Abstract
Chronic venous insufficiency (CVI) is the most advanced form of chronic venous disease (CVD), and is often associated with skin changes such as hyperpigmentation, eczema, lipodermatosclerosis and venous skin ulceration that cause discomfort, pain, sleep disturbances, absenteeism in the workplace, disability and deteriorated quality of life (QoL). The purpose of this study is to evaluate the prevalence of CVI and skin changes in patients who turn to Continuous Assistance Services due to the presence of disturbing symptoms of their condition.
Data were evaluated by consulting the medical records, during a 16‐month period, available with three Continuous Assistance Services of the Italian territory.
The overall population of the referring centres consisted of 1186 patients [739 females (62·31%) and 447 males (37·69%)]. Seventy‐nine patients (6·66%) consulted the emergency unit for venous symptoms related to CVD. Patients with more severe disease (CVI, categories C4–C6) represented the majority accounting for 60·75%, while patients with moderate disease (C3) accounted for 35·44% and patients with mild disease (C1–C2 stages) accounted for 3·79%.
The main finding of this study is that despite CVI not being a disease that commonly requires medical emergency/urgency intervention, patients with CVI, especially in advanced stage with skin changes, may turn to Continuous Assistance Service for treating bothersome symptoms related to their condition.
Keywords: Chronic venous disease, Chronic venous insufficiency, Continuous Assistance Services, Skin changes, Venous symptoms
Introduction
Chronic venous disease (CVD) is a common problem affecting adult population, especially in Western countries 1, 2, 3. As previously described, the prevalence of CVD among individuals younger than 30 years was <10% in men and women; prevalence in men and women aged ≥70 years is 57% and 77%, respectively 3, 4. CVD symptoms range from varicose veins to leg oedema, and serious dermal manifestations consisting of hyperpigmentation, eczema, lipodermatosclerosis and venous skin ulceration 5, 6. All clinical manifestations of CVD can be classified using CEAP classification 7, 8. Skin changes that occur in CVD are a result of chronic venous hypertension and severe inflammation 9, 10, 11, 12, 13, 14, 15, 16, 17 and indicate an advanced form of CVD known as chronic venous insufficiency (CVI) 1, 4. Frequently, the presence of CVI causes discomfort, pain, absenteeism in the workplace, disability and deteriorated quality of life (QoL) 18.
CVD management has undergone a revolution based on technological advances 19: Duplex ultrasound has impacted almost every facet of phlebology, including preoperative diagnosis, periprocedural monitoring, postoperative surveillance and even our understanding of the disease process itself. Moreover, the high prevalence of CVD has a considerable impact on health care resources. Evidences have shown that the median duration of ulceration was 9 months, 20% of ulcers had not healed within 2 years and 66% of patients had episodes of ulceration lasting longer than 5 years 20, 21, 22. Venous ulceration has dramatic consequences that impair the individual's ability to engage in social and occupational activities, reduce QoL and impose financial constraints. Moreover, it has been estimated that venous ulcers cause the loss of approximately 2 million working days and incur treatment costs of approximately $3 billion per year in the Western countries. Overall, CVD has been estimated to account for 1–3% of the total health care budgets in countries with developed health care systems 4, 23, 24.
Patients with severe CVI may experience multiple and significant symptoms, including pain, depression, sleep disturbances and discomfort from lower leg inflammation 25.
In Italy among the services available for emergency care ‘The Doctor on Duty – Continuous Assistance Service’ 26 is the most used first aid service.
This free‐of‐charge service is available on Saturdays, Sundays and during the night (from 8 pm to 8 am) every day and for emergencies; the service is in operation all over the Italian territory.
On calling the telephone number of this service, the doctor on duty will give patients advice and make in‐office or in‐home examination if needed. After medical examination, he can prescribe medicines and /or suggest immediate hospital admission.
The aim of this study is to evaluate the prevalence of CVD and skin changes in patients who turn to Continuous Assistance Services due to the presence of disturbing symptoms of their condition.
Materials and methods
A retrospective, multicentre study was performed in the period between January 2014 and April 2015. The study was approved by the local research ethics committee, and was carried out in accordance with the principles set forth in the Declaration of Helsinki. All patients provided written informed consent before study participation.
Data regarding venous symptoms, history of venous diseases and treatments, and presence of varicose veins, oedema and skin trophic changes in the legs were evaluated by consulting the medical records available with three Continuous Assistance Services of Provincial Health Authority of Catanzaro, Italy, and Provincial Health Authority of Vibo Valentia, Italy.
Inclusion criteria were patients with CVD and venous symptoms.
Exclusion criteria were patients with different conditions than reported above.
