Chronic venous disease: What if everything started with early care? A discussion with experts

Podcast transcript

Professor Davies: My name is Alun Davies and I am the Professor of Vascular Surgery at Imperial College, and I’m also the Editor-in-Chief of the journal, Phlebology. It is my great pleasure to be joined by Professor Andrew Nicolaides from the University of Nicosia Medical School in Cyprus, Professor Stavros Kakkos from the University of Patras Medical School in Greece, and Dr Gerardo Estrada-Guerrero from the Beneficencia Española de Tampico in Mexico.

They have joined me today to discuss the very key highlights from their symposium, which was held at the 2023 European Venous Forum, which was entitled, “Chronic venous disease: what if everything started with earlier care?”. The symposium was supported by Pierre Fabre.

I’m going to start by asking some questions to Professor Nicolaides, whose presentation discussed the phenomena of “functional chronic venous disease.” Andrew, can you please tell us more about that?

Professor Nicolaides: Thank you, Alun. As we know, chronic venous disease [[CVD]] refers to a large spectrum of morphological and functional disorders, and the clinical signs of chronic venous disease may range from reticular veins to active venous ulcers, while the symptoms, which include pain, heaviness and the sensation of swelling, burning, itching, and so on, are there.^1,2 However, this is the most important point that we make at the introduction. There is a very poor correlation between the signs and symptoms of chronic venous disease.^1,3 For example, many patients experience symptoms without having any clinical signs, whereas others may be asymptomatic despite advanced and obvious disease such as a leg ulcer.

Now, the prevalence [[sic, presence]] of chronic venous disease symptoms in the absence of clinical signs—which corresponds to what we know as class 0S [[C_0S]] using the CEAP classification system ² —is now known as “functional chronic venous disease,” and it happens in approximately 20% of the general population.^4,5

Professor Davies: Andrew, can you tell us what is the clinical significance of this functional chronic venous disease?

Professor Nicolaides: Yes, sure. Much we have learned about this functional chronic venous disease has come from the Acireale study, which was an epidemiological project involving more than 1000 adults, which was conducted in Italy between 1989 and 1992.^6,7 In this study, symptoms with no visible or palpable signs were present in 31% of individuals, and in approximately half of these—that is, 16% of the total population—there was no evidence of venous reflux when duplex scanning was done.^6,7 And this phenomenon was termed by the authors “hypotonic phlebopathy,” which we now know as functional chronic venous disease.^6,7 And they called it this way because these individuals had an abnormal venous compliance and the venous volume at rest was increased—it was nearly double of what is present in a normal [[sic, healthy]] person.^6,7

So, we now need more research to better understand the pathophysiology of functional chronic venous disease. And I believe that earlier diagnosis with proper management of this condition may delay the disease progression and may improve patient outcomes.

Professor Davies: Right, now let’s move on to one of our other colleagues, Professor Kakkos. Would you like to tell us what is the current evidence and the clinical implications of disease progression?

Professor Kakkos: Thank you. The natural history of CVD is not well understood, but some studies have begun to show that disease progression is common and indicative of continuing CVD pathophysiology. For example, a longitudinal analysis of the Edinburgh Vein Study found that 58% of adults with varicose veins or chronic venous insufficiency at baseline clinically progressed over an average follow-up of 13 years ⁸ Almost one-third of adults with isolated varicose veins at baseline went on to develop chronic venous insufficiency—that is, venous edema or skin changes—while 98% of those with both varicose veins and chronic venous insufficiency deteriorated during follow-up. ⁸

Factors associated with CVD progression in the Edinburgh Vein Study included age, family history of varicose veins, prior deep vein thrombosis, overweight, superficial reflux, and the number of refluxing venous segments. ⁸ In another study that included 73 patients undergoing varicose vein surgery, CVD progression in the initially asymptomatic contralateral limb occurred in approximately half of those patients over 5 years of follow-up. ⁹ Significant risk factors for CVD progression in this study were prolonged standing, obesity, and limited elastic stocking use, ⁹ suggesting that early intervention and control of such factors could improve long term outcomes.

Professor Davies: Okay, thank you very much. And now I’d like to turn to our third colleague, Dr Estrada-Guerrero, about how are you addressing the need for early diagnosis and management of chronic venous disease in Mexico?

Dr Estrada-Guerrero: Thank you, Professor Davies, for your question. As we know in research data, the patients in early stages are very common. Recent studies have demonstrated that patients with C₀ symptomatic [[C_0S]] is higher. And specifically in Mexico, we have a real big problem for some cases. Number one, according to the epidemiological data of the Vein Consult Program in Mexico, we have a high prevalence of chronic venous disease, around 70%. ⁵

Number two, our health system doesn’t have pharmaceutical treatment for CVD. Our guidelines only mention the pentoxifylline for stages C₆. ¹⁰ The incidence of chronic venous disease in northern Mexico was 58.7% in 2021. ¹¹ And I think this is very important—we know the principal symptoms, but it’s not so easy for the primary care physicians to detect an accurate diagnosis.

The primary care physicians in Mexico are aware of the symptoms of chronic venous disease, yet we recognize that it is difficult for them to diagnose and refer patients during the early stages of disease. To better educate primary health care providers on the optimal management of chronic venous disease, we developed “Congreso Vascular Tampico,” or CVTAM, which is an annual meeting for primary care physicians, nurses, and related specialists. In these meetings, we discuss the signs, symptoms, diagnosis, and treatment of chronic venous disease, and the ideal time to refer patients to a vascular surgeon. More than 300 primary health care providers in Mexico have attended CVTAM meetings over the last 9 years, and data from my own practice indicate that more patients with early chronic venous disease are being referred to vascular surgeons as a result.

Once patients with early CVD are referred to a vascular specialist, we can provide the best-available care in line with international clinical practice guidelines. ¹ When patients need treatment, 54% of my patients use Ruscus extract because we have level 1A evidence that it improves early stage symptoms. ¹² Based on my experience in Mexico, I believe that educational programs like CVTAM can facilitate the early diagnosis of CVD and improve the management of this disease worldwide.

Thank you so much and it was a great honor to share this information with you. Definitely, we have a lot of work to spread among the world population on chronic venous disease. Thank you.

Professor Davies: I’d like to thank you very much, and I’d like to take this opportunity to thank Professor Nicolaides, Professor Kakkos, and Dr Estrada-Guerrero for joining me today, and for highlighting and discussing the importance of early care in people with chronic venous disease. Thank you all very much.