This is an update of a chapter by M Robbins, S J Frankel, K Nanchahal, J Coast and M H Williams published in the First Series.
Chronic venous disease is the most common vascular condition to affect the lower limb. It covers a wide range of conditions which can be broadly categorised as varicose veins, chronic venous insufficiency and venous ulcers. Venous disease is associated with a large burden of ill-health and it consumes a substantial amount of NHS resources. In the United Kingdom each year roughly half a million people consult their general practitioners about varicose veins and associated symptoms. Varicose veins are one of the most common conditions seen in surgical clinics, they make up a significant part of the elective surgery workload and they are responsible for a large proportion of patients on surgical waiting lists in NHS hospitals. Venous ulcer care is a major component of district nurse services. Venous disease has been a Cinderella area of health care, in terms of both research and treatment, though this situation is changing. Moreover, this situation has raised important questions about what conditions the NHS should treat.
Whilst there is lay recognition that a varicose vein is a tortuous twisted vein, a standard definition has not yet been agreed. In addition, the exact pathophysiology surrounding the development of varicose veins remains controversial. Most varicose veins are primary (i.e. arising de novo) and whilst there are some recognised predisposing factors, structural abnormalities and abnormal haemodynamic effects which may influence their development, there is no agreement on which of these is the main cause of veins becoming varicose.
Venous ulcers are located at the severe end of the spectrum of chronic venous disorders of the leg. A chronic venous ulcer can be defined as an area of discontinuity of epidermis, persisting for 4 weeks or more and occurring as a result of venous hypertension (increased pressure) and calf muscle pump insufficiency. Venous hypertension is the undisputed initiating factor in venous ulcer development but a detailed understanding of the aetiology of venous ulcers is lacking - not least information on the natural history of varicose veins in relation to venous ulcers.
There appears to be a high degree of acceptance of symptoms of venous disorders of the leg among affected persons, but for around a third of people they do present a significant problem. Symptoms reported by patients presenting with varicose veins include aching pain, tiredness/feelings of heaviness, throbbing, itching and swelling in the lower limbs. Not all varicose veins are associated with symptoms. Cosmetic dissatisfaction with the appearance of varicose veins is probably universal, although the impact it has on an individual and his or her lifestyle will be a matter of personal outlook. Few studies of function or quality of life have been carried out for venous disorders of the leg. Those that exist report that patients with varicose veins have a reduced quality of life compared with the general population and that those with venous leg ulcers have a poorer quality of life than age-matched controls.
The management of venous disorders is thought to represent between 1% and 3% of total health care expenditure. In Great Britain in 2000/01, 107 020 persons were admitted to hospital for operations for varicose veins of the lower limb. The management of leg ulcers comprises a significant portion of the workload of community and hospital nurses, general practitioners, dermatologists, surgeons and physicians involved in the care of the elderly. Each ulcer costs around £2000-£4000 per annum to treat and the total cost to the National Health Service in 1995 was estimated at £600 million.
Recurrence of varicose veins after treatment is a significant problem to the health service. This occurs in 20-80% of cases treated for primary varicose veins, depending on the definition of recurrence used, length of follow-up and the initial treatment. The rate of occurrence increases with time, with an estimated recurrence rate of around 50% to 5 years. Approximately 20% of varicose vein surgery is for recurrent disease. Recurrence may be due to inadequate assessment and initial surgery and to the development of new varicose veins. Venous ulcers take time to heal; up to 50% of venous ulcers may be present for 7 to 9 months, between 8% and 34% may be present for more than 5 years, and about 70% of patients have recurrent ulcers.
No universally accepted classification of chronic venous disease has been agreed and of those classifications that exist, few have been based on objective measurements of abnormal venous pressure/flow. The classification systems used most widely are those developed by Widmer in 1978, Porter in 1988 and the CEAP (clinical signs, etiologic classification, anatomic distribution and pathophysiologic dysfunction) classification presented by the American Venous Forum in 1995. None of these have been formally validated.
The sub-categories to be used in this chapter are:
The population distribution of varicose veins has to be put in a context of uncertainty. The many studies that consider the prevalence of varicose veins and venous disorders are difficult to interpret, as:
The prevalence of venous-related oedema and skin changes is not well documented but there is a large number of studies on the prevalence of leg ulceration. Venous ulcers are the commonest cause of leg ulceration. However, as with the studies on varicose veins, the variations between definitions and methodology employed in these studies makes it difficult to give a definitive prevalence figure.
The best available data representative of the UK population is the Edinburgh vein study, carried out between 1994 and 1996. Incorporating the results of this study into the sub-categories defined in the previous section a prevalence of varicose veins and chronic venous insufficiency (CVI) has been estimated (see Table S1). These estimates underestimate the population prevalence, as the Edinburgh study only included 18-64 year olds and venous disease is commoner in older ages. In addition, there are no data available on non-caucasians.
| Sub-category | Estimated prevalence (%) | Male | Female |
| A | Mild discretionary* | 40 | 31 |
| B | Severe non-discretionary** | 8 | 7 |
| C | Venous ulcer*** | 1 | 1 |
| * Based on the prevalence of trunk varices (Grade 1) and CVI (Grade 1). ** Based on the prevalence of trunk varices (Grade 2-3) and CVI (Grade 2). *** VU is both healed and active ulceration - the latter about 0.1-0.25%. | |||
Most varicose veins arise de novo (i.e. primary), but some are secondary to obstruction or valve damage (e.g. post deep vein thrombosis or pelvic tumour). Whilst many risk factors for varicose veins have been postulated (including age, pregnancy, ethnicity, family history, obesity, occupations requiring prolonged standing or sitting, lack of dietary fibre, use of constricting corsets and sitting posture for defecation), the evidence linking most factors to varicose vein development is limited. Age is the most important, but recent studies have not found significant gender differences and an association with obesity seems to be confined to females. If the link with obesity is real, the prevalence of varicose veins could increase with the rising levels of obesity in the UK population.
The scope for primary prevention is limited. Specific measures suggested include weight control, reducing the amount of standing, greater physical activity and prophylaxis against DVT (e.g. in surgical patients). The use of compression stockings after an acute DVT has been shown to reduce the incidence of CVI and venous ulcer which can occur as a post-thrombosis complication.
Many people with varicose veins will choose not to seek any medical advice. People who do go to their general practitioner are primarily concerned about the cosmetic appearance of their veins or present with symptoms associated with varicose veins. Concern about the future course of the veins is also a common underlying reason. Symptoms draw attention to varicose veins but it has been found that varicose veins may not be the cause of the symptom. Women are more likely to consult their GP with varicose veins than men.
The National Institute of Clinical Excellence has published a guide to appropriate referral from general practice to specialist services for varicose veins. The guide emphasises that most varicose veins require no treatment and say the key role of primary care is to provide reassurance, explanation and education.
An initial diagnosis of varicose veins is usually made up of the signs observed by the general practitioner and the symptoms reported by the patient. However, the accuracy of clinical examination in identifying the site of incompetence is poor. Whether a diagnosis of varicose veins then becomes a referral for treatment and/or further assessment at an outpatient clinic depends upon the severity of the signs and symptoms, the likelihood of complications, patient preferences and the supply of treatment options. There is no single test available to provide answers to the many questions that need to be asked to decide if and how to treat varicose veins and other venous disorders of the leg. For this reason a number of specialised investigations have evolved over the years and include non-invasive methods (continuous wave Doppler ultrasound, duplex scanning, plethysmography, near-infrared spectroscopy) and invasive methods (phlebography/varicography, foot venous pressure measurements, ambulatory venous pressure). Each technique of investigation has its own advantages and disadvantages, and out of the series of tests available in the vascular laboratory, several methods will measure the same thing. Whatever the method used, the interpretation is open to inter-observer variation and can be expensive and time-consuming. The duplex method has become the investigation of choice, especially for recurrent disease, post-DVT disease, and for CVI or venous ulcer. And in the UK it would be unusual for any patient to undergo any test other than a duplex outside a research protocol.
The general indications for treatment of varicose veins are to prevent complications related to venous disease, to relieve symptoms and to improve the appearance of the leg. However, there is no national consensus as to which varicose veins should be treated based on site of incompetence, severity, etc. and as to which types of treatment to be offered (see below).
