Symptoms in individuals with small cutaneous veins

Transcription

1 Symptoms in individuals with small cutaneous veins K Kröger a C Ose b G Rudofsky a J Roesener b and H Hirche b Abstract: The clinical relevance of small cutaneous veins (SCV) is still being discussed. In the Duesseldorf/Essen civil servants study the prevalence of SCV and the individual symptoms and age-dependent changes were analysed. This cross-sectional study recruited 9935 employees; 9100 could be nally evaluated for this analysis. All volunteers were asked to ll out the questionnaire and were clinically examined. Primarily the clinical ndings were documented adapted to the Basel Study and later modi ed according to the CEAP classi cation: (a) class 0 no visible or palpable clinical signs of venous disease (b) class 1 small cutaneous veins (c) class 1 reticular veins (d) class 2 varicose veins. In all 64% of the volunteers had no signs of venous disease (class 0: age years); 10% had small cutaneous veins (class 1: age years). SCV was more frequent in females (25%) than in males (6%). Only 5% of those with SCV had already consulted a physician. A striking result was that individuals with SCV generally complained about more leg symptoms of which leg swelling and muscle cramps during the night were the most frequent. Continual leg swelling was reported by 24% of individuals with SCV as opposed to 10% of those without. Leg cramps and restless legs also were more often documented in individuals with SCV (29% vs 22% and 10% vs 7%). These ndings were all statistically signi cant (p 0.001). After adjusting for age and sex though there were few or no differences between groups (leg swelling: odds ratio (OR) 1.3; 95% con dence interval (95% CI) and cramps: OR 1.1; 95% CI ). A gender separate estimation of the rates showed that females suffer more often from any symptom. Regarding leg cramps restless legs and itching the OR were not different for females and males. For leg swelling the ageadjusted OR were signi cant for women (OR 1.4; 95% CI ) compared with men (OR 1.1; 95% CI 0.7 2). Individuals with SCV seem to have more symptoms compared with healthy people. However this analysis shows that age and sex are the most relevant explanations for these symptoms. Key words: cramps; epidemiology; itching; restless leg; small cutaneous veins; swelling; varicose veins Introduction Varicose veins are frequently found in humans. Owing to the broad spectrum of manifestations the importance of varicose veins as a clinically signi cant syndrome is dif cult to assess. In most countries half the adult population show signs of venous disease that they consider to be dis- guring (women 50±55% men 40±50%) but fewer than half of these will have visible varicose veins (women 20± 25% men 10±15%). 1 2 Most epidemiologic studies concentrate on trunk varicose veins and do not systematically differentiate their results with regard to reticular varices or small cutaneous veins (hyphenweb varices intradermal veins or spider veins). 3 4 Although small cutaneous veins are the most frequent venous disease their clinical role remains unclear. 5 Only in one age-strati ed sample of 1566 individuals with small cutaneous veins were these found to a Department of Angiology and b Institute of Medical Informatics Biometry and Epidemiology University of Essen Germany Address for correspondence: Knut KroÈger Department of Angiology University Hospital Essen Hufelandstrasse Essen Germany. Tel: ; Fax: ; knut.kroeger@uniessen.de Ó Arnold 2002 be related to leg symptoms such as heaviness tension or swelling (in women only). 6 To investigate the clinical relevance of small cutaneous veins (SCV) in a larger population we analysed the prevalence of SCV as well as the individual symptoms and agedependent symptom changes in the Duesseldorf/Essen civil servants study. Population and Methods This cross-sectional study was conducted in a population of civil servants in the German cities of Duesseldorf and Essen. From December 1989 to July 1993 a total of 9935 employees were recruited and 9100 of these could be evaluated for the varicose veins examination (Figure 1). All volunteers were asked to ll out a questionnaire and were clinically examined. The questionnaire consisted of 17 items 11 of which referred to the venous system (see Appendix I). After receiving instructions they lled out the questionnaire by themselves. Clinical examinations were performed by trained investigators in rooms kept at constant room temperature while the volunteers were standing. Clinical ndings regarding the veins were differentiated into four classes adapted from those used in the Basel study 7 : (a) no varicose veins at all / x02vm416oa

