Servier – Phlebolymphology

RISK FACTORS

Obesity: an important risk factor for the development of chronic venous insufficiency
E. RABE (Germany)

Obesity: a risk factor for chronic venous disease?
J. P. BEGNINI (France)

The Bonn study is an epidemiologic study which took place in Bonn between October 2000 and March 2002. This study in 3072 members of the general population evaluated the prevalence and the risk factors of chronic venous disease. This population was selected randomly from registries. All participants were examined by clinical means and by duplex ultrasound. Among this population, 87.5% had telangiectasia, 23.2% varicoses veins, and 17% chronic venous insufficiency (CVI, C3 to C6). The main risk factors for varicose veins, after adjustment for gender, age, and region of residence, were: age, female gender, and pregnancies but not obesity. One of the most important risk factors of CVI was obesity, and the relative risk increased with the body mass index (BMI = weight in kg/[height in cm]2). In a multivariate analysis, the odds ratio reached 10.5 for men and 7.9 for women for a BMI >40 (respectively 6.5 and 3.1 for a BMI between 30 and 40).
In a French longitudinal survey, 241 obese patients (BMI between 32 and 59) were recruited before gastric surgery (gastroplasty or bypass) and examined by clinical means and duplex ulltrasound. No significant difference in BMI was found in this population for prevalence of varicose veins or the classification in CEAP. This study had an evident bias of recruitment. Because of this, the mean age in this study was only 36.6 years.

EDEMA
Prophylaxis and treatment of leg edema

Chairpersons: H. Partsch (Austria), A. Scuderi (Brazil)

Prevention of occupational leg swelling by compression stockings
H. PARTSCH, J. WINIGER, B. LUN (Austria)

Twelve patients – 8 females, 4 males, aged 21 to 60 years (mean 41.4 years) with sitting and/or standing professions – were investigated. Clinical and duplex examinations revealed large varicose veins (CEAP class C2) in 5 legs and venous edema (C3) in 1. Five patients reported heaviness and tiredness in the evening; three of these had varicose veins or venous edema. The volume of both lower legs up to a height of 43 cm was measured using water volumetry, once in the morning and then 7 hours later. The procedure was carried out for 4 days, during which the patients wore below-knee compression stockings of different compression levels, alternately on one leg only in a random order. The pressure of each individually fitted stocking at b-level was measured using the Hatra method. According to this compression pressure the tested stockings fitted into the following CEN classes: support stockings (pressure 5.9±2.4 mm Hg), class A (11.2±1.8 mm Hg), class I (18.1±2.8 mm Hg) and class II-stockings (21.8±1.8 mm Hg). As a result the average evening edema of the noncompressed legs over 4 days (n=48) was 76.7±45.9 mL. There is no correlation between the amount of leg swelling and subjective complaints. Support stockings with a mean pressure below 10 mm Hg achieved a reduction of evening edema of 27.3+60.6 mL (P<0.05). With the other stockings the mean values of the lower legs could be reduced to values, which on average were lower in the evening than in the morning (Class A: -34.1±56.7 mL, class I: -40. 4±45.2 mL and class II: -59.1±42.2 mL. All differences compared with the volume increase without stockings were statistically highly significant (P<0.001). Subjective symptoms were improved mainly by the stockings exerting a pressure above 10 mm Hg, but not by the support stocking. The author has concluded that swelling of the lower legs after sitting and/or standing work is a phenomenon which can be found in all individuals, and may be more pronounced in patients with varicose veins. Calf-length compression stockings with a pressure range between 11 and 21 mm Hg are able to reduce or even totally prevent this evening edema, and may therefore be recommended for people with a profession involving long periods sitting or standing.