A variety of medications are available for the relief of various individual symptoms such as heaviness, discomfort, itching, cramps, pain and aching, and swelling.
Compression is the mainstay of venous ulcer treatment. It acts to reduce vein calibre, capillary filtration and venous reflux and improves venous pumping. These effects increase venous return, improve lymphatic drainage and decrease oedema. Materials used for compression include elastic and inelastic bandages, and elastic stockings. There are many ways of applying compression such as single layers of bandaging, multiple layers of bandaging, compression stockings or a combination of bandages. Intermittent pneumatic compression is an alternative method.
Sclerotherapy is the injection of an irritant solution into an empty vein resulting in an endothelial reaction, fibrosis and complete venous destruction. Compression usually accompanies sclerotherapy. Its importance in the sclerotherapy process, the strength of compression and the length of time it is applied varies and depends on the technique used. As a mode of treatment, sclerotherapy has been variably popular in Europe and the United States.
Echo-sclerotherapy is a modification of schlerotherapy which involves injection of a sclerosing agent into a vein under ultrasound guidance and therefore in real proximity to the leakage point.
The basis of surgery is to ligate (tie off) any incompetent venous connections and/or to strip out (remove) any varicose veins.
The types of operation available to treat varicose veins include:
Continuous wave laser systems, such as carbon dioxide lasers and argon lasers, have been tested for their effects on leg veins. Some laser systems show promise as alternative or complementary therapies for telangiectasias. Whilst compression therapy is the main venous ulcer therapy, various other interventions including electrical stimulation, laser therapy and ultrasound have been used in addition to, or in replacement of, compression where compression is contraindicated. New therapies for varicose veins include radiofrequency ablation and the use of a laser probe to close off the long saphenous vein under ultrasound control.
Day case surgery for varicose veins has been shown to be economic, safe and effective and to reduce waiting time for surgery. It is now widely accepted as the most appropriate way to treat many patients who need common surgical procedures and there has been a national drive to increase the percentage of varicose veins dealt with as day cases. However, day case surgery is disliked by a proportion of patients and in the private sector varicose vein surgery is almost never carried out as a day case. Patients for whom day surgery may be unsuitable include patients with extensive varicosities, patients needing open calf perforator surgery, patients requiring postoperative bed rest for venous ulcers, and patients with pre-existing medical conditions.
Increasing pressure on surgical resources in terms of inpatient beds and operating theatre availability has lead to increasing waiting lists for varicose veins. A number of waiting list initiatives have demonstrated that varicose vein waiting lists can be significantly reduced. Waiting for an operation can result in deterioration in the clinical condition of the patient and considerable morbidity for the patients while they wait.
There is a wide variation in the management of venous leg ulcers with types of care including hospital inpatient care, hospital outpatient clinics, primary care clinics and home visits. The introduction of community ulcer clinics has been shown to significantly improve leg ulcer healing and reduce costs by about £150 000 per 250 000 population per annum.
Data on current service provision is based on hospital episode data from NHS hospitals in England (HES data) from 1990/91 to 2000/01. There were 45 216 main operations for varicose veins in NHS hospitals in England in 2000/01. The rate of surgical treatment for varicose veins increased after 1990/1 until 1995/6 when there were 121 operations per 100 000 population. Since then the rate has declined and is now back at 1990 levels with a rate of 92 per 100 000 population in 2000/01. The rates for treatment for varicose veins are highest amongst females between 35 and 64 years of age. The most notable trend is that the proportion of operations for varicose veins carried out as day surgery has increased considerably, from 19% of operations in 1990/91 to 55% of operations in 2000/01. Other important trends are the increase in waiting times for varicose vein operations and the noticeable decrease in length of stay for those patients admitted as inpatients. There are no routine data on the indications for surgery or on surgery for recurrent disease by which to evaluate the appropriateness of outcomes of surgery.
Similarly, there are no routinely collected data on elective hospital treatment carried out in England and Wales by the independent sector. However, a recent study found that surgery performed in independent hospitals accounted for 24% of the ligation or stripping operations for varicose veins in England and Wales in 1997-98, and the number of operations privately funded accounted for 21% of these operations.
As venous ulcers are largely managed in outpatient clinics, there are limited routine data on workload or on the processes or outcomes of care.
The effectiveness of the different forms of management for varicose veins and venous ulcers can be assessed by the amount of reduction in the presenting symptoms and signs, and long term, by the volume of need for further treatment, including that for recurrent disease. The effectiveness of different types of treatment still remains unclear. This is reflected in the large variation in the balance of treatment types between countries (e.g. in drugs, sclerotherapy and surgery). A Task Force on Chronic Venous Disorders of the Leg was established in September 1993 with the purpose of comprehensively evaluating this area of medicine. One of its mandates was to critically review existing scientific evidence on the diagnosis and treatment of the condition. The results of their evaluation are reported in section 6. Where more current effectiveness data have been identified this information has been included. The Cochrane Peripheral Vascular Disease Group is co-ordinating systematic reviews of many aspects of venous disease management.
Key features of a venous disease service appear to be:
Venous disease is the most common vascular condition to affect the lower limb.(1) The term 'chronic venous disorders of the leg' covers a wide range of conditions, including asymptomatic incompetence of venous valves, venous symptoms, telangiectases, reticular veins, varicose veins, oedema, skin changes and leg ulceration. These can be broadly categorised into varicose veins, chronic venous insufficiency (CVI) and venous ulcers. The relationship between these conditions in the general population is illustrated in Figure 1.
Figure 1: The relationship between varicose veins, chronic venous insufficiency and leg ulceration in the population
This chapter addresses varicose veins of the lower limbs but excludes those that may arise as a complication of pregnancy and the puerperium. Varicose veins may be primary or secondary (usually associated with past venous thrombosis affecting the deep and communicating veins).(2) The chapter will also consider other chronic venous disorders of the leg since:
The relevant ICD disease codes and OPCS operation codes can be found in Appendix 1.
An interpretation of the evidence concerning appropriate levels of NHS provision of treatment for varicose veins and other venous disorders of the leg is presented. The broad questions addressed in this analysis are these:
Health care needs can be defined in terms of the individual's capacity to benefit from treatment. The problem faced by commissioning authorities when considering treatments for varicose veins and associated conditions is in defining the level of particular treatments that should be provided to permit such benefits to be experienced. The question is therefore not simply whether individuals may benefit, but which individuals with which categories of morbidity should be provided with which specific forms of care. In the light of publicity over new drugs termed as 'lifestyle' drugs, such as sildenafil, a decision as to whether the NHS should be funding treatments for less severe venous disorders of the leg such as telangiectases, reticular veins and asymptomatic varicose veins, which may be seen as funding cosmetic surgery, will be questioned.
In the United Kingdom each year roughly half a million people consult their general practitioners about varicose veins and associated symptoms.(3) Varicose veins are one of the most common conditions seen in surgical clinics; they make up a significant part of the elective surgery workload and are responsible for a large proportion of operations on waiting lists in NHS hospitals.(4) The independent sector reduces some of this burden, being responsible for around 24% of surgery for varicose veins.(5) Although it has been suggested in the past that there is a low level of interest in varicose veins in the medical profession,(6) and that operations for varicose veins are seen as low priority and are often performed by the least experienced member of the surgical team, often without supervision,(3) there has been considerable change in the last decade, with varicose veins now being taken on increasingly by interested vascular surgeons.(7)
A standard definition of what constitutes a varicose vein has not yet been agreed. The Oxford Medical Dictionary defines them as 'veins that are distended, lengthened and tortuous'.(8) Porter described varicose veins as dilated, palpable subcutaneous veins generally larger than 4mm.(9) The World Health Organisation defines them as 'saccular dilatation of the veins which are often tortuous'.(10) However, these definitions, taken literally, could be restrictive and unhelpful to a commissioner of health care, who will be faced with conditions that the definition would exclude but which are often referred to under the umbrella heading of varicose veins or, more broadly, venous disease. This is discussed further in the section on sub-categories.
In the absence of a precise definition of varicose veins, it is important to understand broadly what varicose veins are and what causes them. Again, this is the subject of much debate.
