Progression of varicose veins and chronic venous insufficiency in the general population in the Edinburgh Vein Study.

OBJECTIVE: The natural history in the general population of chronic venous disease in the legs is not well understood. This has limited our ability to predict which patients will deteriorate and to assign clinical priorities. The aims of this study were to describe the progression of trunk varicose veins and chronic venous insufficiency (CVI) in the general population, to identify important lifestyle and clinical prognostic factors, and to determine the relationship between venous reflux and progression. METHODS: The Edinburgh Vein Study is a population-based cohort study in which randomly selected adults aged 18 to 64 years had an examination at baseline. This included a questionnaire on lifestyle and clinical factors, standardized assessment and classification of venous disease in the legs, and duplex scan to detect venous reflux in eight segments of each leg. A follow-up examination 13 years later included a reclassification of venous disease to ascertain progression in the development or increase in severity of varicose veins and CVI. RESULTS: Among 1566 adults seen at baseline, 880 had a follow-up examination, of whom 334 had trunk varicose veins or CVI at baseline and composed the study sample. The mean (standard deviation) duration of follow-up was 13.4 (0.4) years. Progression was found in 193 (57.8%), equivalent to 4.3% (95% confidence interval [CI], 3.7-4.9) annually. In 270 subjects with only varicose veins at baseline, 86 (31.9%) developed CVI, with the rate increasing consistently with age (P = .04). Almost all subjects (98%) with both varicose veins and CVI at baseline deteriorated. Progression of chronic venous disease did not differ by gender or leg, but a family history of varicose veins and history of deep venous thrombosis increased risk (odds ratio [OR], 1.85 [95% CI, 1.14-1.30] and 4.10 [95% CI, 1.07-15.71], respectively). Overweight was associated with increased risk of CVI in those with varicose veins (OR, 1.85; 95% CI, 1.10-3.12). Reflux in the superficial system increased the likelihood of progression, especially in combination with deep reflux (OR, 2.57; 95% CI, 1.55-4.25) and when located in the small saphenous vein (OR, 4.73; 95% CI, 1.37-16.39). CONCLUSIONS: Nearly half of the general population with chronic venous disease deteriorated during 13 years, and almost one third with varicose veins developed skin changes of CVI, increasing their risk of ulceration. Age, family history of varicose veins, history of deep venous thrombosis, overweight, and superficial reflux, especially in the small saphenous vein and with deep reflux, might influence the risk of progression.

Incidence of chronic venous disease in the Edinburgh Vein Study.

BACKGROUND: Epidemiologic research in chronic venous disease has focused on prevalence and associated risk factors. Evidence on the risks and incidence that this condition will develop is limited. The aim of this study was to measure the incidence of new varicose veins and chronic venous insufficiency (CVI) in an adult population and to investigate risk factors associated with the development of these conditions. METHODS: The Edinburgh Vein Study is a cohort study of a random sample of the general population. Invitations were sent to 1456 men and women at baseline to participate in a 13-year follow-up examination. Each participant completed a questionnaire on lifestyle and medical history and underwent an examination that included clinical classification of venous disease. RESULTS: After a mean follow-up of 13.4 (standard deviation, 0.4) years, 880 of 1456 individuals participated (60.4% response). The overall incidence (95% confidence interval [CI]) of C2 varicose veins was 18.2% (15.2%-21.6%), giving an annual incidence rate of 1.4% (1.1%-1.7%), with incidence rates similar in men and women: the 13-year age-adjusted incidence of varicose veins was 15.2% (10.4%-20.0%) in men and 17.4% (13.1%-21.7%) in women (P = .97). The 13-year incidence of varicose veins increased consistently with age from 9.8% in those aged 18 to 34 years to 25.7% in those aged 55 to 64 years (P < .001). The 13-year incidence (95% CI) of CVI was 9.2% (7.0%-11.9%), and the annual incidence rate was 0.7% (0.5%-0.9%). The incidence of CVI was similar in men and women and increased consistently with age (P < .001). Participants with a family history of venous disease were more likely to develop C2 varicose veins (odds ratio, 1.75; 95% CI, 1.12-2.71). Obesity was associated with the development of CVI: the 13-year incidence (95% CI) was 6.1% (3.7%-9.6%) in those who were of normal weight and 23.6% (14.2%-37.0%) in obese participants, with an age-adjusted odds ratio of 3.58 (1.70-7.56). CONCLUSIONS: The Edinburgh Vein Study is one of a few cohort studies to report the incidence of varicose veins and CVI in the general population. The incidence of varicose veins and CVI did not differ significantly by sex and was strongly associated with increasing age. The risk of developing varicose veins was increased in those with a family history, and the risk of CVI was increased in those with higher body mass index.

