Varicose veins and chronic venous disease are common, and some funding bodies ration treatment based on a minimum diameter of the incompetent truncal vein. This study assessed the effect of maximum vein diameter on clinical status and patient symptoms.

Symptom assessment in varicose veins is complex, and vein diameter has been used as a tool for rationing reimbursement by healthcare providers and insurers. The aim of this study was to examine the relationship between vein diameter, clinical severity, and disease-specific quality of life in patients with venous disease. Duplex scans from patients with truncal vein reflux awaiting intervention were assessed and the maximal vein diameter (VD) was recorded. The Aberdeen Varicose Vein Questionnaire (AVVQ), the Venous Clinical Severity Score (VCSS), and clinical CEAP grade was recorded. Data were available for 339 patients, of whom 59% were female, 10% obese; mean (SD) age was 49.6 years (16.2 years), and 55% were C1-C3. The mean (SD) AVVQ was 21.1 (11.7), median (IQR) VCSS 6 (4-8), and clinical CEAP 3 (2-4). Mean (SD) VD was 8.4 mm (3.9 mm). A weak but significant correlation was found between CEAP and VD (Spearman's 0.145, P = .008), and VD and VCSS (Spearman′s 0.145, P = .008). No correlation was found between VD and AVVQ (Spearman′s 0.077, P = .160). Vein diameters >6 mm had a significantly greater quality of life impairment (AVVQ 22.06 vs 19.00, P = .029) and clinical disease severity (VCSS 6 versus 5, P < .001). Male patients had higher AVVQ (P = .001) and CEAP (P = .026) with a larger VD (P = .008), but there was no significant difference in VCSS scores between genders (P = .140). Patients with larger vein diameters presented with worse clinical disease severity (CEAP and VCSS) but not with a worse quality of life. Male patients suffered worse clinical stage and quality of life scores. A maximum vein diameter >6 mm was associated with a significantly greater quality of life impairment and clinical disease severity.

Venous disorder is common in the general population. Uncomplicated varicose veins represent a significant proportion of the disease burden, and can impact considerably on quality of life, producing a wide spectrum of symptoms. Little is known about the natural course of the disease at this stage and the treatment strategy employed is often not based on robust scientific evidence. The aim of this article is to elucidate the options to manage uncomplicated varicose veins. There are likely to be significant geographic differences in the treatment strategy employed, and it is hoped that we will arouse discussion among physicians regarding the management of this very common medical condition. The reader will be asked for their preferred treatment choice for a given clinical case vignette.

Abstracts from Phlébologie Annales Vasculairess from Phlébologie Annales Vasculaires Nd:YAG laser treatment of haemorrhagic venous ectasia in patients on AVK

Summary The aetiology and pathogenesis of varicose veins remains poorly understood. At present two popular theories exist; the ascending and descending theory of varicose vein development. The descending theory proposes that the primary pathology arises from proximal abnormalities usually affecting the terminal valve at the saphenofemoral junction (SFJ) or saphenopopliteal junction (SPJ). Incompetent valves in a proximal vein segment result in the reflux of venous blood and an increase in haemodynamic pressure on the valve immediately distal, resulting in subsequent incompetence and distal vein dilatation. The theory is supported by cadaveric studies, reporting reduced or absent valves in the external iliac and femoral veins in patients with evidence of venous insufficiency and in cadaveric studies and limbs undergoing superficial venous surgery in comparison to normal limbs, valves are significantly reduced overall and particularly reduced in the proximal two thirds of the vein. Varicosities are also found in consistent locations distal to valves. In addition, valvular incompetence occurs in the absence of venous symptoms, suggesting it may be the primary event. A study of 4020 limbs investigated with venous colour duplex confirmed that in patients with varicose veins, the majority had incompetence at the SFJ, of those, 72% had SFJ incompetence with complete incompetence of the entire GSV and a further 19% had above knee GSV incompetence. Distal incompetence in the presence of SFJ incompetence was rare (4%) [11]. Although the descending theory cannot account for every observed pattern of venous reflux, the presence of an incompetent SFJ significantly influences patterns of reflux and provides support for the descending theory.

