Original article

Programme for detecting chronic venous insufficiency in Belgium J-C Schoevaerdts* and I Staelens-

Department of Cardiovascular Surgery, Mont-Godinne University Hospital, UCL; -AZ VUB Vascular Surgery,

Laarbeeklaan 101, B-1090 Brussels, Belgium

Abstract Objective: Epidemiological study related to the detection of chronic venous disease (CVD) in a Belgian population and gathering of a maximum amount of epidemiological data on CVD. Method: Survey based on a questionnaire completed by a general practitioner during consultation. Results: In total 3813 files of patients with CVD were completed and analysed. Of these patients suffering from CVD, 70% were women with a mean body mass index of 26.2 and a clinical, aetiological, anatomical and pathological elements classification as follows: C0 ¼ 10%; C1 ¼ 19%; C2 ¼ 29%; C3 ¼ 19%; C4 ¼ 16%; C5 ¼ 4%; C6 ¼ 3%. Risk factors, clinical signs, complications and therapeutic approach are analysed and described. Conclusion: High level of statistically analysable data could be obtained within a reasonable period. The study confirms the socioeconomic importance of CVD. For example, an industrial disablement of an average duration of 23.6 days is found in 6% of patients. Phlebology 2007; 22: 171–178

r 2007 Royal Society of Medicine Press

Keywords: Venous insufficiency; epidemiological study; varicose veins; venous survey

Introduction Chronic venous insufficiency is a disorder that is very prevalent. In Belgium venous disease affects 40% of the population, but it is relatively rarely diagnosed and little treated. Furthermore, chronic venous insufficiency is a progressive disease, whose consequences may be serious for the patient. The clinical classification (clinical, aetiological, anatomical and pathological elements [CEAP])1–5 that describes the progression of chronic venous disease (CVD) starts with C0, which represents patients manifesting symptoms without any objective sign, and progresses through the clinical stages

Correspondence: Professor J-C Schoevaerdts MD, Department of Cardiovascular Surgery, Mont-Godinne University Hospital, UCL, B-5530 Yvoir, Belgium. Email: [email protected] Accepted 19 December 2006

to C6, which refers to the most severe clinical complication – active venous ulcer of the leg. At the earliest stages many symptoms may be associated with this disorder. Symptoms such as leg pain, a feeling of heaviness, restless legs, night cramps, a sensation of swelling and itching have been reported by patients suffering from CVD. Unless dealt with adequately, CVD will progress to the more serious stages, such as oedema, trophic cutaneous disorders and leg ulcers. True prevention of venous insufficiency would make it possible to avoid the progression towards the more advanced stages. It should be borne in mind that the cost of treating this disease increases exponentially as the disorder worsens (varices, ulcers, thromboses, embolisms, etc.).

Materials and methods The present study is an epidemiological study (thanks to the partnership between the Benelux Phlebology Vol 22 No. 4 2007

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J-C Schoevaerdts and I Staelens. Programme for detecting chronic venous insufficiency

Society of Phlebology and Laboratoires Servier Benelux [Servier Research Group]) carried out with the assistance of 502 Belgian general practitioners and involves the detection of chronic venous insufficiency in Belgium in a group of 3813 patients. Its aim was to include, on the one hand, the detection and management of venous disease at an early stage and, on the other, to gather a maximum amount of epidemiological data on chronic venous insufficiency. The method used is based on a questionnaire to be completed by the general practitioner each time he suspects or detects a case of venous insufficiency during consultation with a patient. A poster announcing this study programme was posted in the waiting room of every general practitioner encouraging patients to discuss the subject with their doctor as soon as they show the following symptoms suggestive of the disorder: pain, swelling, heaviness, redness and tingling in the legs. An analysis of the risk factors and the history, with regard to the presence of CVD, was performed for every patient who participated in the detection trial. Each participant was assigned an appropriate clinical category (C) according to the CEAP classification. The subject was diagnosed as suffering from CVD when any type of venous pathology (classification C1–C6) was seen in at least one leg. The questionnaire (see annex) was completed by the doctor immediately after the consultation and adjusted for statistical analysis of the results by an analysis company (statistical study conducted by Marketing Research and Strategic Support NV Halle, Belgique).

