In your clinical practice, what makes you initiate the management of chronic venous disease: signs or symptoms?



1. L. M. CHERNUKHA, Ukraine
2. A. S. GAWEESH Egypt
3. A. HATRI, R. GUERMAZ Algeria
4. E. KOLOSSVARY Hungary
5. D. PRATAMA Indonesia
6. S. TZANEVAAustria
7. I. A. ZOLOTUKHIN Russian Federation
8. M. ZUMMO Canada
 
 

Larysa Mikhaylovna CHERNUKHA, MD, PhD


Professor, Main Research Fellow of Main Vessels Surgery Department O. Shalimov National Institute of Surgery and Transplantology of the National Academy of Medical Sciences of Ukraine, Vice President, Association of Vascular Surgeons, Phlebologists, Angiologists of Ukraine

Address for correspondence: Larysa Mikhaylovna CHERNUKHA, MD, PhD, 53-a Vasylkivska str.ap.21, 02000, Kyiv, UKRAINE (email: vasc.phlebo@gmail.com)

 
Whether it’s the signs or symptoms of chronic venous disease (CVD) that lead me to initiate treatment can be considered from a philosophical viewpoint. Developement of CVD in lower limbs (LL) is a consequence of pathological venous hypertension. Macrohemodynamic changes associated with valvular failure in the superficial (deep) veins initiate a cascade of inflammatory reactions. The inflammation, initiated by venous hypertension, is a key moment in the prolongation of the development of pathological processes; clinically, it is manifested by CVD symptoms and signs.1
 
Patients with initial symptoms, indicating the development of a disease, do not always consult a doctor; very often, patients ignore this “symptomatic” stage. In most cases, the patients that consult doctors have already developed external disease signs, the progression of which may overshadow the symptoms or make them seem less obvious.
 
If we look past the general “philosophy” and consider a specific clinical condition that is pathognomonic for CVD (especially the most common nosology—varicose vein deformation of primary etiology), we must first focus on the definition of “symptoms and signs.” A misunderstanding of this terminology is the basis for the subsequent misunderstanding not only between the patient and the doctor, but also between doctors themselves.2 Second, we need to assess the patient’s clinical status and complaints, knowing it is often difficult for patients to find the right words for their interpretation.3
 
The fact is despite the high prevalence and frequency of occurrence, more than 75% of adults present characteristic venous symptoms3 that are not always caused by CVDs of the LL (monopathognomonic), but can be “mixed,” and can be initiated by concomitant diseases (comorbidities such as musculoskeletal diseases). Doctors often see patients who have typical CVD signs but do not have symptoms or simply do not recognize them. It can be assumed that the stage of expressed symptoms was missed (eg, with the development of varicose veins, at the stage of venous wall stretching, the “activity” of nociceptors—which react intensively to the venous wall stretching at the initial stages of disease—is lost).4
 
In turn, studies show that 19% of patients (every fifth patient!) at the C0s stage have a severe pain syndrome with no clinical signs. Again, it’s important that the link between symptoms and their onset together with CVD of the LL is made at the early stages of disease development. At that point, there are no CVD signs, and the symptoms can be more pronounced than with “severe” CVD of the LL.
 
Ideally, we should not wait for signs of CVD of the LL to manifest before treatment is begun; treatment should begin as soon as symptoms appear. However, patients do not always come for treatment at the preclinical stage, without signs of disease. Sometimes, it is the doctors that do not pay proper attention to patients without signs of disease, thinking “nothing to operate on; therefore, nothing to treat.”
 
Discussion with the patient, consideration of clinical and instrumental examination findings, and, necessarily, active medical thinking are key to achieving a correct diagnosis and determining correct treatment approaches; at the appearance of initial symptoms, pathogenetically based treatment can slow down or prevent the development of the disease, even more so its severe forms.
 
Treatment regimens in CVD should be based on venoactive drugs, such as micronized purified flavonoid fraction, with higher levels of guideline recommendation.5,6 This includes the earliest stage of CVD, where there are no visible or palpable signs (C0s). Treatment to inhibit inflammation and improve venous hypertension may offer the greatest opportunity to prevent CVD progression and related complications.
 
The key importance of symptoms is undeniable—one should not wait for signs to appear. It is necessary to prescribe patho-genetic treatment!