Acquisition of 3-D arterial geometries and integration with computational fluid dynamics.

A system for acquisition of 3-D arterial ultrasound geometries and integration with computational fluid dynamics (CFD) is described. The 3-D ultrasound is based on freehand B-mode imaging with positional information obtained using an optical tracking system. A processing chain was established, allowing acquisition of cardiac-gated 3-D data and segmentation of arterial geometries using a manual method and a semi-automated method, 3D meshing and CFD. The use of CFD allowed visualization of flow streamlines, 2-D velocity contours and 3-D wall shear stress. Three-dimensional positional accuracy was 0.17-1.8mm, precision was 0.06-0.47mm and volume accuracy was 4.4-15%. Patients with disease and volunteers were scanned, with data collection from one or more of the carotid bifurcation, femoral bifurcation and abdominal aorta. An initial comparison between a manual segmentation method and a semi-automated method suggested some advantages to the semi-automated method, including reduced operator time and the production of smooth surfaces suitable for CFD, but at the expense of over-smoothing in the diseased region. There were considerable difficulties with artefacts and poor image quality, resulting in 3-D geometry data that was unsuitable for CFD. These artefacts were exacerbated in disease, which may mean that future effort, in the integration of 3-D arterial geometry and CFD for clinical use, may best be served using alternative 3-D imaging modalities such as magnetic resonance imaging and computed tomography.

Risk factors for chronic ulceration in patients with varicose veins: a case control study.

BACKGROUND/OBJECTIVE: Identifying which patients with varicose veins are at risk of progressing to more severe forms of chronic venous disease could help in assigning clinical priorities and targeting appropriate treatments. The aim of this study was to determine, in subjects with varicose veins, the characteristics of venous disease and other factors associated with an increased risk of ulceration. METHODS: One hundred twenty subjects with varicose veins and an open or healed venous leg ulcer were compared with 120 controls with varicose veins and no history of venous ulcer on this case control study. Subjects were recruited from hospital settings and primary care. Each subject completed a questionnaire on lifestyle and medical history and underwent an examination comprising of clinical classification of venous disease (CEAP), duplex scanning, quantitative digital photoplethysmography, and measurement of dorsiflexion. Multiple logistic regression analyses and calculation of receiver operating characteristic (ROC) curves were performed to identify the combination of factors which most accurately predicted which patients with varicose veins will develop leg ulcers. RESULTS: An increased risk of ulceration was associated with the severity of clinical venous disease, especially with the presence of skin changes (P < .0001). Other significant risk factors included history of deep vein thrombosis (DVT) (P = .001), higher body mass index (BMI) (P = .006), smoking (P = .009), and reflux in the deep veins (P = .0001). Ulceration was associated with reduced volume of blood displaced as reflected by photoplethysmography and a limited range of ankle movement (not wholly due to the effects of an active ulcer) (both P < .05). Multivariate analyses showed that skin changes including lipodermatosclerosis (odds ratio [OR] 8.90, 95% confidence interval [CI] 1.44-54.8), corona phlebectatica (OR 4.52, 95% CI 1.81-11.3) and eczema (OR 2.87, 95% CI 1.12-7.07), higher BMI (OR 1.08, 95% CI 1.01-1.15), and popliteal vein reflux (OR 2.82, 95% CI 1.03-7.75) remained independently associated with increased risk of ulceration while good dorsiflexion of the ankle (OR 0.88, 95% CI 0.81-0.97) and an effective calf muscle pump (OR 0.96, 95% CI 0.92-0.99) remained protective factors. ROC curve analyses indicated that a model based on clinical observation of skin changes, duplex scanning for popliteal reflux, and calf muscle pump tests would be the most accurate in determining which patients with varicose veins develop leg ulcers. CONCLUSIONS: The results of this study confirm that, in patients with varicose veins, those with skin changes of chronic venous insufficiency and deep vein incompetence are at greatly increased risk of ulceration. However, the risks may also be increased in those who smoke, are obese, and have restricted ankle movement and reduced calf muscle pump power.