Results In total, 3813 files were completed correctly and analysed in Belgium: 56% in the Dutch-speaking community and 44% in the French-speaking community. Seventy-six percent of the patients were found to be suffering from CVD, 17% from CVD accompanied by haemorrhoids and 7% from a single haemorrhoid. Of these tested 75% were women and 25% were men, 24% were under 40 years of age, 35% were between 40 and 60 and 41% were over 60 years. The mean body mass index (BMI) was 26.2 (mean: 73 kg with a mean height of 1.70 m). Various risk factors for varicosis were analysed. A history of varicosity in the family was reported in 52% of cases (38% from the mother’s side, 8% from the father’s side and 6% from both sides), hormonal 172

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factors in women (68% previous pregnancies, 23% hormonal contraception and 4% pregnant women), a sedentary lifestyle in 45%, overweight in 43%, prolonged standing in 26% and professional factors. In the overall population of this study, i.e. 3197 files, 19% were retired people, i.e. 619/3197, of whom 381/2363 were women (16%) and 238/834 were men (29%), 19% were housewives (633/3197), 11% were unemployed, 10% were employees, 2% were students and 39% had other various professions. Venous disease affected the patients bilaterally in 74% of the patients, unilaterally on the left in 13% and unilaterally on the right in 13%. In women, bilateral insufficiency was present in 76% of the patients and unilateral insufficiency in 12% on the right and 12% on the left. In men, there was bilateral insufficiency in 66%, unilateral insufficiency on the right in 15% and on the left in 19%. The diagnosis written down by the doctor at the end of the visit made it possible to classify patients in the CEAP classification. Ten percent of patients did not show any visible signs (C0), 19% had telangiectases (C1) and 29% had truncal varicose veins (C2). Oedema was seen in 19% of the patients (C3), and trophic lesions (C4) (dermatitis, severe white atrophy) were diagnosed in 16% of the patients. Four percent of patients were suffering from ulcer scars (C5) and 3% from active ulcers (C6). The patients reported their symptoms spontaneously or in reply to the questions set and/or on questioning by the doctor — heaviness in the legs in 75% of cases (54% spontaneously, 21% when questioned); on cosmetic grounds: 57% (42% spontaneously, 15% when questioned); swelling of the leg: 50% (36% spontaneously, 14% when questioned); night cramps: 47% (28% spontaneously, 19% when questioned); pain in the legs: 45% (33% spontaneously, 12% when questioned); painful restless legs: 30% (16% spontaneously, 14% when questioned) and burning or heat sensations in 40% (26% spontaneously, 14% when questioned). Clinical examination by the doctor during the consultation identified the following lesions: telangiectasis in 73% of patients, varices along the course of the great saphenous vein in 52% varices along the course of the small saphenous vein in 40%, oedematous swelling in 35%, complications such as purpuric pigmented dermatitis or hypodermatitis in 23% of cases, white atrophy in 7%, active venous ulcer in 3% and active superficial phlebitis in 12%. Clinical signs were found in the leg in 75% accompanied by pubic varices in 1% of cases.