 

References

    1. Labropoulos N. Location of venous reflux in primary chronic venous disease and correlation with clinical severity: a review. Medicographia. 2016;38(2):148-154.

    2. Perrin MR. Description and definition of venous symptoms in chronic venous disorders: a review. Medicographia. 2015;37(1):10-15.

    3. Eklöf B. Venous pain: more than ever a topic of research. 2015;37(1):122:3-5.

    4. Pascarella L. Daflon and the protection of venous valves. Phlebolymphology.
    2016;23(1):20-30.

    5. Eklöf B, Rutherford RB, Bergan JJ, et al; American Venous Forum International Ad Hoc Committee for Revision of the CEAP Classification. Revision of the CEAP classification for chronic venous disorders: consensus statement. J Vasc Surg. 2004;40(6):1248-1252.

    6. Nicolaides A, Perrin M. The updated guidelines held in Cyprus on ‘The management of chronic venous disorders of the lower limbs’ and the place of venoactive drugs. Int Angiol. 2013;32(suppl 1):106-107.

 
 
 

Ahmed Sherief GAWEESH, MD, MSc, PhD


Consultant Vascular Surgeon, Director, iVein Clinic Co., Lecturer in Vascular Surgery & Endovascular Unit, Alexandria University

Address for correspondence: Ahmed Sherief GAWEESH, MD, MSc, PhD, iVein Clinic, 4th Floor, 8 Kolleyet el Tebb Street , El Raml Station, Alexandria, EGYPT (email: agaweesh@gmail.com)

 
Chronic venous disease (CVD) is the most common vascular pathology seen during the daily practice of vascular surgeons. It encompasses a wide spectrum manifestations, including symptoms that can sometimes be incapacitating, usually resulting from dysfunctional drainage of blood from the lower limbs. Left untreated, it can be a progressive disease, which can also become complicated (bleeding, thrombosis, or ulceration), affecting the patient’s quality of life. So every vascular surgeon nowadays is aware that CVD is much more than just a cosmetic concern.
 
A variety of treatment options are currently available, including noninterventional treatment in the form of compression stockings and venoactive drugs; interventional procedures in the form of sclerotherapy for spider or reticular veins; reflux ablation by laser, radiofrequency, or glue; and deep venous reconstructions by endovenous stenting, surgical endophlebectomy, or bypass. Choosing the proper modality for treatment in modern practice should be tailored following careful analysis of each patient’s history, clinical presentation, and after investigating the underlying pathophysiologic cause(s).
 
The question remains, however, whether we should base our decision to treat patients solely on the presence of signs, ie, “what we see,” or according to a patient’s symptoms, ie, “how the patient feels.” The fact that some patients with early varicose veins remain asymptomatic should not withhold us from investigating patients for any underlying pathophysiologic abnormality. There is no evidence that asymptomatic CVD cannot become complicated. Besides, CVD has been shown to develop and progress in about half of unilateral-treated CVD patients in their contralateral previously asymptomatic limbs in 5 years.1 Although the natural history of CVD progression has not yet been clearly established, it is estimated to be somewhere between 3.5% and 7% per annum.2 Furthermore, symptoms related to venous insufficiency can be present in nearly a fifth of the screened population in epidemiological studies denoted as C0s, even in the absence of any signs of CVD.3 This subgroup of patients can benefit from venoactive drugs, eg, flavonoids, which can be quite effective in improving symptoms of uncomplicated CVD and improve the quality of life of treated patients. Although their role in preventing complications or progression of disease remains to be explored, flavonoids have also been shown to promote venous leg ulcer healing.
 
In conclusion, CVD is a disease with variable patterns of presentation, can progress, and can become complicated. The decision to initiate management should be taken once CVD is diagnosed, regardless of whether patients have signs, symptoms, or both. Treatment should be tailored according to each patient’s presentation and should not be delayed in asymptomatic patients until signs develop or vice versa.

 

References

    1. Kostas TL, Ioannous CV, Drygiannakis L, et al. Chronic venous disease progression and modification of predisposing factors. J Vasc Surg. 2010;51(4):900-907.