Accelerating the transit time of barium sulphate suspensions in small bowel examinations.

PURPOSE: To determine whether hyperosmolar and effervescent agents proven individually to accelerate transit time in the barium small bowel examination have an additive effect when combined, surpassing that of either agent alone. MATERIALS AND METHODS: One hundred and forty-nine patients were randomised to four groups. Three hundred milliliters of barium sulphate alone was given to the first group. Fifteen milliliters of iodinated hyperosmolar contrast agent (Gastrografin, meglumine/sodium diatrizoate, Schering) was given in addition to barium sulphate to the second group while six packets of effervescent granules (Carbex, Ferring) were added for the third group. The final group was given a combination of both additives and barium sulphate. The time taken following ingestion for the contrast column to reach the caecum, as assessed by frequent interval fluoroscopy, was recorded. A subgroup of 32 patients were selected randomly from the four groups, 8 from each and assessed for quality of examination. Statistical assessments were made using Kruskal-Wallis and Mann-Whitney tests. RESULTS: One hundred and nineteen patients were analysed after exclusions. The addition of accelerant to barium sulphate, both individually and in combination significantly reduced the small bowel transit time (p<0.001). No significant difference existed between the additives when used with barium alone. The combined group had significantly faster transit times compared to the hyperosmolar group (p=0.02). Differences between combined and effervescent groups tended towards significance (p=0.09). No significant difference existed between groups when examination quality was assessed. CONCLUSION: These results suggest that the addition of combined effervescent and hyperosmolar agents to the barium suspension may significantly shorten the small bowel transit time without adversely affecting examination quality. This has implications for patient acceptability of the examination as well as potentially reducing screening time and therefore radiation dose.

Lifestyle factors and the risk of varicose veins: Edinburgh Vein Study.

The objective of this study was to determine the inter-relationships between a range of lifestyle factors and risk of varicose veins to identify which factors may be implicated in the etiology. An age-stratified random sample of 1566 subjects (699 men and 867 women) aged 18 to 64 years was selected from 12 general practices throughout Edinburgh. A detailed self-administered questionnaire was completed, and a comprehensive physical examination determined the presence and severity of varicose veins. The slightly higher age-adjusted prevalence of varicose veins in men than in women (39.7% versus 32.2%) was not explained by adjustment for an extensive range of lifestyle risk factors (male odds ratio [OR] 2.11, 95% confidence interval [CI] 1.51-2.96). In both sexes, increasing height showed a significant relationship with varicose veins (male OR 1.50, 95% CI 1.18-1.93 and female OR 1.26, 95% CI 1.01-1.58). Among women, body mass index was associated with an increased risk of varicose veins (OR 1.26, 95% CI 1.02-1.54). The current study casts doubt as to whether varicose veins occur predominantly in women. In addition, no consistent relationship with any lifestyle factor was shown. Self-reported evidence suggested a familial susceptibility, thereby warranting future genetic studies.

Patient, operative, and surgeon factors that influence the effect of superficial venous surgery on disease-specific quality of life.