The aetiology and pathogenesis of varicose veins remains poorly understood. At present two popular theories exist; the ascending and descending theory of varicose vein development. The descending theory proposes that the primary pathology arises from proximal abnormalities usually affecting the terminal valve at the saphenofemoral junction (SFJ) or saphenopopliteal junction (SPJ). Incompetent valves in a proximal vein segment result in the reflux of venous blood and an increase in haemodynamic pressure on the valve immediately distal, resulting in subsequent incompetence and distal vein dilatation. The theory is supported by cadaveric studies, reporting reduced or absent valves in the external iliac and femoral veins in patients with evidence of venous insufficiency and in cadaveric studies and limbs undergoing superficial venous surgery in comparison to normal limbs, valves are significantly reduced overall and particularly reduced in the proximal two thirds of the vein. Varicosities are also found in consistent locations distal to valves. In addition, valvular incompetence occurs in the absence of venous symptoms, suggesting it may be the primary event. A study of 4020 limbs investigated with venous colour duplex confirmed that in patients with varicose veins, the majority had incompetence at the SFJ, of those, 72% had SFJ incompetence with complete incompetence of the entire GSV and a further 19% had above knee GSV incompetence. Distal incompetence in the presence of SFJ incompetence was rare (4%) [11]. Although the descending theory cannot account for every observed pattern of venous reflux, the presence of an incompetent SFJ significantly influences patterns of reflux and provides support for the descending theory.

Venous hypoxia has long been postulated as a potential cause of varicosity formation. This article aimed to review the development of this hypothesis, including evidence supporting and controversies surrounding it. Vein wall oxygenation is achieved by oxygen diffusing from luminal blood and vasa vasorum. The whole media of varicosities is oxygenated by vasa vasorum as compared to only the outer two-thirds of media of normal veins. There was no evidence that differences exist between oxygen content of blood from varicose and non-varicose veins, although the former demonstrated larger fluctuations with postural changes. Studies using cell culture and ex vivo explants demonstrated that hypoxia activated leucocytes and endothelium which released mediators regulating vein wall remodelling similar to those observed in varicosities. Venoactive drugs may improve venous oxygenation, and inhibit hypoxia activation of leucocytes and endothelium. The evidence for hypoxia as a causative factor in varicosities remains inconclusive, mainly due to heterogeneity and poor design of published in vivostudies. However, molecular studies have shown that hypoxia was able to cause inflammatory changes and vein wall remodelling similar to those observed in varicosities. Further studies are needed to improve our understanding of the role of hypoxia and help identify potential therapeutic targets.

Objectives A number of modalities are now available for the treatment of varicose veins. The aim of the study was to investigate the factors considered important by patients when contemplating treatment of their varicose veins. Methods Consecutive new patients referred to a vascular surgery service were invited to complete a short anonymous questionnaire prior to their consultation. The questionnaire consisted of 13 multiple choice questions relating to symptoms, potential varicose vein treatments and patient knowledge of existing therapies. Results Of 111 patients, there were 83 complete responses (75%). Symptoms of pain or aching were reported as moderate or severe by 77/103 (75%) of patients and significantly limited the activities of 47/101 (47%). Although the majority (89/103 [86%]) of patients were aware of surgery, only 52/103 (51%) knew of the existence of endothermal ablation (either laser or radiofrequency) and only 23/103 (22%) were aware of foam sclerotherapy. Some 58/92 (63%) were in favour of local anaesthetic treatment. Most patients (74/103, 72%) felt inadequately informed to express a preference regarding treatment type prior to their consultation, although 24/103 (23%) expressed a preference for endovenous treatment. Interestingly, 74/92 (80%) stated that the opinion of their vascular surgeon would be likely to or definitely influence their treatment decision and the majority of patients stated that what they had read in magazines (54/80, 64%) or on the Internet (51/85, 60%) would have no influence on their decision regarding treatment, respectively. Conclusion Only a minority of patients referred with varicose veins were aware of endovenous treatments or felt adequately informed to express a treatment preference prior to consultation. Over half of patients expressed a preference for local anaesthetic therapy and a preference for a single visit treatment, although most would be strongly influenced by the opinion of their vascular surgeon and not influenced by media advertising.