Venous blood from the skin and subcutaneous fat in the legs is returned to the heart through veins working against gravity. These veins contain valves to prevent a back-flow of blood. There are three types of vein in the lower limbs, and two of these are important when considering venous disease.
Some venous blood drains towards the deep venous system through perforating veins or via the long or short saphenous veins which join the deep system at the sapheno-femoral junction in the groin and the sapheno-popliteal junction behind the knee. It can also drain directly into the deep venous system or bypass the deep system entirely and enter the pelvis.(12) The deep veins carry more blood at a higher pressure than the superficial veins.
Blood is moved from the leg to the heart primarily by the pumping action of the leg muscles, i.e. by muscular compression. The deep veins are subjected to intermittent pressure both at rest and during exercise from pulsations of the adjacent arteries and contractions of the surrounding muscles, which compress the veins and force blood up the limbs towards the heart. As the muscles surrounding the deep veins relax, the pressure within the deep vein lowers temporarily. This causes venous blood to be drawn from the superficial veins into the deep veins, in turn lowering the superficial venous pressure. Competent valves are required to prevent reflux, and to protect the superficial veins and capillaries from a sudden rise in venous pressure when the muscles contract.
In basic terms, the three components of the venous system of the limb - deep veins, superficial veins and perforating veins - work together. Dysfunction of any of these results in dysfunction of the other two.(11) However, although varicose veins have been recognised for centuries the exact pathophysiology surrounding the development of varicose veins remains controversial. The vast majority of varicose veins arise de novo (i.e. primary); a minority are secondary to obstruction, e.g. pelvic tumours or post DVT. Varicose veins do have some recognised predisposing factors, structural abnormalities and abnormal haemodynamic effects which may influence their development.(13)
Predisposing factors to varicose veins are difficult to establish due to the interplay of environmental and genetic elements. Family history of varicose veins, increasing age, female sex (though this is now questioned), parity, ethnicity and occupation may all be factors in the development of varicose veins. A case also exists for the role of height, weight, smoking (though the evidence is weak) and tight underclothes. Aggravating factors such as a fibre-depleted diet (leading to constipation), and long hours standing and sitting have been emphasised, and a recurring hypothesis is that the adoption of the 'industrial lifestyle' is the major predisposing factor to the development of varicose veins. These risk factors will be discussed further in section 4.
One school of thought is that varicose veins occur when the valves in the veins are incompetent, i.e. they fail to prevent blood returning to the direction from which it has come resulting in reflux.(14)(15) This leads to enlargement of the vein (in length and width) and tortuosity. The location of incompetence varies. Deep vein thrombosis (DVT) is a common mechanism for the destruction of valves in the deep and perforating veins.(11) DVT is estimated to precede the development of varicose veins in as many as 25% of patients,(16) though more information is needed on the association between DVT and varicose veins.
Valvular incompetence in the superficial veins has been said to contribute to 80% of venous disorders.(17) Although valves in varicose veins are stretched and do become atrophic,(18) some believe this to be secondary to the disease process and at present there appears to be little evidence overall to suggest a role for an inherent valvular abnormality as the main cause of primary varicose veins.(13)
A number of studies now support the hypothesis that a change in the vein wall precedes valvular incompetence.(18-22) The suggestion that varicose veins are caused by abnormal collagen metabolism has been the subject of much dispute, and changes in elastin content and an increase in smooth muscle in the vein wall as the cause of varicose veins have been suggested.(13) A study in 1992 found a significantly reduced vein wall elasticity and an increased arterial flow in high-risk limbs compared with normal limbs but no corresponding increase in the incidence of valvular incompetence.(23) This study therefore suggests that the role of the venous valves in the development of varicose veins is secondary to changes in the elastic properties of the vein wall and the rate of arterial flow. However, another study of the wall structure and composition of varicose veins with reference to collagen, elastin and smooth muscle content suggested that varicose veins are a dynamic response to venous hypertension and are not thin-walled structures.(24)
It is thought that increased and irregular blood flow in the veins causes them to become dilated. In addition, the role of arteriovenous fistula in the development of varicose veins were thought to be contributory aetiological factors. However, very few believe this and the evidence for these theories is limited and inconclusive.(13)
CVI is manifested by lower limb oedema and lipodermatosclerosis, i.e. skin changes such as pigmentation, atrophy and eczema. It arises secondary to venous hypertension. The high pressure leads to oedema and leakage of protein has local inflammatory effects.
A chronic venous ulcer can be defined as an area of discontinuity of epidermis, persisting for four weeks or more and occurring as a result of venous hypertension and calf muscle pump insufficiency.(25) It is easily recognised when it is situated in the 'gaiter' region near the medial malleolus (the protuberance at the lower end of the tibia), and occasionally adjacent to the lateral malleolus (the protuberance at the lower end of the fibula); it has a shallow base with a flat margin and the surrounding skin has features of long standing venous hypertension, i.e. haemosiderin pigmentation, atrophie blanche, eczema, and dilated venules over the instep of the foot.(26)
Venous ulcers are located at the severe end of the spectrum of chronic venous disorders of the leg (see Figure 1). Because of this they occur more often in subjects with other forms of venous diseases such as varicose veins and skin changes.(27) Venous leg ulceration has been reported to account for 70-95% of all leg ulcers(26)(28) and 20-50% of these are said to be a consequence of varicose veins.(29)(30) However, there is a general lack of data explaining the way varicose veins develop into venous ulcers, and at what point treatment could be advised as being prophylactic rather than remedial.
Venous hypertension is the undisputed initiating factor in venous ulcer development. More severe venous incompetence is associated with a higher risk of ulceration. The higher the venous pressure, the greater the risk, whether incompetence involves the deep or superficial venous system.(31) The reasons why venous ulcers go on to develop is still an area of debate but there are three main theories (see Box 1).
An important determinant of venous ulcers is the venous hypertension that can arise after deep vein thrombosis, especially if it extends above the knee. Brandjes et al have shown that wearing a compression stocking can reduce the incidence of the post-thrombotic limb.(32) This condition commonly occurs after DVT; in the Brandjes study of DVT it occurred in 60% of the control arm within 2 years.
|
| Adapted from Hollinsworth 1998.(297) |
More recently, thrombophilia is being investigated as a risk factor for chronic venous ulceration, with a review of the literature concluding that patients with chronic venous ulceration appear to have a prevalence of thrombophilia much higher than the general population but similar to post-DVT patients.(296) One study investigating the prevalence of thrombophilia in patients with chronic venous leg ulceration found that 41% of these patients had thrombophilia.(79) This rate was 2 to 30 times higher than the rate in the general population but was similar to that reported for patients with DVT. However, in patients with chronic venous ulceration, thrombophilia did not appear to be related to a history of DVT, a pattern of reflux or severity of disease.
There appears to be a high acceptance of symptoms of venous disorders of the leg among affected persons.(36) In around two-thirds of patients who have varicose veins the condition is medically insignificant, i.e. it is seen by the patient as insufficiently important to mention spontaneously in health questionnaires despite being diagnosable on clinical examination. This acceptance could be put down to the fact that varicose veins are such a widespread disease and in most patients are only a slowly progressing condition.(37) For the remaining patients, varicose veins do present a significant problem,(38) one of which may be concerns about the future impact of the disease.
Symptoms reported by patients presenting with varicose veins include aching pain, tiredness/feelings of heaviness, throbbing, itching and swelling in the lower limbs. The relationship between the visible severity of varicose veins and symptoms is, however, weak. Cosmetic dissatisfaction with the appearance of varicose veins is probably universal, although the extent to which it distresses an individual and affects his or her lifestyle will be a matter of personal outlook.
Varicose veins can sometimes be complicated by haemorrhage and thrombophlebitis. The presence of varicose veins is a risk factor for venous thrombosis during abdominal and pelvic major surgery. The role of thromboprophylaxis in varicose vein surgery is uncertain - these patients are generally younger than major surgery patients, are at risk of bleeding postoperatively and compression methods cannot be easily applied (at least to the operated limb).