According to literature 7, atrophie blanche (white atrophy) is defined as localised, often circular whitish and atrophic skin areas surrounded by dilated capillaries and sometimes hyperpigmentation; corona phlebectatica as fan‐shaped pattern of numerous small intradermal veins on medial or lateral aspects of ankle and foot: synonyms include malleolar flare and ankle flare; eczema as erythematous dermatitis, which may progress to blistering, weeping or scaling eruption of skin of leg; oedema as perceptible increase in volume of fluid in skin and subcutaneous tissue, characteristically indented with pressure. Venous oedema usually occurs in ankle region, but may extend to leg and foot; lipodermatosclerosis (LDS) is localised chronic inflammation and fibrosis of skin and subcutaneous tissues of the lower leg, sometimes associated with scarring or contracture of Achilles tendon; pigmentation is brownish darkening of skin, resulting from extravasated blood and usually occurs in ankle region, but may extend to leg and foot; reticular vein is dilated bluish subdermal vein, usually 1–3 mm in diameter and often tortuous; synonyms include blue veins, subdermal varices and venulectasies; telangiectasia is confluence of dilated intradermal venules less than 1 mm in caliber; synonyms include spider veins, hyphen webs and thread veins; varicose vein is subcutaneous dilated vein 3 mm in diameter or larger, measured in upright position; venous ulcer is full‐thickness defect of skin, most frequently in the ankle region.
History of previous venous thromboembolism events was recorded and special efforts were made to rule out superficial thrombophlebitis.
Results
Sample
A total of 1186 patients [739 females (62·31%) and 447 males (37·69%)] were considered for this study. Table 1 summarises the demographic characteristics of the sample. The mean age of the cohort was 56 years and 36·93% of patients were aged 65 years or more and the majority were women.
Table 1.
Demographics of enrolled patients
Characteristics | Enrolled patients |
---|---|
Females | 739 (62·31%) |
Males | 447 (37·69%) |
Age >65 years | 438 (36·93%) |
Any work activity | |
Yes | 485 (40·89%) |
No | 701 (59·11%) |
Acute myocardial infarction | 103 (8·68%) |
Acute cerebrovascular disease | 49 (4·13%) |
(Transient Ischemic Attack (TIA), cerebral stroke) | |
Acute urinary retention | 18 (1·52%) |
Acute muscle‐skeletal diseases | 96 (8·09%) |
Allergy asthma | 109 (9·19%) |
Chronic Obstructive Pulmonary Disease (COPD) | 57 (4·80%) |
Gastroesophageal reflux | 96 (8·09%) |
Atrial fibrillation | 44 (3·71%) |
Endocrine diseases | 41 (3·45%) |
Haemorrhoids | 66 (5·56%) |
Intestinal occlusion | 19 (1·60%) |
Acute abdominal pain | 71 (5·99%) |
Nephrolithiasis | 83 (7·00%) |
Pressure ulcers | 10 (0·84%) |
Arterial hypertensive crisis | 51 (4·30%) |
Acute skin wounds | 36 (3·03%) |
Epilepsy | 10 (0·84%) |
Acute gastrointestinal intoxication | 16 (1·35%) |
Shock | 21 (1·77%) |
Heart failure | 100 (8·43%) |
Airways obstruction | 11 (0·93%) |
Chronic venous disease | 79 (6·66%) |
Seventy‐nine of the aforementioned patients (6·66%) complained of sudden bothersome subjective symptoms to their legs, due to concomitant CVD, that prompted them to consult the emergency unit (Table 2).
Table 2.
Demographics of patients with venous symptoms turned to Continuous Assistance Service
Characteristics | Enrolled patients |
---|---|
Females | 45 (56·96%) |
Males | 34 (43·04%) |
Age >65 years | 31 (39·24%) |
Height (cm) | 163·4 ± 9·8 |
Weight (kg) | 74·5 ± 13·1 |
BMI | 28·3 ± 2·04 |
Health behaviours | |
Tobacco | 24 (30·38%) |
Alcohol | 11 (13·92%) |
Type of work or lifestyle | |
Sedentary | 55 (69·62%) |
Non‐sedentary | 24 (30·38%) |
Family history of venous pathology | |
Yes | 51 (64·56%) |
No | 28 (35·44%) |
Signs | |
No signs (only symptoms) | 3 (3·80%) |
All types of varicose veins | 63 (79·75%) |
Oedema | 31 (39·24%) |
Cutaneous changes without ulcer | 76 (96·20%) |
Active ulcer | 5 (6·33%) |
Symptoms | |
Pain | 72 (91·14%) |
Heaviness | 79 (100%) |
Swelling | 47 (59·49%) |
Cramps | 18 (22·78%) |
History of venous thrombosis | |
Deep vein thrombosis | 14 (17·72%) |
Superficial vein thrombosis | 23 (29·11%) |
Duration of CVI (years) | 13 ± 6·7 |
Doppler ultrasound evaluation | |
Yes | 24 (30·38%) |
No | 55 (69·62%) |
Therapeutic history | |
Venoactive drugs | 16 (20·25%) |
Elastic stockings | 13 (16·45%) |
Surgery | 21 (26·58%) |
Age range | 61·0 ± 12·4 |
Median age (years) | 56 |
CVI, chronic venous insufficiency.