    2. Shepherd AC, Lane TRA, Davies AH. The natural progression of chronic venous disorders: an overview of available information from longitudinal studies. Phlebolymphology. 2012;19(3):138-147.

    3. Rabe E, guex JJ, Puskas A. Epidemiology of chronic venous disorders in geographically diverse populations: results from the Vein Consult Program. Int Angiol. 2012;31(2):105-115.

 
 
 

Ahmed HATRI, MD, PhD and Rachida GUERMAZ, MD, PhD


A. Hatri : Professor in Internal Medicine, Angiologist , general Secretary of the Algerian Society of Vascular Medicine
R. Guermaz: Professor in Internal Medicine, President of the Algerian Society of Vascular Medicine

Address for correspondence: Arezki Kehal Clinic, Birtraria Hospital, Algiers, ALGERIA (email: h_azzeddine@yahoo.fr, guermaz@yahoo.fr)

 
Chronic venous disease (CVD) leads to substantial socioeconomic costs, accounting for more than 2% of the healthcare budgets in Western countries.1,2 Its prevalence increases linearly with age.
 
CVD should be managed from the very first functional signs and symptoms: heavy legs, pain, swelling, tingling in the feet and ankles, restless legs, etc.
 
These signs and symptoms are not trivial, as complications may arise and become aggravated with time. They have a strong negative impact on patients’ quality of life, are a source of discomfort, and impair daily activities. CVD can rapidly become a true handicap, limiting or even obliging to discontinue certain activities. Trophic disorders, such as cutaneous pigmentation, eczema, and even ulcerations, appear later in the course of its evolution.
 
CVD treatment should not be limited to the surgical stripping or the endovenous obliteration of a varicose vein. It should take into account all patients’ complaints and is not limited to a medical prescription. A healthy lifestyle is of the utmost importance: it’s effective and inexpensive, it aims to encourage movement: walking, exercises to prevent venostasis, deep breathing, etc.3,4
 
Treatment aims to relieve patients’ symptoms, prevent CVD complications, and limit the progression of the disease.
 
In the initial stage of the disease, the evidence provided by physical examination is scanty. Thus, there is a risk that the physician might consider the condition trivial. Functional signs reported by the patient are at the forefront; they are a consequence of tissue damage due to venous stasis in the capillaries with hemorheological disturbance, an increase in capillary leakage, and inflammation within the interstitial fluid, clinically resulting in evening ankle edema, which disappears during the night in the lying position.
 
The initial stage of the disease represents the best moment for the prescription of venoactive medicines. Indeed, no other treatment can be proposed at this stage: sclerotherapy is not useful in the absence of significant hemodynamic involvement, and venous contention measures are often poorly accepted at the initial stage, particularly by young women in countries with a warm climate.
 
Venoactive medicines will act, according to their mode of action, on the different components responsible for the functional signs of venous disease. Varicose disease will unfortunately continue its evolution; however, thanks to these medicines, this will be delayed and controlled.
 
Treatment should last a sufficient time and, most importantly, should be continued throughout the warm season, from April or May until the end of September. During the winter, treatment every other month will be useful in order to ensure effective tissue drainage, in combination with appropriate venous contention.
 
Venous disease should therefore be managed from the very first stages of its evolution. Treatment should ideally be initiated when patients are not too advanced in age and before the development of complications that characterize neglected CVD.
 
CVD should therefore be regarded as a whole. A rigorous approach to its diagnosis and treatment can only be beneficial to the patient and, as a consequence, also allow healthcare savings.

 

References

    1. Ramelet AA, Monti M. Phlébologie, 4th ed. Paris, France. Masson, 1999.

    2. Ramelet AA, Kern P, Perrin M. Les varices et télangiectasies. Paris, France. Masson; 2003.

    3. Lyseng-Williamson KA, Perry CM. Micronised purified flavonoid fraction – a review of its use in chronic venous insufficiency, venous ulcers and haemorrhoids. Drugs. 2003;63(1):71-100.