BACKGROUND AND OBJECTIVE: Superficial venous surgery for CEAP 2 disease leads to an improvement in disease-specific quality of life (QoL) in the short term. However, which factors influence the magnitude of this improvement, how surgery affects QoL in patients with CEAP 4 to 6 disease, and whether this improvement is durable are not known. The objective of this study was to identify patient, operative, and surgeon factors that might influence the change in disease-specific QoL in the 2 years after superficial venous surgery. METHODS: This prospective study was comprised of 203 unselected, consecutive patients with CEAP 2 to 6 disease who underwent saphenous with or without subfascial endoscopic perforator surgery and who completed the Aberdeen Varicose Vein Symptoms Severity Score (AVVSSS) before surgery and at 4 weeks, 6 months, and 2 years after surgery. Univariate and multivariate analyses were performed. RESULTS: At baseline, recurrent and ulcer (CEAP 5 and 6) diseases were associated with a higher (worse) AVVSSS. Surgery was associated with a significant improvement in median (interquartile range [IQR]) AVVSSS: baseline, 17.8 (11.8 to 27.2); 4 weeks, 13.8 (7.9 to 21.3); 6 months, 9.6 (4.2 to 15.8); and 2 years, 8.1 (4.0 to 14.7). One hundred seventy-five patients (86%) at 6 months and 177 patients (87%) at 2 years reported an improvement in AVVSSS. Postoperative AVVSSS at both 6 months and 2 years was most significantly influenced by preoperative score (P <.0001). After adjustment for baseline AVVSSS, the following factors were identified in multivariate analysis as having a significant and independent positive (+) or negative (-) impact on AVVSSS: at 6 months, (-) recurrent disease (P =.009), (-) CEAP 4 disease (P =.026); and at 2 years, (+) long saphenous surgery (P =.02), (-) CEAP 5 disease (P =.030). CONCLUSION: In this unselected series, saphenous surgery with or without subfascial endoscopic perforator surgery led to an improvement in disease-specific QoL in 87% of patients out to 2 years. Although univariate analysis results suggested that many baseline factors might be associated with outcome, multivariate analysis results suggested that only surgery for recurrent disease and for CEAP 4/5 disease remained as significant negative, and only long saphenous surgery as significant positive, independent prognostic factors. These data provide evidence of the medium-term clinical effectiveness of venous surgery across the full spectrum of CEAP clinical grades, show the importance of multivariate analysis, and reemphasize the importance of minimization of recurrence.

Chronic venous insufficiency: clinical and duplex correlations. The Edinburgh Vein Study of venous disorders in the general population.

OBJECTIVE: The objective of this study was to determine the prevalence of chronic venous insufficiency (CVI) in the general population and to correlate its clinical features with sonographically proven venous reflux. DESIGN OF STUDY: The study design was a cross-sectional survey of the general population. SUBJECTS AND METHOD: Ambulatory men and women, aged 18-64 years, were selected randomly from 12 general practices. Subjects were examined for CVI. Eight segments of the deep and superficial veins were assessed for reflux by means of duplex scanning. RESULTS: A total of 1566 subjects were screened (867 women, mean age 44.8 years; 699 men, mean age 45.8 years) of whom 124 were diagnosed as having CVI: 95, grade 1; 19, grade 2; and 10, grade 3. The age-adjusted prevalence for the whole population was 9.4% in men and 6.6% in women. Prevalence of CVI correlated closely with age and sex, being 21.2% in men >50 years and 12.0% in women >50 years. Heaviness and tension, and a feeling of swelling, aching, and itching, were significantly associated with worsening grade of CVI. CVI was significantly associated with reflux in all deep and superficial segments. The frequency of reflux in both superficial and deep segments increased with the clinical severity of disease. In 30.8% of subjects with CVI in the left leg, reflux was limited to the superficial system. CONCLUSIONS: The prevalence of CVI rises steeply with age. There is a strong correlation between venous symptoms and the presence and severity of CVI. CVI is associated in approximately one third of the subjects with incompetence limited to the superficial system and in these a good therapeutic outcome could be expected from surgery to the superficial veins. The severity of clinical features, including Basle CVI grade 1, correlates significantly with prevalence of valvular reflux in the deep and superficial systems. If leg ulcers are to be prevented by timely intervention, a better understanding of the natural history of the association between presenting features and disordered hemodynamics is required.