Women are more likely to consult their doctor for varicose veins than men. A study in Edinburgh found that only 10% of men reported a previous doctor's diagnosis of varicose veins, compared with 17% of women. This was despite the fact that these men on examination were subsequently found to have a significantly higher prevalence of lower limb varices than women.(39)
Few studies of function or quality of life have been carried out for venous disorders of the leg. Biland and Widmer reported that 10% of patients with varicose veins had an inability to work and 25% demonstrated reduced well-being.(40) Smith et al, using the Aberdeen Questionnaire, found that patients with varicose veins have a reduced quality of life compared with the general population and that this is significantly improved at 6 weeks by operating on them.(41) People with leg ulcers have a poorer perceived quality of life than age-matched controls, mainly because of pain and odour.(42) Studies of patients with venous ulcers in the UK have shown high levels of depression, pain and isolation, with very considerable gains from effective treatment.(43) In some severe cases, venous ulcers may lead to long-term entry into care in nursing or residential homes.(44)
The management of venous disorders is thought to represent between 1% and 3% of total health expenditure, with this estimate not including some supplies, cosmetic products and social costs such as lost productivity.(27)
In Great Britain in 2000/01, 107 020 persons were admitted to hospital for operations for varicose veins of the lower limb (HES data).(45) In a study carried out in five countries in 1992 (the UK, France, Spain, Italy and Germany),(38) medical costs of venous disorders as estimated from the total amount of resources used annually for ambulatory care (doctors and nurses, drugs purchased and hospital costs) added up to £300 million for the UK. In Germany, around 2% of all people with varicose veins deemed themselves unfit to work for several weeks each year because of complaints related to the condition.(37) Venous disease also creates longer-term costs in disability and dependence on state-funded invalidity pensions.(44) Invalidity costs stemming from venous disease were 0.4% of the total in the UK in 1992.(38)
The management of leg ulcers comprises a significant portion of the workload of community and hospital nurses, general practitioners, dermatologists, surgeons and physicians involved in the care of the elderly. Each ulcer costs around £2000-4000 per annum to treat(46) and the total cost to the National Health Service in 1995 was estimated at £600 million per annum.(25) There is also a considerable cost to the patient(47) and carers.
Recurrent varicose veins are a significant problem, with recurrence reported as occurring in 20-80% of cases treated for primary varicose veins, although this depends on the definition of recurrence employed, the length of follow-up and the initial treatment.(48) The rate of occurrence increases with time. Juhan et al assumed a recurrence rate of around 50% to 5 years.(49) Approximately 20% of varicose vein surgery is for recurrent disease.(50) The average time between the first and second operation ranges from 6 to 20 years.(48) The reasons commonly cited for recurrence include inadequate assessment, incomplete or inadequate surgery, neovascularisation and the subsequent development of reflux from the deep to superficial venous systems.(51-5) Surgery for recurrent varicose veins is technically more demanding and prolonged.(56)
Venous ulcers are chronic and recurrent:(2) up to 50% of venous ulcers may be present for 7 to 9 months, between 8% and 34% may be present for more than 5 years, and between 67% and 75% of patients have recurrent ulcers.(57)(58)Venous ulcers are the most common types of lower limb ulcer, followed by arterial and neuropathic. They are commonest in the gaiter area above the ankle.(63)
A classification of varicose veins that is of operational use to commissioning authorities is clearly important. However, there is a lack of a clear and universally accepted classification of varicose veins that is easy to use in practice.(59) There are a number of classification systems for varicose veins that are widely used, but they are usually incorporated into classifications of venous disease and are based on clinical severity (see Table 1). Few classification systems use objective measurements.
| Author | Class | Definition |
|---|---|---|
| Widmer (1978)(60) | Varicose veins | |
| 1 | Hyphenwebs: intradermal venectasis | |
| 2 | Reticular varices: dilated tortuous veins, not belonging to the main trunk or its major branches | |
| 3 | Trunk varices: dilated, tortuous trunks of the long or short saphenous vein and their branches of the first or second order. | |
| Each category is graded 1-3 according to the degree and extent of tortuosity and prominence. | ||
| Chronic venous insufficiency | ||
| Categorised into grades I, II and III according to the presence of dilated subcutaneous veins, skin changes and ulceration. | ||
| Porter (1988)(9) | 0 | Asymptomatic |
| 1 | Mild, i.e. mild to moderate ankle swelling, mild discomfort, and local or generalised dilation of subcutaneous veins. Usually superficial veins only. | |
| 2 | Moderate, i.e. hyperpigmentation of the skin, moderate brawny oedema, and subcutaneous fibrosis. There is usually prominent local or regional dilatation of the subcutaneous veins. | |
| 3 | Severe, i.e. chronic distal leg pain associated with ulcerative or pre-ulcerative skin changes, eczematoid changes, and/or severe oedema. Usually involves the deep venous system with widespread loss of venous valvular function and/or chronic deep vein obstruction. | |
| 'CEAP' (1995)(61) | 0 | No visible or palpable signs of venous disease |
| 1 | Telangiectases or reticular veins (also called spider veins/thread veins/star bursts/matted veins) | |
| 2 | Varicose veins | |
| 3 | Oedema | |
| 4 | Skin changes ascribed to venous disease (e.g. pigmentation, venous eczema, lipodermatosclerosis) | |
| 5 | Skin changes (as defined above) in conjunction with healed ulceration | |
| 6 | Skin changes (as defined above) in conjunction with active ulceration |
Widmer's classification(60) presented in 1978 is commonly used but is related only to the clinical appearance of the limb. It has been used in clinical studies of treatments of venous disorders but its validity has never been formally assessed.(27) A committee chaired by Porter in the US(9) described classifications by anatomic region, by clinical severity, by physical examination and by functional assessment. Again, although this classification has been used in many studies on diagnosis and treatment, it has not been formally validated.(27) The most recent classification system to be published is the CEAP classification presented by the American Venous Forum in 1995. This is based on clinical signs, etiologic classification, anatomic distribution and pathophysiologic dysfunction (CEAP) (see Appendix 2). It was developed to provide a comprehensive, objective classification that could be promoted worldwide.
The ease of application of the CEAP classification and its validity has yet to be formally assessed.(27) However, there has already been some criticism of it.(62) The fact that it is all-encompassing has been deemed unnecessary from a clinical point of view and also that it has attempted to classify on more than one extreme. In addition, its use for epidemiological research has been questioned, as it describes an individual patient and would therefore give rise to many sub-groups.(37) It has been suggested that a working classification of chronic venous disease relating to valvular incompetence and/or obstruction alone is required.(62) A proposal for two basic classifications has been put forward by Darke and Ruckley(62):
The VEINES Task Force (VEnous INsufficiency Epidemiologic and Economic Study), set up in part to review the classification of chronic venous disorders of the leg, proposes a scoring system which also uses the CEAP clinical classification but weighs venous disease according to the probability of future leg ulceration.(27) The Task Force's suggested scoring system is shown in Table 3. Scores reflect the outcome values in individual patients, not the treatment efficacy, so that the maximum value is achieved if the problem is completely cured. The classification purposely mixes symptoms and signs as this is how patients present to their physicians, and does not require the use of investigations that may not be universally available. This system has also still to be assessed for its validity.
| Class (based on CEAP clinical class) | Weight |
|---|---|
| Symptoms and/or telangiectases | 1 |
| Varicose veins | 5 |
| Oedema (venous) | 10 |
| Skin changes | 20 |
| Healed venous ulcer(s) | 50 |
| Active venous ulcer(s) | 100 |
| Source: Kurz et al.(27) | |
The sub-categories used in this chapter are displayed in Table 4 and are based on the above classifications and a similar classification proposed by Krijnen et al.(36) For ease of use by commissioners, we have grouped asymptomatic with cosmetic/mild discomfort or swelling, and severe pain/swelling with skin change without ulcer, based on the Darke and Ruckley scheme. However, our sub-categorisation is not perfect. A study in Edinburgh(64) has concluded that if decisions to operate on varicose veins are based simply on the nature, severity and chronicity of symptoms, or the extent and severity of varicosities on clinical examination, they are likely to be unreliable.
This section presents information on the prevalence and incidence of venous disease of the leg gathered from a multitude of studies. It highlights the differing epidemiological terminology, populations studied, assessment methods and definitions used.