    4. Ramelet AA. Traitement de la maladie veineuse chronique. Rev Med Suisse. 2004;0:23644.

 
 
 

Endre KOLOSSVÁRY, MD


St. Imre University Teaching Hospital

Address for correspondence: Endre KOLOSSVÁRY, MD, St. Imre University Teaching Hospital, Department of Angiology, Tétényi u. 12-16, 1115 Budapest, HUNGARY (email: kolossendre@gmail.com)

 
In medical and even in colloquial communication, the terms of symptoms and signs are widely used. According to the common definitions in the medical dictionaries, the distinction between symptoms and signs is basically related to the individual who notices something abnormal in relation to a medical condition. According to this concept, whereas symptoms are detected by the patient, signs are discovered by the physician by any means of examination.1
 
However, numerous examples may be given showing that this distinction is not accurate and that the exact nature of contrast is not clear. We may reject the view of distinguishing signs from symptoms based on patient-subjective versus clinicianobjective attitude or that signs are visible externally and symptoms are internal feelings. The essential feature of a sign, according to Lester S. King, is that there is both a sign (or “signifier”) and a “thing signified.” So “the essence of a sign is to convey information”; it can only be a sign, properly speaking, if it has a meaning.2
 
Besides the ontological problem of lacking an exact definition of symptoms and signs, the challenge in using these terms is more pronounced in asymptomatic cases when only signs can be detected. There are also conditions with symptoms and no objectively detectable signs.
 
In reference to chronic venous disease (CVD), orientation by focusing on the pattern of symptoms and signs is rather challenging, as the provocative title indicates.
 
This problem is especially characteristic in the case of functional disease. Functional CVD (FCVD) corresponds to the first C class (C0, no visible or palpable signs) in the CEAP classification (C, clinical; E, etiologic; A, anatomic; P, pathophysiologic).3 The prevalence of FCVD was close to 20% in the Vein Consult Program.4 Andreozzi et al recommended a typology of FCVD, with four groups showing patency and no reflux by ultrasound examination and different duration of symptoms. The prevalence of symptoms in these cases were mainly heavy legs (74.39%), followed by night (resting) cramps and restless leg syndrome (29.26%).5
 
In these cases, the dilemma is even more complex in contrast to examples where we may base our clinical decisions on existing symptoms and signs with a different pattern.
 
In my view, two points may be raised that can potentially contribute to a reinterpretation of the seemingly contradictory approach that is hidden in the conflict of symptom or sign conception.
 
Firstly, aching, night cramping, and restless legs are not visible indeed. However, the pattern of these findings, especially after excluding other conditions not related to CVD, in fact, conveys information for venous specialists. In this sense, the exact distinction between symptoms and signs just fades out.
 
Secondly, the exclusion of functional alteration in the venous system, as essential criteria for FCVD, represents a probably more complex challenge than outlined in the work of Tsoukanov et al.6 In their study, in almost half of C0 patients, transitory reflux was detected by duplex ultrasound examination in the evening only and not in the morning, with an association of larger great saphenous vein (GSV) diameter in the evenings. After micronized purified flavonoid fraction (MPFF) treatment for 2 months, the signs of transitory reflux and GSV diameter difference disappeared in parallel with diminishing symptoms. This analysis draws attention to the importance of functional investigations and the difficulties of detection of early signs of CVD.6
 
In conclusion, answering the question about symptoms or signs as a priority in the management of CVD, I recommend pondering over the deeper meaning of this distinction and closely following the new results of research on functional alteration in CVD. I would not argue for preference for either of these two terms.

 

References

    1. Cox AP, Ray PL, Jensen M, Diehl AD. Defining ‘sign’ and ‘symptom.’ CEUR Workshop Proceedings. 2014;1309:42-48.

    2. King LS. Medical Thinking: A Historical Preface. Princeton, NJ; Princeton University Press; 1982.

    3. Serra R, Andreucci M, De Caridi g, Massara M, Mastroroberto P, de Franciscis S. Functional chronic venous disease: a systematic review. Phlebology. 2017;32(9):588-592.

    4. Rabe E, guex JJ, Puskas A, Scuderi A, Fernandez Quesada F. Epidemiology of chronic venous disorders in geographically diverse populations: results from the Vein Consult Program. Int Angiol. 2012;31(2):105-115.

    5. Andreozzi gM, Signorelli S, Di Pino L, et al. Varicose symptoms without varicose veins: the hypotonic phlebopathy, epidemiology and pathophysiology. The Acireale project. Minerva Cardioangiologica. 2000;48(10):277-285.