OBJECTIVES:A variety of endovenous therapies for the treatment of superficial venous incompetence are currently available. The aim of this study was to evaluate the prevalence of endovenous techniques used by consultant vascular surgeons in the United Kingdom.METHODS:An anonymous online survey of 16 multiple choice questions relating to the nature and provision of treatment for varicose veins was devised. Consultant members of the Vascular Society of Great Britain and Ireland were invited to participate by email.RESULTS:A total of 108/352 (31%) surgeons completed the survey. The majority offered surgery as the first-line treatment for primary great saphenous vein (GSV) and small saphenous vein (SSV) incompetence (69% and 74%, respectively). Endovenous procedures were offered as first-line treatment by 32/108 (29.6%) for GSV reflux, 36/51 (70.6%) surgeons performed these under local anaesthetic and 21/51 (41.2%) were performed as an outpatient procedure. The most important factor influencing treatment decisions was considered to be patient preference by 77/108 (71.3%) surgeons, although 48/61 (78.7%) respondents were restricted by primary care trusts with regard to endovenous treatments, and 33/108 (30.6%) offered different treatments to private patients.CONCLUSION:Traditional surgery remains the most commonly offered treatment for patients with varicose veins. The provision of endovenous therapies varies greatly, and there are significant differences in local availability regarding these treatments.

Endovenous laser ablation (EVLA) and radiofrequency ablation (RFA) are both associated with excellent technical, clinical and patient-reported outcomes for the treatment of varicose veins. The aim of this study was to compare the techniques in a randomized clinical trial. Consecutive patients with primary great saphenous vein reflux were randomized to EVLA (980 nm) or RFA (VNUS ® ClosureFAST ™ ) at a single centre. The primary outcome measure was postprocedural pain after 3 days. Secondary outcome measures were quality of life at 6 weeks, determined by the Aberdeen Varicose Vein Questionnaire (AVVQ) and Short Form 12 (SF-12 ® ), and clinical improvement assessed by the Venous Clinical Severity Score (VCSS). Analyses were performed on the basis of intention to treat using multivariable linear regression. Some 131 patients were randomized to EVLA (64 patients) or RFA (67). Mean(s.d.) pain scores over 3 days were 26·4(22·1) mm for RFA and 36·8(22·5) mm for EVLA ( P = 0·010). Over 10 days, mean(s.d.) pain scores were 22·0(19·8) mm versus 34·3(21·1) mm for RFA and EVLA respectively ( P = 0·001). The mean(s.d.) number of analgesic tablets used was lower for RFA than for EVLA over 3 days (8·8(9·5) versus 14·2(10·7); P = 0·003) and 10 days (20·4(22·6) versus 35·9(29·4) respectively; P = 0·001). Changes in AVVQ, SF-12 ® and VCSS scores at 6 weeks were similar in the two groups: AVVQ ( P = 0·887), VCSS ( P = 0·993), SF-12 ® physical component score ( P = 0·276) and mental component score ( P = 0·449). RFA using VNUS ® ClosureFAST ™ was associated with less postprocedural pain than EVLA. However, clinical and quality-of-life improvements were similar after 6 weeks for the two treatments. Registration number: ISRCTN66818013 ( http://www.controlled-trials.com ). Copyright © 2010 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Varicose veins impose a huge burden on a patient’s quality of life. The reported symptoms of unsightly cosmesis, heaviness, aching, itching or burning and the potential complications that include leg ulcers, infections, stasis changes and thrombosis have contributed to considerable morbidity and cost to the health service. Approximately more than 50,000 varicose vein operations are performed each year in England and Wales, with an estimated annual cost at £400–600 m. At present, the vast diversity of new treatment options for varicose veins have led to many questions and disputes among physicians as to which is the most efficacious. However, as long-term success rates of new interventions are still awaited, reliable and validated outcome measures are required in order to evaluate these modalities. An outcome measure allows the evaluation of health-care delivery and has traditionally looked at mortality and morbidity but is now increasingly incorporating the concept of ‘patient satisfaction’. Patient reported outcome measures (PROMs) are intended to measure patients’ baseline health status, assist in monitoring their journey through intervention and allow comparison of varying treatment modalities and treatment centres. To date, various quality-of-life assessment tools have been developed and validated for use in venous disease, each with their own strengths and weaknesses. There are two classes of outcome measures: generic and disease specific. Generic tools currently utilized to assess varicose vein treatment include the 36 Item Short form Health Survey and Nottingham Health Profile. These are usually applied across broad range of diseases and are a measure of patients’ subjective wellbeing. Health economic questionnaires such as the Euroquol currently allow calculation of the cost-effectiveness of interventions in Quality of life Adjusted Years, which governs whether or not treatments are recommended on the National Health Service. It has, however, been suggested that they may not be sensitive enough to fully evaluate improvements in outcomes in some disease states and that a more sensitive tool is required. Conversely, disease-specific instruments such as Aberdeen Varicose Vein Questionnaire (AVVQ), Venous insufficiency epidemiological and economic study, Chronic Venous Insufficiency Questionnaire and Specific Quality of life Outcome Response Venous are specific for venous disease. They allow patients to report their own symptoms and are thought to be more sensitive to changes following interventions; however, at present we do not have a disease-specific questionnaire to measure cost-effectiveness or disease burden and therefore cannot say who’s score is worthy of treatment. Currently PROMs are being used by the Department of Health in the UK in order to evaluate service provision. Perhaps we could analyse the PROMs to elucidate who would benefit most from intervention. Would those who score very highly be the ones who reap the most benefit, whether it be physical or cosmetic-related improvement? Conversely, would those who have low scores tolerate delay in treatment on a non-urgent basis, if indeed are likely to benefit at all? If so, could we use these PROMs as a tool to offload the pressure on the use of scarce health-care resources, particularly for interventions of uncomplicated varicose veins and also to prioritize scheduling for waiting lists? At present, there is a lack of evidence in the published literature supporting this notion. Data from a small study presented by Beresford et al. have shown patients with moderate varicose vein disease, i.e. AVVQ 12.5–25, gained significant and long-term benefit from varicose vein surgery, although patients with mild disease were unlikely to benefit significantly. However, other studies have found that even patients with low preoperative scores gained improvements following intervention, although they were more likely to report a worsening of their symptoms compared with those with more severe disease. Although PROMs have shown to be sensitive tools in the evaluation of treatment outcomes, there is no convincing evidence to support their use to predict who will benefit from intervention. In addition, not all clinician’s and patients have sufficient interest in using formalized assessments as a tool to evaluate treatment success or predict outcome. The system would also be open to significant bias if