Meaningful interpretation of the epidemiological studies on varicose veins requires the following knowledge:
'as long as the terminology varies between the different schools and languages, as long as generally acceptable criteria for the clinical diagnosis of primary and secondary varicose veins have not been developed, the data of national surveys as well as of other samples are not comparable.'(10)
Callam(78) analysed all studies looking at the prevalence of varicose veins available in 1994 and estimated the prevalence of venous disease in the lower limb (see Table 5). This shows that venous disease in the general population is common and that women appear to be affected more than men. It also shows that at the more severe end of the scale only a small percentage of the population are affected.
| Severity | Prevalence (%) | |
|---|---|---|
| Men | Women | |
| Venous disease (all types)* | 40-50 | 50-55 |
| Visible varicose veins** | 10-15 | 20-25 |
| Chronic venous insufficiency*** | 2-7 | 3-7 |
| Chronic venous leg ulceration | 0.5-1 | 1-1.5 |
| * Any evidence of venous disease including venectasia. ** Reticular and truncal varicosities. *** Hyperpigmentation, eczema and liposclerosis. | ||
A review of the literature to December 2000 has revealed a number of studies published since this review. Some of these are probably more relevant to the UK population. The results of all studies identified by this literature review are tabulated in Appendix 3.
The prevalence studies that are more representative of the UK population are described below.
In early national health surveys, recording a number of chronic disorders, the prevalence of varicose veins was found to be relatively low. An estimated national prevalence of around 2% was found in a number of surveys among random samples of the population (US National Survey 1961-63, UK Survey of Sickness 1950, the Sickness Survey of Denmark 1952 and the Canadian Sickness Survey of 1950-51).(80) However, the results from these surveys are questionable - the definition for varicose veins was often not stated and the surveys were by questionnaire alone and usually administered by untrained non-medical personnel.(81) This low prevalence is made more questionable by other population and regional surveys and Callam's study,(78) designed specifically to consider prevalence of varicose veins, which have shown higher rates of prevalence.
Ideally, a population study including either the whole population or a stratified random sample defined by age and sex is required to reveal the true prevalence of a disease such as varicose veins.(82) However, regional surveys that are limited to a specific neighbourhood or city have proved to be of great value in epidemiological research.(37) In addition, unlike the early national surveys, the majority of regional surveys identified are designed primarily for investigating venous disorders rather than a number of diseases.
Regional studies in Europe and the United States identified in a MEDLINE search to October 2001 are listed in Table 6. This information shows a wide variation in the prevalence of varicose veins with prevalences reported between 6% and 85%, depending on the type and severities of varicose vein included in the study and the methodology of the study. Several of the studies indicate that if all types of varicose veins are included, more than half of the adult population is affected(83) as per Callam above.
| Study | Country | Year | Population/setting | Total no. | Prevalence of varicose veins | ||
|---|---|---|---|---|---|---|---|
| Female | Male | Total | |||||
| Preziosi et al(84) | France | 1994-8 | Participants of the SUVIMAX cohort. Women 35-60; men 45-60 (representative of the French population for the age range under consideration) | 3,065 (1,747 women; 1,318 men) | 18.1% - medically diagnosed 12.4% - self-diagnosed |
10.8% - medically diagnosed 7.4% - self-diagnosed |
|
| Evans et al,(83) Bradbury et al(64) | Scotland | 1994-6 | Men and women aged 18-64 resident in Edinburgh | 1,566 (867 women; 699 men) | Trunk 1: 26% 2 or 3: 6% Hyphenweb 1: 84% 2 or 3: 10% Reticular 1. 85% 2 or 3: 6% |
Trunk 1: 33% 2 or 3: 6% Hyphenweb 79% 2 or 3: 6% Reticular 82% 2 or 3: 4% |
|
| Cesarane et al(82) | Italy | 1994 | Residents of San Valentino, a village in Central Italy aged 8-94 (mean age 46.3 ± 7) | 746 (379 women; 367 males) | About 8% (venous diseases) | ||
| Canonico et al(85) | Italy | 1991-2 | Males and females aged 66-96 (mean 74.2) (a random sample drawn by means of a stratified multistage sampling design using electoral rolls) | 1,319 (560 men; 759 women) | 35.2% | 17.0% | 362 (27.4%) |
| Franks et al(65) | England | 1989 | Patients from general practices in West London aged 35-70 | 1,338 | 31.5% | 17.5% | 25% |
| Leipniz et al(86) | Germany | 1989 | Randomly selected from population. Males and females aged 45-65 | 2,821 | 29% | 14.5% | 20.2% |
| Laurikka et al(66) | Finland | 1989 | People born in 1929, 1939 and 1949, i.e. 40, 50 and 60 year olds. | 5,568 | 42% | 18% | |
| Rudofsky(87) | Germany | 1988 | Community sample. Males and females >15 years | 14,000 | 15% | ||
| Henry and Corless(88) | Ireland | 1986 | Random sample of households | 4,900 | 622 (12.7%) | ||
| Fischer H(89) | Germany | 1983 | Random sample city 17-70 (intracutaneous to trunk varices) | 4,530 | 59% | ||
| Novo et al(90) | Western Sicily, Italy | 1977-9 | A sample of the population of the village of Trabia, which mainly comprises farmers and fishermen and a few craftsmen and traders. | 1,122 | 46.2% | 19.3% | 35.2% |
| Weddell(67) | Wales | 1966 | Randomly selected from the electoral roll. Males and females 15+ | 289 | 53% (non-clinical: 36%; clinical: 17%) | 37% (non-clinical: 31%; clinical: 6%) | |
| Coon et al(91) | United States | 1959-60 and 1962-5 | Residents of Tecumseh, a city in S.E. Michigan, 10 years + | 6,389 | 25.9% (moderate to severe 16.7%) | 12.9% (moderate to severe 7.4%) | |
| Arnoldi(92) | Denmark | 1958 | Clinic attendees > 25 years old | 1,981 | 38% | 18.4% | 28% |
| Lake et al(71) | United States | 1942 | Males & females over 40 years representing four different types of occupational activity: sitting, standing, walking , climbing | 536 | 73.2% | 40.7% | 57% |
The Edinburgh vein study(39)(64)(83) is probably the most relevant study to the UK population and will be described in more detail. It looks at the prevalence of varicose veins and chronic venous insufficiency. It considers a wide age range, includes both sexes, defines the classification of chronic venous disease and uses clinical examination in addition to a questionnaire. It does not however, have any data on non-Caucasians.
The primary aim of the study was to conduct a detailed population survey of the prevalence of all grades of venous disease in a randomly selected age stratified sample of the adult population. It was a cross-sectional survey of men and women aged 18-64 years old resident in Edinburgh. The sample was selected from computerised registers of 12 general practices with catchment areas geographically and socio-economically distributed throughout Edinburgh. There were 1566 participants out of 2912 people who were initially approached, giving a response rate of 53.8%. A follow-up of a sample of 194 non-respondents suggested that participants were more likely to have a history of diagnosed venous disease than the general population, hence the prevalence figures may be overestimated. Participants were also more likely to be women (n=867) than men (n=699) and from the older age group range (mean age was 44.8 for women and 45.8 for men).
Subjects attended a research clinic or, if they were unable to do this, were visited at home. All participants completed a self-administered questionnaire which was subsequently checked by a member of the research team. The questionnaire asked about the presence of various symptoms often attributed to venous disease. It also recorded personal and occupational details, relevant medical and family history and possible risk factors for venous disease. After completion of the questionnaire, both legs were examined. The method of classification of venous disease was adapted from Widmer (see Table 1). Trunks were defined as 'dilated, tortuous trunks of the long and short saphenous vein and their branches of the first or second order', reticulars as 'dilated, tortuous subcutaneous veins not belonging to the main trunk or its major branches' and hyphenwebs as 'intradermal varices'. Each of these three groups was subdivided into grades of severity 1-3. In practice, grade 1 trunks ranged from a small, discrete, visible or palpable length of dilated trunk vein to more obvious but not grossly dilated veins; grade 2 trunks were more extensive and/or more grossly dilated trunk varices; and grade 3 were varices at the most severe end of the spectrum.(39) Patients were examined after they had been standing for at least two minutes and varices were graded 1 to 3 accordingly using standard reference photographs. Subjects were also examined for the presence of any pitting ankle oedema, and assessed for CVI. Grade 1 CVI corresponds to malleolar flare, grade 2 CVI corresponds to skin changes, and grade 3 CVI corresponds to healed or active ulceration.