    6. Tsukanov yT, Nikolaichuk AI. Transitory (evening) venous reflux in patients with intracutaneous varicosity and medicamentous correction thereof [in Russian]. Angiol Sosud Khir. 2016;22(2):110-116.

 
 
 

Dedy PRATAMA, MD


President of Indonesian Society for Vascular and Endovascular Surgery (ISVS)

Address for correspondence: Dedy PRATAMA, MD, Division of Vascular and Endovascular Surgery Dr. Cipto Mangunkusumo Hospital / Faculty of Medicine, University of Indonesia, INDONESIA (email: dedygpratama@yahoo.com)

 
In Indonesia, the incidence of chronic venous disease (CVD) ncreases every year. Although there currently is not sufcient data available from national-scale studies from the Indonesian Ministry of Health, the prevalence of CVD is assumed to be as high as that in developed countries, considering the similar risk factors in society such as lifestyle, less exercise, smoking, high pregnancy rate, and use of hormonal contraceptive. Due to the worsening progression of the disease, the economical effect arising from it, and the significant decrease in quality of life, management of CVD is of immediate concern.
 
The prognosis of CVD will worsen drastically if it reaches the late stage: chronic venous insufficiency (CVI) or postthrombotic syndrome (PTS). With a limited number of experts— especially vascular surgeons—and limitations in physicians’ knowledge, early care of the disease can be suboptimal, influencing disease progression significantly. In my experience, the patients who come to the vascular surgery clinic are usually in stage C3 (having edema) based on the CEAP classification (stratifying patients according to severity of presentation; C, clinical; E, etiologic; A, anatomic; P, pathophysiologic). Most of them have had complications such as dermatitis, hyperpigmentation, lipodermatosclerosis, thrombophlebitis, leg ulcer, and deep vein thrombosis. The patients in such condition could not be treated by conventional or minimal invasive surgery alone. Some come in with even worse conditions that can only be managed conservatively by compression stockings and a micronized purified flavonoid fraction (MPFF) drug, such as diosmin plus hesperidin. The prognosis for CVD patients with complications is not satisfying.
 
Unfortunately, Indonesian national health insurance cannot cover both conservative therapies. Compression stockings are not covered because they are considered cosmetic therapy, and MPFF is categorized as traditional medicine. As the symptoms’ recurrence is frequent and the treatment duration is for a lifetime, CVD therapy is a financial burden. From the macroeconomic point of view, the treatment of CVD would be costly and could account for 1% of the national health expenditure. The loss of work hours is estimated to be more than 2 million hours annually, either due to morbidities or to clinic visiting schedules. Furthermore, if the psychological impact on influencing productivity is taken into consideration, CVD would cause significant losses for the economy in a developing nation.
 
It should be kept in mind that the most important thing in managing chronic diseases, including CVD, is the quality of life. The losses described above supposedly trigger us to manage the patients’ condition comprehensively by considering physical, economical, and psychological aspects. We believe that it is urgent to treat CVD before the disease progresses and incurs further complications.
 
So, when should we initiate therapy? Is it when the patient feels the symptoms or when the signs appear on physical examination? On the basis of the reasons above and also to emphasize the importance of quality of life, we believe that CVD management should begin with the presence of symptoms.
 
The earliest classification stage of CVD is C0, either with or without symptoms (C0s or C0a, respectively). Generally, patients start to seek medical help at the C0s stage. Diagnostic procedures must be used to determine the causes of symptoms, even in the absence of signs. Next, therapy in accordance with the pathophysiology and complaints must be started immediately to get rid of the symptoms, to prevent further progression of CVD, and to enhance the overall quality of life. If we refer to the 2015 European Society for Vascular Surgery guidelines for CVD management, the earliest management is recommended to start when symptoms are present, even if no signs are found, as this prevents progression of the disease. We can at least educate patients about preventive efforts, such as physical exercise and the control of patient risk factors.
 
We believe that the patients’ quality of life is still the first priority in the management of CVD.
 