J-C Schoevaerdts and I Staelens. Programme for detecting chronic venous insufficiency

The first symptoms were seen, on average, eight years earlier, but the disease could go back 25 years, with more marked subjective symptoms during the first five years. Then, after a symptomfree period from the 5th to the 10th year, the subjective symptoms resumed up to the 25th year. The period of industrial disablement due to venous disease was granted in 6% of the patients lasting 23.6 (SE72) days on average (15 days as the median). Hospitalization due to the venous symptoms or to their complications had to be prescribed in 8% of cases (i.e. 292/3813). This hospitalization lasted on average 8.9 days (SE71.1, median: 5), and 1% of patients (56/3813) declared that they had to retire early on account of venous disease. During the consultation for the survey, the general practitioner adopted a therapeutic approach even when it was not yet necessary— general and dietary advice usually given for venous disease in 73% of patients, wearing compression stockings in 24% and phlebotonic medication in 67%. The period for which phlebotonic medication was taken was estimated at one year in 80% of cases, two years in 13%, from two to three years in 3% and over four years in 1% of cases. Of these, 202 patients were referred to a venous specialist (surgeon or dermatologist) and 150 for surgical approach.

Discussion Venous return disorders are frequent and lead to serious disease. However, there are few epidemiological studies in this area and more specific data on the prevalence of the risk factors and the natural history of the disease have to be sought in the various geographical regions of the world.6–10 The aim of our study was to pinpoint certain data in Belgium. The advantage was that the replies to the questionnaire were collected by doctors facing their patients; they were able to ask questions on the spot and immediately record the replies and the clinical findings. In this respect, the questionnaire does not go into detail about the questions put to members of the family (apart from mother’s and father’s histories), knowing that only the data obtained by one and the same doctor examining and questioning the family members are of value and will differ from the data obtained by questioning the patient himself. Clearly, our method relies on the general practitioner and does not, of course, have the value of a study conducted by a medical observer specialized in phlebology. Of course, this disadvantage is offset by the possibility of obtaining a very large

Original article

number of valid replies within an acceptable study period, in this case a period of two years. Our study is limited to a clinical examination and the patient’s history does not include paraclinical methods such as ultrasound methods (Doppler, echo Doppler, etc.). The advantage is that the population included in the study comes from a general population and not from a selected population9 (for example, a population of workers whose work involves a lot of standing or under very specific conditions). The general prevalence of varicose disease cannot be established in our study as we do not know how many patients passed through the doctors’ consulting rooms. In contrast, we have noted that in this population, among the patients who had varices, 75% were women and 25% were men.11–18 Among the risk factors, a family history of varicose disorders was reported in 52% of the cases; 38% of these came from the mother’s history and 8% from the father’s history, and 6% from both. This is in line with the various studies that have examined genetic predisposition.19–21 It is interesting to note the importance of the influence of hormonal factors in women. Sixty-eight percent of women with venous insufficiency had been pregnant and the varices appeared after these pregnancies. Twenty-three percent of the women were on hormonal contraceptives and 4% were pregnant at the time of the clinical examination.6,15,22–24 While it is known that pregnancy increases the risk of the appearance of varices, the cause of this is difficult to define. Three causes are usually mentioned: compression of the iliac veins by the uterus, the hormonal factor and hydrosaline retention. Obesity is also a known risk factor;6,15,25,26 43% of our population were overweight (BMIX26.2). A sedentary lifestyle was frequently the case (45%); otherwise 26% of the patients stood for long periods.9 Bilateral insufficiency (76%) was frequent, with the left leg predominating only in men (19% compared with 15% in the right leg).27 Of these symptoms, in one out of two cases, the symptoms were suggested by the doctor. Cosmetic inconvenience and heaviness in the legs were the symptoms most frequently reported spontaneously by the patient. The high frequency of telangiectasis corresponds to the usual statistics;25 telangiectasis must be considered as a venous disorder and not necessarily as a sign of chronic venous insufficiency. The clinical and haemodynamic significance of corona phlebectatica remains debatable and is not Phlebology Vol 22 No. 4 2007

