on some of the consequences of severe CVI on the microcirculation of humans. Translating the findings from the animal experiments to human pathology, beneficial pharmacological effects may be expected also in severe stages of CVI. Even when the disturbed pumping function is not restored, there is some hope that the consequences of chronic venous insufficiency (edema, skin changes, and ulceration) can be improved by the administration of venoactive drugs.

In the first part of their Consensus papers entitled “Effects of venoactive agents on the symptoms of chronic venous disease” Claude Garde and coworkers concentrate on subjective symptoms in patients with mild venous pathology. In the chapter on “Review of epidemiology” it is stated that over 18 million adults in France – 57% of women and 26% of men – present with venous disease.
Is it really true that more than half of French females suffer from chronic venous disease (CVD) or is there confusion due to the translation from French (maladie) into English (disease)? Shouldn’t we rather speak about “chronic venous disorder (another “CVD”), at least in the majority of cases?

Is this just a game of words?
There could be a difference: a disease always needs to be treated, while this is not necessarily the case for a disorder. In this case, therapy can be administered but does not need to be. Of course this definition may be discussed. When a patient consults the doctor because of chronic pain in the legs the doctor will probably react even if no venous pathology can be recognized. Is the prescription of a medicine by a doctor enough to define the condition as a “disease”? These certainly are unsolved questions and hot topics, especially when it comes to reimbursement.

The second part of the consensus document from Claude Garde et al deals with edema that would correspond to Widmer’s stage I of CVI. A patient with chronic edema needs therapy so that the term “chronic venous disease” may be justified.

I would propose that the international phlebological nomenclature in English texts should follow the last consensus statement of the CEAP group1 which uses the term chronic venous disorders (CVD). This expression encompasses the broad spectrum of venous problems that can be observed in daily practice, including spider veins, and varicose veins with and without symptoms, but also the severe stages of CVI, which in fact are to be considered as a chronic disease needing sustained treatment.

Hugo Partsch, MD