POST-THROMBOTIC SYNDROME
Prophylaxis and treatment of leg edema

Chairpersons: H. Partsch (Austria), A. Scuderi (Brazil)

Leg compression for the treatment of symptoms of deep vein thrombosis and the prevention of post-thrombotic syndrome
W. BLÄTTLER (Switzerland)

Compression started immediately upon diagnosis of proximal DVT leads to a more rapid and sustained relief of symptoms and regression of signs than bed rest, and allows a faster return to daily activities. The benefit is almost the same whether bandages or stockings are used. Observational studies showed that most patients with proximal (crurofemoral) DVT can be fitted with ready-made calf-size stockings exerting a pressure of 23 to 32 mm Hg (Sigvaris 503) and one third of patients with pelvic DVT are treated similarly. Comparison of two management studies showed that stockings are increasingly preferred over bandaging for outpatient management (in 71% versus 29%). Two randomized controlled trials compared compression treatment with stockings for the prevention of the post-thrombotic syndrome (PTS). Its incidence (around 50%) was reduced by half when started about 2 weeks after diagnosis, usually at discharge from the hospital. Ready-made round-knitted stockings exerting a pressure of 30 to 40 mm Hg at the ankle were as effective as custom made flat-knitted stockings exerting a pressure of 35 to 45 mm Hg. No reliable data are available on the rate of recurrence of DVT. In conclusion the author has underlined that leg compression is effective for both the treatment of the clinical symptoms of acute DVT and the prevention of the PTS. These findings suggest that leg compression should be started immediately upon diagnosis. Despite a clear trend towards the easier-use stockings, compression with bandages remains the optimal regime for handicapped patients and those with severe edema.

RECURRENCE 0F VARICOSE VEINS AFTER SURGERY (REVAS)
LECTURE

The profile of the “REVAS patient”
M. PERRIN (France)

Fourteen clinics in 8 countries enrolled 201 lower limbs (170 patients). The mean age was 55.6 (range 27 to 82). Female patients constituted 69%, and the number of previous surgical procedures was 1.2 (range 1 to 3). The period of time between last intervention and consultation was 136 months (range 1.8 to 692.1). The C of the CEAP was used in a descriptive way (elaborated CEAP). By definition all patients were quoted as C2; 24.6% were only C2 and 75.4% C2+ (14 combinations), C1 was present in 52%, C3 in 37%, C4 in 20%, C5 in 8%, and C6 in 2%; 77% were symptomatic and 23% asymptomatic. Concerning the etiology, 181 were quoted as P (91%), 10 secondary (5%), and 8 congenital (4%). Fifty-five patients (27%) had a deep venous abnormality and 110 (55%) an incompetent perforator. One hundred and eightyeight (95%) patients had reflux only and seven (4%) a combination of reflux and obstruction. Topographical sites of recurrence were: groin 37%, thigh 68%, popliteal fossa 23%, lower leg 85%, and other 11%. Sources of recurrence were: pelvic or abdominal 17%, saphenofemoral 47%, thigh perforator 30%, saphenopopliteal junction 5%, popliteal perforator 5%, gastrocnemius vein 9%, lower-leg perforator 43%, and no source 10%. The numbers of sources were: 0 10%, 1 37%, 2 32%, 3 15%, and more than 3 7.5%. Clinical significance of reflux was: probable 82%, unlikely 10%, uncertain 8%. Then nature of sources for the same site were: technical failures 19%, tactical failure 10%, neovascularization 20%, uncertain 20%, mixed 17%, and information not given 14%. For a different site there were: persistent 12%, new 32%, uncertain/not known 21%, and information not given 35%. Possible contributory general factors were: family history 68%, obesity 24%, pregnancy 16% (percentage based on female population), oral contraception 9.9% (percentage based on female population aged less than 65 years old), and lifestyle factors 43%. Possible specific contributory factors were: primary deep vein reflux 13%, postthrombotic syndrome 5%, angiodysplasia 3%, and calf pump dysfunction 10%. The profile of patients with REVAS shows that the majority were symptomatic, with various combinations of patterns. Sources of reflux feeding the recurrence were predominantly of multiple origins, and its causes were variable. When recurrence occurred at the site previously operated on, revascularization was as frequent as technical failure.

Recurrence of varicose veins: can it be reduced?

J. FERNANDES E FERNANDES (Portugal)

Professor Fernandes e Fernandes presented his own results after varicose vein surgery (stripping the insufficient long saphenous vein and avulsion of collaterals) with a minor recurrence rate of 11% and a major recurrence rate of 4%. He pointed out the value of mapping the sites of incompetence in order to treat them and preserve normal venous segments.