Chronic venous disease: a disease whose severity is underestimated


Head, Department of Vascular Surgery, Nizam’s Institute of Medical Sciences, Panjagutta Hyderabad, India

Address for correspondence: Professor Pinjala Ramakrishna, Head, Department of Vascular Surgery, Nizam’s Institute of Medical Sciences, Panjagutta, Hyderabad 500 082, India



Chronic venous disease (CVD) is an umbrella term that comprises wide varieties of clinical manifestations such as varicose veins, venous ulcers, edema, venous eczema, telangiectasia, hyperpigmentation of the skin, atrophie blanche and lipodermatoslerosis.1,2
It is mostly individuals involved in occupations requiring long periods of standing that are affected with CVD.3 In order to eliminate the ambiguity in the diagnosis of CVD and to establish a valid and reliable methodology for such diagnosis across the world, the CEAP (clinicaletiology-anatomy-physiology) classification system was developed and subsequently revised by the American Venous Forum.4 According to this classification, CVD is identified on the basis of various features, including clinical symptoms (C, graded as C0–C6, see Figure 1), etiologic factors (E), anatomical features (A), and pathophysiological events (P). The CVD stages C3 and above are considered to be chronic venous insufficiency (CVI).

Prevalence of CVD

Incidence of CVD has been comprehensively determined by the Vein Consult Program through a meticulously designed approach using the CEAP classification system and involving 6232 general practitioners from 20 countries across five geographical regions of the world.5 Of the 91 545 subjects analyzed in the study, prevalence of CVD (clinical symptoms C1–C6) was determined to be 63.9%. Figure 2 depicts prevalence rates by class, as observed in that study.5 However, studies evaluating the incidence of CVD in India are limited. An epidemiological survey carried out way back in 1972 on Indian railroad workers determined the prevalence of varicose veins to be 25% in South India and 6.8% in North India.6

Quality of life and CVD

An individual’s quality of life (QOL) is largely influenced by CVD. Several independent studies from different countries on diverse subjects have unequivocally established that CVD drastically reduces the QOL of an individual.7,8,9,10 In a prospective observation study on Indian patients, QOL was approximately 50% at baseline and improved significantly (P<0.001) after treatment with micronized purified flavonoid fraction.11 Furthermore, data suggests that the higher the degree of CVD the lower the QOL.

Morbidities associated with CVD

Associations between CVD and various other morbidities have been shown in different studies. A significantly elevated prevalence of CVD was observed with various cardiovascular risk factors, as well as diabetic neuropathic foot.12,13,14,15 Furthermore, emphysema/chronic obstructive pulmonary disease and skeletal/joint diseases were also frequently found with venous disorders.15 Rarely, chronic venous ulcers could develop into potentially life threatening Marjolin’s ulcer.16 Apart from this, venous endothelial cells isolated from CVD patients strongly express various proinflammatory markers, which might contribute to systemic inflammation in CVD patients.17 Psychosocial disorders such as anxiety and depression are frequently observed in CVD patients.18

Figure 1. Pinjala CVD

Figure 1. Grading of chronic venous disease according to the CEAP classification system. Abbreviation: CEAP, classification system stratifying patients according to severity of disease presentation (C, clinical; E, etiology; A, anatomy; P, physiology).


Economic burden due to CVD

High prevalence, cost of investigation and treatment, and loss of working days due to CVD have a significant socioeconomic impact, and the problem is compounded because CVI is progressive and has a propensity to recur.19 The economic burden of CVD treatment is attributed to direct costs, such as medical and nursing costs and costs of investigation and treatment, and indirect costs, such as those related to loss of working days.20 Several studies carried out in different countries have shown that CVD incurs a significant economic burden.21,22,23,24,25,26

Pinjala Fig 2 CVD

Figure 2. Prevalence of chronic venous disease across the world according to CEAP clinical class.
Abbreviation: CEAP, classification system stratifying patients according to severity of disease presentation (C, clinical; E, etiology; A, anatomy; P, physiology). After reference 5: Rabe et al. Int Angiol. 2012;31(2):105-115. © 2012, Edizioni Minerva Medica.



CVD is one of the most common vascular disorders observed across the world and can severely impact QOL, reduce patients’ working hours, and impose a socioeconomic burden. Moreover, the Bonn Vein study reveals that the progression rates of CVD from lower to higher grades increases with time (in a span of 6.6 years, the prevalence for varicose veins rose from 22.7% to 25.1%, and CVD increased from 14.5% to 16%).27 Despite the increased disease burden with prolonged duration, a high level of acceptance prevails among patients suffering with venous disorders, and both patients and physicians often trivialize the presence and severity of CVD.28
Nonetheless, despite the capability of CVD to cause grave consequences, it remains one of the prominently underestimated and neglected diseases. Knowing CVD’s potent disruptive nature, it is paramount to give it serious consideration and to define proper measures to prevent and/or manage it.



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