Women were more likely than men to have lower leg symptoms (see Table 7), despite fewer women having trunk varices than men (32% versus 40% age-adjusted prevalence). The prevalence of symptoms increased with age in both men and women, and this links in with the increased prevalence of varicose veins (all severities) with age.
| Leg symptoms | Men (n=699) | Women (n=867) | P value |
|---|---|---|---|
| Heaviness or tension | 16.0 | 28.6 | ≤0.010 |
| Feeling of swelling | 9.2 | 23.0 | ≤0.010 |
| Aching | 32.5 | 53.8 | ≤0.010 |
| Restless legs | 20.0 | 35.1 | ≤0.010 |
| Cramps | 34.0 | 42.0 | ≤0.010 |
| Itching | 19.0 | 25.3 | ≤0.010 |
| Tingling | 16.0 | 19.8 | 0.084 |
| Source: Bradbury et al.(64) | |||
Hyphenweb and reticular varices were very common in both sexes (see Table 8), although the majority had these varices only to a mild degree. Trunk varices were more common in men than women, the age-adjusted prevalence of trunk varices being 39.7% in men and 32.2% in women. Again, the majority of affected subjects had mild lower limb varices. The figures for varicose veins are higher than Callam's figures, partly due to the detailed physical examination undertaken in the Edinburgh study. However, the prevalence of venous insufficiency is comparable to Callam's figures.
| Grade | Males n=699 | Females n=867 | p-value | |||
|---|---|---|---|---|---|---|
| % | n | % | n | |||
| Hyphenweb varices | 1 | 79.2 | 554 | 84.4 | 732 | 0.260 |
| 2 | 5.9 | 44 | 9.2 | 76 | 0.030 | |
| 3 | 0 | 0 | 0.6 | 5 | - | |
| Trunk varices | 1 | 33.3 | 238 | 26.2 | 223 | 0.009 |
| 2 | 5.4 | 39 | 5.6 | 47 | 0.888 | |
| 3 | 1.0 | 7 | 0.5 | 4 | 0.241 | |
| Reticular varices | 1 | 81.6 | 571 | 85.3 | 739 | 0.422 |
| 2 | 4.0 | 29 | 6.4 | 54 | 0.042 | |
| 3 | 0 | 0 | 0 | 0 | - | |
| CVI | 1 | 6.9 | 51 | 5.3 | 44 | 0.157 |
| 2 | 1.3 | 10 | 1.1 | 9 | 0.607 | |
| 3 | 1.0 | 8 | 0.2 | 2 | 0.058 | |
| Source: Evans et al.(39) | ||||||
Many studies investigate limited age groups, samples of clinic populations or specific occupational groups (see Appendix 3). Studies of selected populations can be useful in identifying the risk factors for varicose veins but are limited in estimating the overall prevalence of varicose veins in a population.
The incidence of varicose veins is the development of new cases over a period of time in a population. The Framingham Study(93) followed up men and women who were living in Framingham, USA. Every 2 years from 1966 over a 16-year period, subjects were examined for varicose veins. Over the 16 years, 396 of 1720 men and 629 of 2102 women who were initially free from varicose veins developed varicose veins. The two-year incidence rate of varicose veins was on average 39.4 per 1000 for men and 51.9 per 1000 for women, i.e. 4-5%. The incidence rate beyond the age of 40 years did not increase with age, suggesting that the relationship between age and prevalence is due to a relatively constant development of new cases as people age.(27)
The 11-year Basel vein follow-up study(94) found that in a group of 660 adult subjects who were free of varicose veins at the initial examination, after 11 years 87% had developed non-relevant varicose veins and 5% relevant varicose veins. Amongst the 510 subjects with relevant varicose veins at entry, 27% developed deep vein thrombosis or superficial phlebitis and 10% developed venous leg ulcers. Among the subjects with non-relevant varicose veins at entry, these proportions were 8% and 0.8% respectively.
Risk factors for varicose veins include fixed factors - female sex, age, pregnancy, ethnicity, geographic location, left iliac vein compression by the right iliac artery, family history - and potentially preventable factors - obesity, occupations requiring prolonged standing or sitting, lack of dietary fibre, use of constricting corsets and sitting posture for defecation.(78) Table 10 summarises the available evidence on risk factors for varicose veins. The VEINES Task Force(27) found that aside from age and sex, evidence linking most factors to varicose vein development is limited, and concluded that the evidence was adequate only for pregnancy and obesity. The findings on the aetiology of primary varicose veins do not suggest that there is large scope for primary prevention.
It is generally believed that women are more commonly affected by varicose veins than men and most studies have shown a female predominance of varicose veins.(66)(67)(72)(84)(85)(88)(90)(91)(95-7) In the majority of studies the sex ratio decreases with increasing age. For example, a study in Israel found that in 20-34 year olds the sex ratio was 6 females:1 male, but in people aged 65-74 this ratio fell to 1.5 females:1 male.(95)
There are a number of exceptions to this rule, notably the Edinburgh vein study (see Table 9), which found that there was a significantly higher prevalence of trunk varices in men compared with women;(39) a study in Switzerland(98) where there was no significant difference between the prevalence of varicose veins in men and women; and a study in New Zealand(74) where, although the prevalence of mild and moderate varicose veins was higher in women the prevalence of gross varicose veins were equally prevalent in men. Higher rates in females might be related to greater self-reporting, especially of less severe varicose veins.
| Age (y) | p value | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| 18-24 | 25-34 | 35-44 | 45-54 | 55-64 | |||||||
| % | n | % | n | % | n | % | n | % | n | ||
| Trunk varices (all severities) | |||||||||||
| Men | 20.0 | 11 | 15.5 | 16 | 36.1 | 57 | 42.0 | 76 | 61.4 | 124 | 0.000 |
| Women | 5.3 | 4 | 13.9 | 22 | 22.6 | 42 | 41.9 | 95 | 50.5 | 111 | 0.000 |
| Total | 11.5 | 15 | 14.6 | 38 | 28.8 | 99 | 41.9 | 171 | 55.7 | 235 | 0.000 |
| Chronic venous insufficiency (all severities) | |||||||||||
| Men | - | 0 | - | 0 | 2.5 | 4 | 7.7 | 14 | 25.3 | 51 | |
| Women | 1.3 | 2 | 1.3 | 2 | 3.8 | 7 | 7.9 | 18 | 12.3 | 27 | |
| Source: Evans C. et al.(39) | |||||||||||
The association between age and prevalence of varicose veins is fairly conclusive. The majority of surveys listed in Table 10 show a steady increase in prevalence of varicose veins with increasing age for all grades of varicosity. The increase, however, was not as significant in the older age groups or was not apparent at all in some studies.(76)(97) In addition, the incidence rate flattens in the Framingham Study, suggesting that age is a less important risk factor in older ages. The Edinburgh vein study (see Table 9) showed that the prevalence of trunk varices increased linearly with age in both sexes, and ranged from 11.5% in the 18-24 year olds to 55.7% in the 55-64 year olds when both sexes were combined (pŁ0.001).(39) The same trend was found in the prevalence of reticular and hyphenweb varices (pŁ0.001).
Varicose veins can be present before adulthood. In a longitudinal study (not presented in Table 10) a cohort of school children aged 10-12 years were examined. The presence of discrete reticular varices was found in only 10% of the pupils. Four years later this figure had risen to 30%, with a number of children developing stem and branch varices.(99)
The age-related patterns suggest that the prevalence of venous disease will increase as demographic change shifts to an older population.
It is generally believed that pregnancy leads to varicose veins due to the pressure of the uterus obstructing venous return from the legs. However, this has been refuted, as the majority of varices appear during the initial 3 months when the uterus is not large enough.(100) A hormonal factor is thought to be responsible or the increased circulating volume of blood.