2 14 K KroÈger et al Volunteers examined n = 9935 n = 9813 after exclusion of volunteers with age < 20 or > 70 or relevant missing values n = 9802 after exclusion of volunteers with missing/wrong venous data n = 9261 after exclusion of volunteers with prior operative treatment or sclerotherapy n = 9100 after exclusion of volunteers with class 4 6 class 0: without varicosis n = 5813 class 1: reticular veins class 2: varicose veins n = 2360 class 1: SCV n = 927 Figure 1 The number of volunteers examined and the decision tree leading to the number nally included in this analysis. (b) small cutaneous veins (SCV) only (c) reticular veins (d) trunk varicose veins (any varicose veins of the small and/or large saphenous veins or their side branches). Nowadays the CEAP classi cation is more common. Therefore the clinical ndings were adapted to the CEAP classi- cation 8 : (a) class 0 ± no visible or palpable clinical signs of venous disease (b) class 1 ± small cutaneous veins (c) class 1 ± reticular veins (d) class 2 ± varicose veins. The splitting of class 1 is necessary because the differentiation of small cutaneous veins and reticular veins is not provided in the CEAP classi cation. Additionally clinical signs of chronic venous insuf ciency such as trophic skin changes haemosiderosis or prior ulceration were documented. These signs would have assigned those affected to the CEAP classes 4 to 6. Aetiologic and anatomic classi cation was made on the basis of the questionnaire in combination with the clinical ndings to recognize secondary varicose veins and involvement of the deep veins. SCV were de ned as intradermal veins with a maximal diameter of 1 mm at the thigh and calf (Figure 2). Intradermal veins below the medial malleolus (also called `corona phlebectatica paraplantaris ) were de ned as a symptom of chronic venous insuf ciency and not accepted as isolated SCV. Reticular veins were de ned as dilated or tortuous subcutaneous veins larger than 1 mm not associated directly with the large or small saphenous veins or their ectatic side branches. Population A total of 57% were male and 43% were female. Distribution of age is shown in Figure 3. The results of the clinical examination are shown in Table 1: 64% (mean age: years) were assigned to class 0 (C0E0A0P0) according to the CEAP classi cation and 10% to class 1 (C1EpAsPr) showing SCV (age: years). The remaining 26% had more pronounced forms of varicose veins. The prevalence of SCV reticular veins and large varicose veins were higher in women and increased with age in both men and women (Figure 4). Figure 2 A typical nding of SCV at the inner side of the distal left thigh. The veins are intradermal the diameters are 1mm and additional reticular veins are not seen. n Figure The age distribution of enrolled volunteers. Table 1 Rates of males and females with different forms of varicose veins according to the CEAP classi cation. CEAP classi cation Males Females Total Class (74%) 2007 (51%) 5813 (64%) Class 1 SCV 243 (5%) 684 (17%) 927 (10%) Class 1 reticular 673 (13%) 870 (22%) 1543 (17%) veins Class 2 varicose 444 (8%) 373 (10%) 817 (9%) veins Total 5166 (100%) 3934 (100%) 9100 (100%) Statistics Associations between the prevalence of SCV and clinical symptoms were analysed with Fisher s exact test. These associations were further examined after adjusting for age and gender. Adjusted odds ratios (OR) and their con dence intervals (CI) were estimated. Results SCV were more frequent in females (25%) than in males (6%) and increased with age. Only 5% of those with SCV had already consulted a physician.