 
 

Stanislava TZANEVA, MD

Address for correspondence: Stanislava TZANEVA, MD University Clinic of Dermatology Medical University of Vienna, Sensengasse 3, 1090 Vienna, AUSTRIA (email: praxis@venen-hautarzt.at)

 
There is still some controversy and discussion in the phlebological community regarding the optimal time for treatment of a patient with chronic venous disease (CVD). In this short article, I will share my thoughts and the procedure that I follow when I have diagnosed CVD in a patient. In general, signs are defined as the physical manifestation of a medical condition and can be objectively observed, whereas symptoms can only be felt and described by the patient. Thus, signs are visible externally and symptoms are internal feelings.
 
Nevertheless, medical signs aren’t always diagnosed by seeing, but also by touching, listening, or smelling. Some of the most common signs I assess in my medical field are the skin signs: color, temperature, structure, surface, and moisture. For example, increased local temperature could be a sign of erysipelas; hardening and immobility of the skin, a sign of lipodermatosclerosis; and foul-smelling odor of a leg ulcer, a sign of wound infection. Another aspect is that signs do not always correlate with the symptoms. In my clinical practice, there are patients with CVD who report considerable complaints but have few objective signs. On the other hand, some patients with evident clinical signs do not describe any subjective complaints.
 
The decision whether to treat a patient with CVD is pretty complex. In my opinion, important decision criteria are whether the superficial, the deep venous system, or both are affected, taking the signs into account. Furthermore, it is crucial if the patient has a venous reflux disease, an obstructive venous disease, or the combination of both. In case of a refluxive superficial disease, the distribution plays a key role, depending on whether trunk veins, side branches, or both are affected.
 
In my view, it is important to weigh the benefits and risks in the specific patient’s situation besides considering the signs and symptoms. For example, the threshold for recommending noninvasive treatments is much lower because the benefit-to-risk ratio is high. This applies especially to compression treatment and therapy with venoactive drugs. If invasive procedures are necessary, it is even more important to consider not only signs and symptoms, but also individual wishes of the patient, life and work situations, compliance, and education of the patient.
 
Sometimes the symptoms reported by the patient have nothing to do with the current venous disease. In these cases, it is important to objectively assess the signs of the venous problem and to make the decision for treatment. However, if the symptoms indicated by the patient are clearly related to the venous disease, I tend to recommend treatment.
 
If the patient does not report any symptoms, but tissue damage from stage C4a with skin changes is visible, I strongly recommend treatment. If a large caliber trunk vein insufficiency with significant reflux is present, I recommend treatment, but I do not recommend treatment in patients with isolated side branch varicose disease. If the deep venous system is affected, I strongly recommend treatment in order to prevent further progression of CVD.
 
In summary, both signs and symptoms are incorporated in my decision to treat or not to treat a patient with CVD, but these are not the only important arguments. Finally, the decision is made individually, depending not only on signs and symptoms, but also on many surrounding factors and information regarding a patient’s life situation and benefit-to-risk analysis.
 
 
 

Igor A. ZOLOTUKHIN, MD, PhD

Address for correspondence: Igor A. ZOLOTUKHIN, MD, PhD, 36-1-381, Novatorov ul., 117997 Moscow, RUSSIAN FEDERATION (email: zoloto70@bk.ru)

 
To be brief, I suggest treatment of chronic venous disease (CVD) if either signs or symptoms are present. For example, for a patient with varicose veins but no symptoms, I suggest treatment; and for a patient with venous symptoms but no signs, I also suggest treatment.
 
Why is that? For starters, this is a linguistic issue. In the Russian language, the words “symptom” and “sign” have the same meaning; we do not distinguish between them the way a native English speaker would. Furthermore, regardless of whether the patient has symptoms vs signs (or both), having either means there is a disease that has to be managed. This is what all medical doctors in Russia have been taught as students and postgraduates.
 
On the basis of my understanding of CVD and on my personal experience, treatment should be initiated as soon as symptoms or signs are noted. For example, let’s say I see a patient with primary varicose veins and no complaints. My understanding of the disease tells me that vein-specific inflammation is behind it. The pathological process would have already started, with leukocytes being recruited from the blood flow by endothelial cells, migration of leukocytes into the venous wall, and remodeling of the venous wall underway. What I know of vein-specific inflammation is that it never stops on its own. Leukocytes move to interstitial tissues, causing damage that leads to symptoms, edema, and trophic disorders. Patients left untreated because they are asymptomatic will experience symptoms sooner or later. From my personal experience, this happens in many, if not all, patients. The literature supports this. The greater the age of the patient, the longer the disease duration; thus, we often observe more advanced stages of CVD. I see no reason to wait to initiate treatment if the patient presents with varicose veins only and complains of nothing. It is only a matter of time before symptoms develop.
 