Objectives This study aimed to assess the trends and regional variations in secondary care treatment of patients with varicose veins in National Health Service (NHS) England based on data published by the Hospital Episode Statistics which was freely and readily available to the public and health-care policy-makers. Methods Hospital Episode Statistics data for patients being treated for varicose veins, and UK Statistics Authority population estimates in all 28 Strategic Health Authorities (SHAs) in England from 2002 to 2006 were retrieved and analysed. Results Between 2002 and 2006 there was a 20% overall reduction (46,190–37,135) in the total number of varicose vein procedures performed in NHS England per year. The number of varicose vein procedures performed per 100,000 population per year varied significantly across the SHAs (P < 0.0001). Similarly, significant regional variations were also noted in the frequency of primary procedures of greater and small saphenous vein (P < 0.0001). During this time, injection sclerotherapy was only performed in 15 (53.6%) SHAs. The annual proportion of varicose vein procedures performed as daycases had increased from 56% to 64% during the period. Conclusion From 2002 to 2006 there was an overall reduction in the total number of varicose vein procedures performed in NHS England with major regional variations.

ObjectivesTo review the mechanisms, diagnosis and treatment options for symptomatic iliac artery compression in cyclists.MethodsPubmed, Medline, Embase and Google were searched using combinations of the terms ‘iliac artery disease’, ‘iliac artery compression’, ‘iliac artery stenosis’, ‘cyclists’ and ‘athletes’.ResultsTethering of the iliac artery by the psoas arterial branch and fibrous tissue, and muscular hypertrophy predispose the vessel to kinking and compression during cycling. Symptoms may only be present on maximal exercise in the cycling position. Provocative exercise tests using a cycling ergometer with ankle brachial pressure index measuring has a sensitivity of 85% to detect arterial insufficiency. Magnetic resonance imaging is increasingly being used as the investigation of choice to confirm the diagnosis, although digital subtraction angiography and colour duplex ultrasonography may also help. Conservative measures including adjustments to the cycling posture and bicycle setup should be recommended to all patients. The evidence for surgical and endovascular treatments is limited and the use of prosthetic graft should be avoided.ConclusionsIliac artery compression should be recognised as an important differential diagnosis in competitive cyclist presenting with lower limb symptoms. Although the optimal treatment strategy remains unclear, early diagnosis may reduce unnecessary investigations, and enable the cyclist to make appropriate adjustments and decisions in treatment management.