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included in the questionnaire of the general practitioner.28 The predominance of the great saphenous vein being affected is normal, and the high frequency of varices along the external course of the leg does not correspond to the frequency of insufficiency of the small saphenous vein (which is usually 15–25%).29,30 The frequency of complications corresponds to the usual frequency reported in the literature and increases with age. Trophic disorders were reported in 23% of the cases and oedema was frequent.31–38 It is interesting to point out that the subjective symptoms such as pain are reported at the beginning of the disease. They probably correspond to the first period of dilation of the venous system. Subsequently, the symptoms lessen only to resume later on account of complications of stasis (hypodermatitis, periphlebitis, ulcers, trophic disorders). Industrial disablement due to venous insufficiency is as high as 6%. Duration of the disablement lasts on average 23.6 days (SE72). The incapabilities associated with hospitalization is reported in 8% of cases (292/3813), lasting on average 8.9 days. We would point out that only hospitalization justified by a complication and not purely for a surgical procedure is included.15 The therapeutic approach frequently consists of general and dietary advice (i.e. more than 73% of the population). This advice consists of recommendations such as keeping legs in a raised position at night or while sitting, or semi-lying down during the day, walking, swimming, dieting, low-salt diet, cold showers. Other recommendations included avoiding constipation, prolonged standing with exposure to the sun, insulation, smoking, high heels, clothes constricting the groin, the top of the thigh or the abdomen, sources of heat from the ground (under-floor heating) and sports involving sudden variations in pressure in the legs (volleyball, tennis, football, skipping, downhill skiing, horse-riding). Wearing compression stockings is not sufficiently recommended or complied with by patients because only 24% of them said that they wear them. Phlebotonic medication is often prescribed in 67% of cases, and is rarely taken for more than two years. Among the 3813 patients, 202 (5.3%) were immediately referred to a specialist; 150 of them for surgical approach which means that nearly 4% of the patients were referred for surgery by the general practitioner. Regarding varicose ulcers, our statistics report a rate of 3% recorded by the doctor. There were, of 174

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course, open active ulcers at the time of the consultation (see the questionnaire: current ulcers) and isolated ulcers or ulcers combined with another cause. We limited ourselves to the active ulcers because we are aware that many old ulcers can be forgotten by the patient or may have healed by the time of the examination, and the scar may not be detectable on clinical examination. It is clear that it is therefore a percentage of active ulcers in relation to a population of patients with venous insufficiency and not, as is often the case during prevalence studies, in an adult population from western regions, where the statistics are close to 0.3% (and 1% if open and healed ulcers are included).31–36,38

Conclusion This epidemiological study through a structured questionnaire completed by general practitioners shows that a high level of statistically analysable data could be obtained within a reasonable period, but it requires a critical approach. This study model could be extended to other countries to enable a comparative analysis for different parts of the world. Three-quarter of the patients with venous insufficiency were women with a BMI of 26.2. A family history of varicosity was present in more than half of the cases, and more than 2/3 of the patients had had one or more pregnancies. Venous insufficiency was bilateral in 3/4 of the patients with the presence of varices, oedematous swelling and/or telangiectasis in 3/4 of the patients; the most frequent symptoms were a feeling of heaviness (3/4 of the patients), swelling of a leg (1/2 of the patients), cosmetic inconvenience (1/2 of the patients) and sporadic night cramps. About one-fourth of the patients had complications of the ‘trophic disorder’ type (white atrophy, dermatitis, ulcers). The study confirms the socioeconomic importance of this condition as it was the reason for industrial disablement with an average duration of 23.6 days in 6% of patients. It required hospitalization in 8% of patients with an average stay of nine days and caused early retirement of 1% of the patients. The treatment applied consisted of the usual advice in 3/4 of patients, to wear compression stockings only in 1/4 of patients (this emphasizes the underutilization of compressive therapy) and, finally, to take phlebotonic medication in 2/3 of patients for a period rarely exceeding one year. About 4% of patients were referred for surgery.

J-C Schoevaerdts and I Staelens. Programme for detecting chronic venous insufficiency

This survey also shows how CVD is a frequent issue in the practice of the general practitioner and how education about venous pathology will always be appreciated.

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