The choice of treatment for primary varicose veins is rather clear to me. If there are no contraindications, I suggest endovenous ablation or surgery, depending on the situation with compression before and after the procedure and medical treatment with micronized purified flavonoid fraction (MPFF) overlapping the date of procedure. If there are venous symptoms, I prescribe MPFF. I prefer this agent because of my understanding of the disease, which tells me that vein-specific inflammation is the target of treatment. MPFF is known as an agent that has an effect on it, improving venous symptoms and edema. This is corroborated by published data, along with my personal experience.
 
In some patients with neither signs nor symptoms, I may also suggest treatment. For example, after deep vein thrombosis (DVT), some patients are signand symptom-free. I believe that doesn’t mean they are disease-free, especially if DVT was proximal. They have deep venous reflux, which alters shear stress. Uncorrected, this triggers vein-specific inflammation.
 
There is no way to fully correct such reflux. So, I believe we need to treat postthrombotic patients by compression in order to reduce reflux and by medical treatment with MPFF in order to control venous inflammation so that patients are kept asymptomatic to the greatest extent possible.
 
In conclusion, regardless of whether the patient has signs vs symptoms, I consider CVD to be a chronic condition with slow but inevitable progression that needs to be managed after it is confirmed.
 
 
 

Michel ZUMMO, BSpSc, MD


Fellow of the Canadian Society of Phlebology, graduate of the American Board of Venous and Lymphatic diseases

Address for correspondence: Michel ZUMMO, BSpSc, MD, 916, boul. St-Joseph E. Montréal (QC), H2J 1K6, CANADA (email: phlebodoc@yahoo.ca)

 
The decision of whether or not to treat chronic venous disease (CVD) is based on the patient’s quality of life (QOL), which can be impaired either by a change in the cosmetic aspect of his or her legs, especially in classes C1 (having telangiectasias or reticular veins) and C2 (having varicose veins), or by improving the symptoms associated with CVD in all clinical stages. By experience, in the earlier clinical stages of CVD, it is not rare for patients not to realize that they have symptoms related to their venous disease until they’ve undergone treatment.
 
Since the signs do not always correlate with the symptoms, treatment can be initiated for both types of presentation. A patient with a CEAP class (stratifying patients according to severity of presentation; C, clinical; E, etiologic; A, anatomic; P, pathophysiologic) of C0 (no visible or palpable signs of CVD), C1, or even C2, disease can be quite symptomatic. On the other hand, and not infrequently, we will encounter patients with a more advanced problem (larger varicose veins, dermatitis, atrophie blanche) with or without a minimum of symptoms. The explanation could be that the group C nerve fibers, responsible for the perception of pain, become depleted of their neurotransmitters as the disease progresses, and the involved veins become larger in diameter.
 
The general perception of the population in regard to varicose vein disease has also changed over time. Thirty years or so ago, varicose veins and CVD were thought to be a medical and/or cosmetic problem affecting primarily, if not exclusively, women. Of course, the prevalence of CVD being estrogen related, it is much more common in women earlier in life, ie, in their reproductive years. Even so, in recent years, the perception that CVD solely affects women has changed, and we see more men in consultation for CVD. They are also consulting at earlier CEAP stages. They also tend to be as preoccupied by the symptoms as by the signs of CVD.
 
We are still unable to predict how the disease is going to evolve in time. Occasionally, we see patients with a dermatitis and even atrophie blanche (CEAP = to C4) without any apparent varicose veins or deep venous insufficiency. We also see patients with large refluxing greater saphenous or short saphenous veins without symptoms or any sign other than apparent varicose veins. So, whether I treat signs or symptoms depends a lot on the patient’s desire for improvement in QOL. However, as a general rule, the decision to initiate treatment is motivated predominantly by the signs of CVD, ie, edema and cutaneous changes, especially in later clinical stages (C3 and over).

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