About 30·38% of the population smoked, 69·62% had a sedentary lifestyle and 64·56% had a familial history of venous disorders. Most patients had symptoms such as pain, heaviness, swelling and cramps. The symptoms increased at the end of the day (63%), at night (44%), after several hours spent in an upright position (40%). The mean body mass index (BMI) was 28·3 ± 2·04.
The most frequent symptoms were heaviness in the legs (100%), pain (91·14%) and swelling (59·49%).
Only 24 patients (30·38%) received diagnosis of CVD through Doppler ultrasound examination, while 55 patients (69·62%) did not receive any instrumental diagnosis of CVD.
The proportion of patients with more severe disease (CVI, categories C4–C6) represented the majority and no significant differences between sexes were found; however, in categories C1–C3, a greater prevalence of the disease was observed in women (Table 3).
Table 3.
Distribution of patients according Clinical, Etiologic, Anatomic and Pathophysiologic classification (CEAP) classification
C1–C2 stages | C3 stage | C4–C6 stages | |||
---|---|---|---|---|---|
Sex | Sex | Sex | |||
Female | Male | Female | Male | Female | Male |
2 (2·53%) | 1 (1·26%) | 19 (24·05%) | 9 (11·39%) | 25 (31·64%) | 23 (29·11%) |
Patients with C1–C2 stages that required medical intervention for venous symptoms were three (3·79%). Patients with C3 stage that required medical intervention for venous symptoms were 28 (35·44%). Patients with C4–C6 stages that required medical intervention for venous symptoms were 48 (60·75%) (Table 3).
For C3 stage and for advanced stages of CVD (C4–C6), we observed a direct proportionality between the severity of the patient's symptoms and the time of the call (data not shown).
Discussion
Chronic venous disorders include numerous signs and symptoms 27 such as several types of varicose veins, vein‐related skin trophic changes, ranging from pigmented dermatitis to lipodermatosclerosis, white atrophy and leg ulcers; pitting ankle oedema; and symptoms attributable to venous dysfunction, such as aching, pain, congestion, skin irritation and muscle cramps, heaviness, tension, feelings of swelling and itching 28, 29, 30. Skin changes in CVI develop as a consequence of venous hypertension and limb oedema with symptoms of pain, limb heaviness and lifestyle limiting ambulation 31, 32. Evidences show that patients with CVI, especially those who had skin changes, require frequent visits to health care facilities; the condition causes a loss of productivity in the young (4·6 million work days per year are lost) and increased disability in the elderly and often requires the use of bulky and malodorous dressings and interventions (elastic dressing, venous ablation, ulcer debridement, skin grafting) resulting in recurrent hospitalisations 33, 34, 35.
The chronicity of this disease results in long‐term established costs, and the frequent recurrences further multiply the expenses 36. The economic and social burden of this condition is significant both for the affected individual and the health care system. In general, the increase in disease severity is associated with reductions in QoL 37, 38. Painful skin changes with their associated restrictions and social isolation result in a heavy psychosocial burden: psychosocial parameters include social isolation, depression, feelings of regret, loss of power and helplessness 38. Only few evidences examined the relationship between CEAP and QoL including some with apparently contradictory results, showing no differences in the QoL of patients with advanced stages of CVD 39, 40, 41, 42.
According to epidemiological features of recent literature 21, 32, 33, this study showed a direct correlation between the sedentary lifestyle and venous symptoms, especially in the evening and at night. Despite CVD being a very common disease, only 30·38% of the patients have undergone Doppler ultrasound evaluation.
The severe aspect of the present observational study was the finding that about 60·75% of patients with CVI in advanced stage (in particular, C4–C6) having skin changes have turned to Continuous Assistance Service. Despite CVI not being a disease that requires medical emergency/urgency intervention, we observed that the presence of skin changes has led to a more severe disease perception in patients. This aspect is probably due to the fact that patients often do not receive appropriate treatment nor are they aware of their disease, and at night, the supine position aggravates venous return 30, 38, 40.
Results of this study confirm the need for a better understanding of the pathophysiology and natural history of CVI in order to optimise public resources for comprehensive and proper management of one of the most common and widespread diseases.
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