The majority of studies in Table 10 show an association between the onset of varicose veins and pregnancy.(67)(71-4)(76)(77)(90)(96)(101) Women with at least one pregnancy generally had a higher prevalence of all types of varicose veins than women who had no pregnancies.(69)(74)(84)(90)(95)(97)(102)(103) Some studies found that parity was only a significant risk factor in younger women.(96)(101) With increasing age, the influence of pregnancy on the prevalence of varicose veins is smaller.(69) A study in Switzerland(73) found that when the age factor was excluded no significant association remained between the prevalence of varicose veins and childbirth. In addition, the Tecumseh community health study(91) and a study in Tanzania(76) failed to show a rising prevalence with increasing number of pregnancies.
A striking feature of the epidemiological studies of varicose veins is a marked geographical variation in prevalence rates, suggesting a possible association with ethnic group or with lifestyle factors. Several studies suggest that varicose veins are rare in Africa and other developing countries(75) when compared to Western societies.(76)(104) A study in Jerusalem(95) showed that men born in North Africa had significantly lower age-adjusted prevalence rates than immigrants from Europe, America and Israel. Other variations shown in different ethnic groups within a country include a higher prevalence in Southern Indian railway workers than in Northern Indian railway workers,(105) a higher prevalence of varicose veins in whites than non-whites in Brazil(97) and a lower prevalence in Southern Europeans than in other Europeans in a study of women in Switzerland.(73) A study comparing female cotton workers in England and Egypt found that the prevalence of varicose veins was significantly higher in English women than in Egyptian women.(101)
The key question is: do Indo-Asians and African Caribbeans in the UK have higher or lower rates of varicose veins than Caucasians? No studies were identified that answer this question, with it being difficult to assess contributions of genetic predisposition and environmental (e.g. Western lifestyle) influences.
A number of studies have found that the risk of varicose veins was higher in those with affected relatives,(69)(101-3) perhaps suggesting a genetic element or shared environmental factors. However, it has been noted that these results should be regarded with caution. In most studies considering a family history, the relatives were not examined. In addition, family members are not good judges of the presence of varicose veins in the rest of the family(67) and persons with varicose veins are more likely to notice this condition in their relatives than persons without varicose veins.(37)
Several authors have found an association between weight and body mass and an increased risk for varicose veins. Of the studies in Table 10, a positive correlation with varicose veins was found in seven studies(69)(72)(84)(90)(95)(101)(102) and no correlation was found in three of the studies.(69)(74)(96) In a further study, the higher the Body Mass Index, the more prevalent varicose veins were in women; but there was no association in the male participants.(85) In a female population in Switzerland, although there was an increased prevalence of varicose veins with increasing body weight, this was not significant when the age factor was excluded.(73) The rising prevalence of obesity in western countries may lead to a greater burden of venous disease.
A number of studies reported an association between body height and varicose veins.(72)(95) The mini-Finland study showed a smoothly graded increase in prevalence with increasing height.(72) However, more studies found no correlation between height and varicose veins.(73)(96)(98)(103)
A person's occupation has been put forward as a possible risk factor for varicose veins. A standing occupation has been indicated in some studies as a significant risk factor for varicose veins,(69)(72)(88)(95)(101)(102) although this has been found to be insignificant in other studies(71)(73) and refuted in others.(67)(105) Work involving heavy lifting was significantly related to the presence of varicose veins in one study.(67) A number of studies show no correlation between occupation and the prevalence of varicose veins.(71)(85)(97) A review of venous insufficiency at work concluded there are undoubted risk factors in the workplace but recommends further research in this area(106)
A correlation between cigarette smoking and varicose veins was found among men in the Framingham Study(93) but other studies have shown no relationship between cigarette smoking and varicose veins.(85)(95)(96)(103) In one study varicose veins were less prevalent in women who smoked.(72)
A diet deficient in fibre has been implicated as a major factor in the causation of varicose veins.(107) It is thought that fibre-depleted diets lead to constipation and the subsequent straining to produce a stool produces high intra-abdominal pressures which are transmitted to the leg veins and progressively dilate them.(76) A positive correlation was shown between constipation and the prevalence of varicose veins in one study(90) but not in other studies.(85)(101)
The role of corsets in the development of varicose veins was investigated in a number of studies(73)(95)(101) and was found to be significant in two of these.(95)(101)
In the Edinburgh vein study there was no obvious relation between social class (classified by occupation) and the age and sex-adjusted prevalence of trunk varices.(39)
Post-thrombotic limb is the term used to describe venous insufficiency when there is evidence of previous deep vein thrombosis (DVT). Studies have reported frequencies of the syndrome in between 5% and 100% of patients having an acute DVT, especially when the DVT extends proximal to the popliteal fossa. This can be reduced by using a compression stocking post DVT.(32)
| Study | Age | Sex | Race | Family | Occupation | Parity | Obesity | Height | Smoking | Other |
|---|---|---|---|---|---|---|---|---|---|---|
| Edinburgh(39) | Prevalence increases with age (p=0.000) | Mild trunk varices were more prevalent in males (p=0.009). Other varices more prevalent in females (NS) | - | - | - | - | - | - | - | Social class (NS) |
| Western Sicily(90) | Prevalence increases with age (SNR) | More prevalent in females (SNR) | - | - | - | Increased prevalence in women with one or more baby (SNR) | More prevalent in respondents with a higher relative body weight (SNR) | - | - | Constipation - patients suffering showed a higher prevalence (SNR) |
| Tampere, Finland(66) | Increased with age (SNR) | More prevalent in females (SNR) | - | - | - | - | - | - | - | - |
| Tecumseh, US(91) | Increased with age (SNR) | More prevalent in females (SNR) | - | - | - | No correlation | - | - | - | - |
| Campania, Southern Italy(85) | No correlation (p=0.75) | More prevalent in females (p=<0.0001) | - | - | No relationship between varicose veins and previous occupation | - | More prevalent in female subjects with a higher BMI (p=<0.0001). Males - no correlation | - | No correlation | Alcohol consumption - no correlation (women p=0.005, NS in men). Constipation - no correlation |
| Cardiff, Wales(67) | Prevalence increases with age (SNR) | More prevalent in females | - | - | Varicose veins more prevalent in men and women whose work involved heavy lifting (p<0.05). No correlation with work involving long hours of standing | Increased prevalence with parity (0.2<p<0.3) | - | - | - | - |
| Ireland(88) | Prevalence increases with age | More prevalent in females | - | - | Increased prevalence in standing employment | Increased prevalence with number of pregnancies | - | - | - | - |
| New York(102) (female sample) | - | - | - | Family history (p<0.0001) | Increased prevalence with standing vocation (>6hrs/day) (p<0.0001) | Increased prevalence with pregnancy (p<0.0001) | Increased prevalence with obesity (<20% over ideal weight) (p<0.0001) | - | - | Oral contraceptive use - no correlation |
| France(84) | Prevalence increased with age (SNR) | More prevalent in females (SNR) | - | - | - | Increased prevalence with parity (p=0.007) | Increased prevalence with increasing BMI (p=0.003) | - | - | - |
| Turkey(103) | Prevalence increased with age | More prevalent in females than males but NS (p>0.005) | - | Positive family history (p=0.001) | - | Association with at least one pregnancy (S) | No association | No association | No association | - |
| Czechoslovakia(69) (female sample) | Prevalence increased with age (p<0.05) | - | - | Positive family history (p<0.01) | Increased prevalence in women standing compared to sitting and changing position | Higher prevalence with at least one pregnancy (p<0.001) | Increased prevalence with rising body weight (S) | - | - | Physical activity - NS. Blood pressure - NS |
| Switzerland(73) (female sample) | Prevalence increased with increasing age (p<0.001) | N/A | Prevalence lower in southern Europeans compared to central Europeans (S) | - | Prevalence higher in women standing at work but no significant correlation (p=0.11 after removing age factor) | Prevalence increased with number of children born but NS when age factor was excluded | Increased prevalence with increasing body weight but NS when age factor was excluded. | No significant association | - | Corsetry - NS |