The prevalence of thrombophilia in patients with chronic venous leg ulceration.

BACKGROUND: Thrombophilia is increasingly recognized as a risk factor for deep venous thrombosis (DVT), which in turn is a major risk factor for chronic venous ulceration (CVU). However, the relationship between thrombophilia and CVU remains unknown. The aim of this study was to define the prevalence of thrombophilia in patients with CVU and to determine whether this is associated with a history or duplex scan evidence of DVT. METHODS: Eighty-eight patients with CVU were prospectively studied. The patients underwent clinical assessment and duplex ultrasound scanning. Blood was drawn for antithrombin, proteins C and S, activated protein C resistance, factor V Leiden, prothrombin 20210A, lupus anticoagulant, and anticardiolipin antibodies. RESULTS: The study included 35 men with a median age of 61 years (interquartile range, 45 to 72 years) and 53 women with a median age of 76 years (interquartile range, 69 to 82 years). Thirty-six percent of the patients had either a history or duplex scan evidence suggestive of previous DVT. The following abnormalities were detected: four, five, and six cases of antithrombin, protein C, and protein S deficiencies, respectively; 14 cases of activated protein C resistance; 11 cases of factor V Leiden mutation; three cases of prothrombin 20210A mutation; eight cases of lupus anticoagulant; and 12 cases of anticardiolipin antibodies. Thrombophilia was not significantly related to previous DVT, deep reflux, or disease severity. CONCLUSION: Patients with CVU have a 41% prevalence rate of thrombophilia. This rate is two to 30 times higher than the rate of the general population but is similar to that reported for patients with previous DVT. However, in patients with CVU, thrombophilia does not appear to be related to a history of DVT, a pattern of reflux, or severity of disease. Many patients with CVU may have unsuspected postthrombotic disease.

A comparison of computerised tomography, laparoscopic ultrasound and endoscopic ultrasound in the preoperative staging of oesophago-gastric carcinoma.

INTRODUCTION AND OBJECTIVE: Oesophago-gastric carcinoma is associated with a poor prognosis despite advances in diagnosis and treatment. Accurate preoperative staging of gastro-oesophageal carcinoma is, therefore, essential in order to determine patient selection for potentially curative resection. The aim of this study was to evaluate and compare the role of computerised tomography (CT), laparoscopic ultrasound (LapUS) and endoscopic ultrasound (EUS) in the staging of oesophago-gastric carcinoma. METHODS AND PATIENTS: Thirty-six patients with histologically proven carcinoma of the oesophagus or stomach who were considered fit for surgical resection were identified from a prospectively collected database. All patients underwent spiral CT, LapUS and EUS as part of their preoperative staging investigations. RESULTS from the staging modalities were compared retrospectively with final histopathology where available and to intraoperative findings where the tumour was irresectable. RESULTS: Locally advanced tumours (T3/T4) were accurately identified by CT in 15/16 (94%) and by EUS in 14/16 (88%). LapUS was unable to detect 11 tumours (of which five were T3/T4) because they were above the diaphragm, but in the locally advanced cases where the tumour could be seen the accuracy was 10/12 (83%). EUS was the best modality for assessing early tumours and locoregional nodal involvement with accuracies of 8/13 (62%) and 21/29 (72%), respectively. EUS accuracies rose to 64, 92 and 83% for T1/T2, T3/T4 and N staging with the exclusion of those patients (n=6) in whom strictures prevented full assessment. LapUS had a specificity of 100%, compared to 90% for CT and was more accurate than CT for assessing distant metastases (accuracy of 26/32 (81%) compared to 23/32 (72%) for CT). CONCLUSIONS: Although this study is small it has confirmed that CT, EUS and LapUS act in a complimentary manner to provide the most complete preoperative staging for patients with oesophago-gastric cancer.