Christine J. Evans

Epidemiology of chronic venous disease

Abstract Chronic venous disease of the legs occurs commonly in the general population in the Western world. Estimates of the prevalence of varicose veins vary widely from 2–56% in men and from 1–60% in women. These variations reflect differences in variability of study populations including age, race and gender, methods of measurement and disease definition. Definitions of chronic venous disease may rely on reports of varicose veins by study participants, based on self-diagnosis or recall of a diagnosis, or on a standardized physical examination. Venous ulceration is less common, affecting approximately 0.3% of the adult population. Age and pregnancy have been established as risk factors for developing varicose veins. Evidence on other risk factors for venous disease is inconclusive. Prolonged standing has been proposed, but results of studies should be interpreted with caution given the difficulty in measuring levels of posture. Obesity has been suggested as a risk factor in women, but appears to be an aggravating factor rather than a primary cause. Other postulated risk factors include dietary intake and smoking, but evidence is lacking. Longitudinal studies using standardized methods of evaluation are required before the true incidence of chronic venous disease and associated risk factors can be determined.

Fiber intake, constipation, and risk of varicose veins in the general population: Edinburgh Vein Study

The purpose of the present study was to determine the relationship between fiber intake, constipation, and clinical venous disease in the general population. The Edinburgh Vein Study was comprised of 1566 men and women aged 18-64 years who were selected at random from the age-sex registers of 12 general practices. Fiber intake, intestinal transit time, defecation frequency and the prevalence of straining at stool were all found to be significantly different between the sexes. Men who reported that they strained to start passing a motion showed a higher prevalence of mild and severe trunk varices compared to men who did not strain. After adjustment for social class, BMI and mobility at work, this group of men showed a significantly elevated risk of having severe trunk varices (OR 2.76, 95% CI 1.16, 6.58). In contrast, no consistent relationships were seen among women. Overall, within this Western general population, an association between dietary fiber, constipation and the presence or severity of varicose veins was not supported.

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.

Pregnancy, Oral Contraception, Hormone Replacement Therapy and the Occurrence of Varicose Veins: Edinburgh Vein Study

Objective: To determine the relationship between varicose veins and duration of menstrual life, age of menopause, pregnancy, oral contraceptive use and hormone replacement therapy (HRT). Design: Cross-sectional study. Setting: City of Edinburgh, UK. Participants: Eight hundred and sixty-seven women aged 18–64 years randomly selected from 12 general practices. Methods: After completing a questionnaire, which included questions on reproductive history, the women underwent a comprehensive clinical examination including the assessment of varicose veins (trunk, hyphenweb and reticular varices), followed by duplex scanning of their legs. Results: Women who had been pregnant at least once were more likely to have minor hyphenweb or reticular varices than women who had never been pregnant (p ≤ 0.05). Women aged 35–54 years who were current users or ex-users of the oral contraceptive pill had a lower prevalence of trunk varicose veins than women who had never taken the pill (p ≤ 0.10). HRT was also associated with a lower prevalence of trunk varices (p ≤ 0.05). Conclusions: These results suggest that alterations in the balance of the sex hormones may have a role in the aetiology of varicose veins.

Original articleFiber intake, constipation, and risk of varicose veins in the general population: Edinburgh Vein Study

The purpose of the present study was to determine the relationship between fiber intake, constipation, and clinical venous disease in the general population. The Edinburgh Vein Study was comprised of 1566 men and women aged 18-64 years who were selected at random from the age-sex registers of 12 general practices. Fiber intake, intestinal transit time, defecation frequency and the prevalence of straining at stool were all found to be significantly different between the sexes. Men who reported that they strained to start passing a motion showed a higher prevalence of mild and severe trunk varices compared to men who did not strain. After adjustment for social class, BMI and mobility at work, this group of men showed a significantly elevated risk of having severe trunk varices (OR 2.76, 95% CI 1.16, 6.58). In contrast, no consistent relationships were seen among women. Overall, within this Western general population, an association between dietary fiber, constipation and the presence or severity of varicose veins was not supported.

Telangiectasia and venous reflux in the Edinburgh Vein Study.

Objective The purpose of this study was to correlate the clinical findings in the Edinburgh Vein Study with the results of duplex scanning of the deep and superficial venous systems. Methods An age-stratified random sample of 1566 people (699 men and 867 women) aged 16–64 were selected from computerized age–sex registers of participating practices (twelve general practices with catchment areas geographically and socioeconomically distributed throughout Edinburgh). Screening included clinical examination, photography and duplex ultrasonography of the superficial veins and the deep veins down to popliteal level. Telangiectasia and varicose veins were graded 1–3 according to severity. Results Since there was good agreement between the duplex findings of the right versus left legs, the current analyses are based on 1092 subjects (486 men and 606 women) with complete duplex scan data in their left legs. There was no significant trend of increasing incompetence in either the deep veins only (P = 0.214) or in the combined deep and superficial veins (P = 0.111) with increasing severity of the telangiectasia. There was a statistically significant trend for increasing incompetence in (a) the superficial veins (P = 0.006) and (b) either the superficial or deep veins (P < 0.001) to be associated with advancing grade of telangiectasia. When stratified by gender, significant trends were maintained for male superficial vein incompetence and for either superficial or deep incompetence in both genders. Examination of incompetence in individual venous segments showed that increasing severity of telangiectasia was significantly associated with an increasing proportion of reflux in the upper and lower great saphenous and femoral vein segments. There was no significant association between small saphenous incompetence and increasing grade of telangiectasia. Conclusion There is a significant, but not wholly consistent, association between grade of telangiectasia and reflux in both the deep and superficial systems. This association does not apply to the small saphenous system.