| England and Egypt(101) (female sample) | Prevalence increased with age EU (p<0.001) | N/a | Prevalence higher in England than Egypt (p<0.001) | Positive family history (p<0.001) | Higher prevalence in standing (England: p<0.001, Egypt: NS) | Prevalence higher in women who had had children (England: p<0.05, Egypt: p<0.01). Only in 15-34 age group | Increased prevalence with body weight (England: p<0.001, Egypt: NS) | - | - | Constipation -NS. Corsetry - Eng: p<0.001 or p<0.01 when standardised, Egypt NS) |
| Basle, Switzerland(98) | Prevalence increased with age | NS | - | - | - | - | NS | NS | - | - |
| New York(71) | More prevalent in females (SNR) | - | - | Walkers higher prevalence than sitters but NS | - | - | - | - | - | |
| Finland(72) | Prevalence increased with age | More prevalent in females | - | - | No association in occupational groups. Standing S in women (p<0.001) | More prevalent in women who have had children increasing linearly up to 5 children (p<0.001) | Increased prevalence with increasing body weight and BMI (S) | In women, more prevalent in taller women (p<0.001) | In women, less prevalent in smokers (p<0.01) | - |
| Western Jerusalem(95) | Prevalence increased with age (p<0.001) | Prevalence higher among women | Prevalence lower in men born in North Africa (p<0.01) | - | Higher prevalence in workers that spent a lot of time standing (p<0.01) | More prevalent with at least one pregnancy (p=0.0011) | More prevalent in heavier groups (p<0.00001) | More prevalent in taller (p=0.007) | No significant association | Corset - more prevalent (p<0.01). Stockings (p<0.01). Inguinal hernia in men (p=0.0006) |
| New Zealand(74) | Prevalence increased with age | Prevalence higher among women of mild and moderate varicose veins but equally prevalent for gross varicose veins | - | - | - | More prevalent with one or more pregnancies | No association | - | - | - |
| Japan(96) (female sample) | Prevalence increased with age | Prevalence higher in women | - | - | - | More prevalent with one or more pregnancies but only in younger age groups | No association | No association | No association | - |
| Tanzania(76) | No association | Prevalence higher in men but NS | - | - | - | No association | - | - | - | - |
| Brazil(97) | Prevalence increases with age (S) but not after 40 years of age in women | Prevalence higher in women (S) | Prevalence higher in white than non-white (S) | - | No association | Correlation between prevalence and number of pregnancies (S) | - | - | - | Posture adopted for defaecation - no association |
| India(105) (male sample) | Increasing prevalence with increasing age | - | Prevalence higher in South Indian than North Indian (pŁ0.001) | ` | No association | - | - | - | No association | - |
| Amsterdam, The Netherlands(36) | Increasing prevalence with age (p<0.0005) | - | - | - | Large number of years in a standing profession on severity (p<0.05) | - | Increasing prevalence with increasing weight (p<0.005) | - | - | - |
| NS = not significant NR= significance not reported = not investigated or reported | ||||||||||
The prevalence of venous-related oedema and skin changes is not well documented. In Tecumseh, USA,(91) 37% of women and 3.0% of men had skin changes. The prevalence increased markedly with age from 1.8% in women aged 30-39 years to 20.7% in women over 70 years of age. The marked gender difference was not demonstrated by the Edinburgh study,(39) which found that 1.1% of women and 1.3% of men had skin changes (hyper- or de-pigmented areas, with or without corona phlebectatica), but again the prevalence increased with age. Under the age of 35 years, CVI (all severities) was extremely rare in women and did not occur at all in men but increased 12.3% in women and 25.2% in men in the oldest age group investigated (55-64 years).
CVI is more common if varicose veins are more severe - if both deep and superficial systems are involved, if both long and short saphenous veins are varicose and if there is below knee involvement.
There are a large number of studies on the prevalence of leg ulceration but, as with the studies on varicose veins, the variations between definitions and methodology employed in these studies makes it difficult to give a definitive prevalence figure. A review by Callam(108) of the prevalence of chronic leg ulceration in Western countries concluded that active chronic leg ulceration has a point prevalence of 0.1-0.2% of the adult population and approximately 1% of the population will suffer from leg ulceration at some time in their lives. Studies by Nelzen agree with this figure, suggesting that the prevalence of healed ulcer is 2 to 4 times higher than of active ulcers and that the prevalence of both together in the population is around 1%.(109-11)
The sex ratio (M:F) is generally though to be 1:2 to 1:3 at all ages(27) but the Edinburgh study(39) found that 1% of men and 0.2% of women had grade 3 CVI (i.e. healed or active ulceration). The prevalence of venous ulcers increases consistently with age,(109-14) with chronic leg ulceration being relatively uncommon below the age of 60,(112) unlike varicose veins. The annual incidence rate in the population over 45 years of age was estimated at 3.5 per 1000 in one retrospective study.(115)
The results from the Fourth National Study of Morbidity Statistics from General Practice(116) can be used to estimate the incidence and prevalence of varicose veins and venous ulcer as they present to GPs in the community (see Table 11) and therefore the potential workload of a typical Primary Care Group (PCG). The study, carried out in 1991-1992, presents data on the level and detail of morbidity seen in general practice and covers a 1% sample of the population of England and Wales (502 493 patients, 468 042 person-years at risk). These persons were on the list of 60 practices volunteering to take part. The prevalence estimates include all severities of varicose veins covered by ICD-9 code 454 (see Appendix 1), and include venous ulcers.
The data from the study reflect the main trends and information gathered from the prevalence studies mentioned earlier, particularly the greater presentation rates in females. They show also the strong prevalence age gradient that continues up to over-75s.
The data suggests that for a typical primary care group (n=100 000) there would be around 1770 people in the PCG with varicose veins (with or without venous ulcer), around 1250 cases presenting with varicose veins for the first time each year and around 2540 consultations with a doctor for varicose veins (with or without venous ulcer) each year. The prevalence suggested by these data does appear to be lower than in most of the prevalence studies. However, it should be recognised that the figures in the GP study are only based on people who present to their general practitioner and does not include people who don't see their GP for their complaint (i.e. does not describe population rates). As mentioned earlier, a significant proportion of people with varicose veins do not present to primary care.
| Varicose Veins of lower extremities ICD 454* | Persons by age group and sex | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Total | 0-4 | 5-15 | 16-24 | 25-44 | 45-64 | 65-74 | 75-84 | 85 and over | ||
| Patients consulting rates (prevalence) per 10 000 person-years at risk | Male | 58 | 1 | 1 | 10 | 31 | 97 | 197 | 232 | 232 |
| Female | 119 | 1 | 1 | 33 | 96 | 186 | 263 | 307 | 244 | |
| Total | 177 | 2 | 2 | 43 | 127 | 283 | 460 | 539 | 476 | |
| New and first ever episodes rates per 10 000 person-years at risk | Male | 40 | 0 | 1 | 8 | 24 | 70 | 123 | 166 | 119 |
| Female | 85 | 1 | 1 | 27 | 75 | 138 | 177 | 193 | 158 | |
| Total | 125 | 1 | 2 | 35 | 99 | 208 | 300 | 359 | 277 | |
| Consultations with doctor rates per 10 000 person-years at risk | Male | 95 | 0 | 1 | 14 | 42 | 177 | 296 | 432 | 368 |
| Female | 169 | 3 | 1 | 37 | 111 | 270 | 431 | 482 | 364 | |
| Total | 254 | 3 | 2 | 51 | 153 | 447 | 727 | 914 | 732 | |
| *This code includes varicose veins with ulcers and inflammation. | ||||||||||
The best available data likely to be representative of the population in England and Wales appears to be the Edinburgh vein study (albeit a Scottish study, but recent and population based). Incorporating the results of this study into the sub-categories defined in the previous section, a prevalence of varicose veins and CVI has been estimated (see Table 12). This estimate is likely to be low if applied to the whole population, as the population studied in the Edinburgh study was limited to18-64 year olds. Other studies have indicated that there is a strong age gradient which continues up to the over-75s age group.
| Estimated prevalence (%) age 18-64 | |||
|---|---|---|---|
| Male | Female | ||
| A | Mild discretionary* | 40 | 31 |
| B | Severe non-discretionary** | 8 | 7 |
| C | Venous ulcer*** | 1 | 1 |
| * Based on the prevalence of trunk varices (Grade 1) and CVI (Grade 1). ** Based on the prevalence of trunk varices (Grade 2-3) and CVI (Grade 2). *** VU is both healed and active ulceration-latter about 0.1-0.25%. | |||
The services and treatment options available to a person in the general population who has varicose veins and related diseases will depend on:
Corbett(117) stated that in terms of providing serv