3 Symptoms in individuals with small cutaneous veins % No. of enrolled individuals % male female 80% 30% Yes No 60% 10% 0% Male 57% Female 43% Class 0 Class 1 SCV Class 1 reticular veins Class 2 varicose veins Figure 4 Males and females are shown separately for 10- year age groups. Each column gives the rate of individuals with class 0 class 1 SCV class 1 reticular veins and class 2 varicose veins. Table 2 The rates of different symptoms are given separately for those with class 0 and those with class 1 (SCV only) including unadjusted p-values. Class 0 Class 1 p values SCV Leg swelling 10% 24% Leg swelling in the evening 5% 13% Swelling in the summer 1% 2% = Muscle cramps during the 22% 29% night Restless legs 7% 10% Itching 11% 13% = 0.08 Individuals with SCV generally complained about more symptoms of which `leg swelling and `muscle cramps during the night were the most frequent (Table 2). `Leg swelling was reported by 24% of those with SCV as opposed to 10% of those without. `Leg cramps and `restless legs were also more often mentioned by individuals with SCV (29% vs 22% and 10% vs 7%). These ndings were all statistically signi cant (p 0.001). Figure 5 shows the differences for the symptom `leg 0% Figure 6 Rates of individuals who complained about leg cramps during the night and those who did not given as a percentage of all those with SCV. swelling in the evening in males and females with increasing age; Figure 6 shows this for `muscle cramps during the night. After adjusting for age and sex no signi cant differences could be shown for the symptoms `cramps `restless legs and `itching. The symptom `leg swelling reached statistical signi cance but showed an OR of 1.3 only (OR 1.3; 95% CI 1.1±1.6). A similar OR could be shown for `leg swelling in the evening (OR 1.4; 95% CI 1.1±1.7). Sex and age showed the strongest association with SCV (Figure 7). A gender separate estimation of the rates showed that females suffer more often from any symptom. Regarding `cramps `restless legs and `itching the OR were no different for females and males. For `leg swelling the ageadjusted OR were signi cant for women (OR 1.4; 95% CI 1.1±1.7) compared with men (OR 1.1; 95% CI 0.7±2). Owing to the low number of males complaining of `leg swelling in the evening (2.6% of all men) and `leg swelling in the summer (0.4% of all men) an age-adjusted separate analysis of these symptoms is not meaningful. Sex* Age (< 40 > 40 years)* Leg symptoms during the night: 50% male female cramps restless legs 30% Yes No itching none of these Swelling of legs: 10% 0% Figure 5 Rates of individuals who complained about leg swelling during the night and those who did not given as a percentage of all those with SCV. generally* in the evening* in the summer* Figure 7 Odds ratios for sex age and different leg symptoms after adjustment for age and gender (* indicates the symptoms that were signi cantly different).

4 16 K KroÈger et al Discussion Clinical symptoms of varicose veins range from dysthesia pain discomfort cramps aching legs sensation of heat restless or tired legs and itching or swelling to skin changes with recurrent ulcers. Although the severity of symptoms is supposed to increase with the severity of varicosity the individual symptoms show much variation. In the `Consensus statement of chronic venous disorders in the leg 4 the clinical relevance of SCV is not clearly de ned. SCV are frequently treated by sclerotherapy and patients usually report an improvement of symptoms afterwards Scienti c evidence for the necessity of treatment (even for compression) has not been shown until now. Quanti cation and objecti cation of venous symptoms is dif cult. For classi cation of the venous disease according to the CEAP system 8 individual leg symptoms are not necessary at all. The more recently published VCSS (venous clinical severity score) considers only pain and oedema as clinical symptoms. 1 1 Other leg symptoms that are dif cult to quantify are relevant for quality of life questions only. Our cross-sectional study took place between 1989 and 1993 and aimed to obtain epidemiological data regarding vascular disease. The population consisted of civil servants in the cities of Duesseldorf and Essen. Our ndings as related to the percentage of people suffering from different forms of varicose veins (36%) the higher rate of varicose veins in females and the age-dependent increase are comparable to other epidemiological studies Symptoms such as `muscle cramps during the night `itching and `restless legs were statistically unrelated to the presence of SCV after adjusting for sex and age. The symptom `leg swelling was statistically correlated with the presence of SCV but showed a low OR. Thus we considered its clinical relevance to be low. All symptoms analysed were predominantly associated with gender (OR 7) and age (OR 2.5). The study conducted by Bradbury et al 6 also reports clinical symptoms of patients with SCV and showed similar data. Indeed `leg swelling was a frequent nding in their study too. In that study 7.8% of people without SCV and 19.8± 22.2% of those with SCV reported swollen legs (compared to 10% and 24% of the volunteers in our study). Muscle cramps were reported by 31% of men and 38% of women without trunk varicose veins. 6 Detailed data regarding people with SCV were not given. Their percentages were higher than ours for `muscle cramps during night (22% of healthy people and 29% of those with SCV). Another study comparing the symptoms of 288 patients with different forms of varicose veins with 356 control patients revealed muscle cramps at night in 78% of patients and 52% of controls. 3 A more detailed differentiation of patients with SCV was not given but a rate of 52% of controls complaining of muscle cramps during the night appears rather high. Our study results are comparable with the results found by Bradbury et al. 6 Unfortunately they did not report ORs. Although both their study and our data revealed a signi cant correlation of SCV with the symptom `leg swelling especially in females the clinical impact can be assumed to be low (see above). The question of whether swelling is directly caused by the SCV or whether both swelling and SCV occur independently in predisposed people remains unclear. Speci c characteristics of the soft tissue may explain both SCV and leg swelling. Conclusion Individuals with SCV seem to have more leg symptoms compared with healthy people. The symptom `leg swelling in particular is statistically more frequent in people with SCV. However our analysis shows that age and sex are the most relevant explanations for these symptoms. Further investigations are necessary to de ne the reasons for SCV and to come to a better understanding of the underlying pathology. Acknowledgements This epidemiologic study was in part nancially supported by Lipha AG Germany. We thank the cities of Essen and DuÈsseldorf for their support. References 1 Callam MJ. Epidemiology of varicose veins. Br J Surg 1994; 81: 167±73. 2 Smith JJ Garratt AM Guest M Greenhalgh RM Davies AH. Evaluating and improving health-related quality of life in patients with varicose veins. J Vasc Surg 1999; 30: 10±19. 3 Hirai M. Prevalence and characteristics of muscle cramps in patients with varicose veins. Vasa 2000; 29: 269±73. 4 Kurz X Kahne SR Abenhaim L et al. Chronic venous disorders of the leg: epidemiology outcomes diagnosis and management. Int Angiol 1999; 18: 83± Evans CJ Fowkes FG Hajivassiliou CA Harper DR Ruckley CV. Epidemiology of varicose veins. A review. Int Angiol 1994; 13: 263±70. 6 Bradbury AW Evans CJ Allan PL Lee AJ Ruckley CV Fowkes FGR. What are the symptoms of varicose veins? BMJ 1999; 318: 353±56. 7 Widmer LK. Peripheral venous disorders Basel III. Bern: Hans Huber Porter JM Moneta GL an International Consensus Committee on Chronic Venous Disease. Reporting standards in venous disease: an update. J Vasc Surg 1995; 21: 635±45. 9 Weiss RA Weiss MA. Resolution of pain associated with varicose and telangiectatic leg veins after compression sclerotherapy. J Dermatol Surg Oncol 1990; 16: 333± Puissegur Lupo ML. Sclerotherapy: review of results and complications in 200 patients. J Dermatol Surg Oncol 1989; 15: 14± Rutherford RB Padberg FT Comerata AJ Kistner RL Meisner MH Moneta GL. Venous severity scoring: an adjunct to venous outcome assessment. J Vasc Surg 2000; 31: 1307± Evans CJ Fowkes FG Ruckley CV Lee AJ. Prevalence of varicose veins and chronic venous insuf ciency in men and women in the general populations: Edinburgh vein study. J Epidemiol Community Health 1999; 53: 149±53. Appendix I: Excerpts from the questionnaire 1) Did you experience prior trauma to your legs or feet? right/left 2) Do you have varicose veins? right/left/both 3) Have you seen a doctor because of your varicose veins?

5 Symptoms in individuals with small cutaneous veins 17 4) Have you ever received treatment for your varicose veins? Compression bandages or stockings Operation/sclerotherapy Pharmaceutical treatment 5) Did your father/mother/ grandfather/grandmother have varicose veins? 6) Have you ever had a phlebitis? 7) Have you ever had a thrombosis or pulmonary embolism? 8) Did you notice swelling of the legs ankles or feet in the last months? At which time of day? In the morning/in the evening/all day In which season? In winter/in summer/all year 9) Which leg symptoms do you have at night? 10) Have you ever had ulcers on the legs? 11) Did or do you take an oral contraceptive? Muscle cramps Restless legs `Pins and needles No symptoms If yes for how many years?