Outcomes in varicose vein disease

Abstract

Introduction Varicose veins are a common problem with 25-50% of the population symptomatically affected, and chronic venous disease leads to significant impairments in quality of life with substantial health system cost implications. Significant variability exists in the symptoms suffered by patients, the treatment offered and the outcomes achieved. Identification of the optimal treatment pathways for patients remains difficult.

Aims i. To ascertain primary care disease knowledge. ii. To assess what affects treatment and identify which patients benefit most. iii. To generate a predictive model of varicose vein outcomes. iv. To assess the impact of altering treatment of varicosities in the context of endovenous truncal vein ablation v. To investigate the early impact of new technologies

Methods i. Two survey studies were completed: ⁃ 21 questions assessing venous disease management pathways was disseminated to General Practitioners. ⁃ 19 questions assessing the management of superficial venous thrombosis and was distributed to General Practitioners and Vascular Surgeons. ii. A cohort of consecutive patients with symptomatic chronic venous disease were assessed and completed quality of life questionnaires pre and postintervention.

iii. Uni-variable and multi-variable analysis of patient cohort data to facilitate the creation of generalised model of venous treatment outcomes iv. A randomised clinical trial assessing the timing of varicosity avulsion in the context of local anaesthetic endovenous truncal ablation. ⁃ Ambulatory Varicosity avUlsion Later or Synchronised (AVULS) trial. v. Assessment of new technologies ⁃ The European Sapheon Closure system Observed ProspectivE (eSCOPE) study a multi-site cohort observational study of cyanoacrylate glue occlusion of truncal vein incompetence ⁃ The VNUS Versus Clarivein for Varicose Veins (VVCVV) multi-centre randomised clinical trial comparing the procedural pain profile of radiofrequency and mechanochemical ablation.

Results i. Education outcomes ⁃ 138 responses were received. The management of chronic venous disease in the primary care setting is disparate and knowledge of current techniques is poor, despite extensive guidance. ⁃ 369 responses were received, from 197 vascular specialists and 172 primary care physicians. Superficial thrombophlebitis management is shown to be diverse and does not adhere to recent evidence. ii. 461 patients were recruited. Patients suffering from chronic venous disease suffer from substantial quality of life impairment, including previously under-recognised depressive symptoms. Treatment of the underlying venous condition provides relief from venous symptoms and improves quality of life. ⁃ Patient symptoms and quality of life do not correlate with anatomical vein diameter, however clinical severity scores do. iii. Predictive modelling produces models that account for 30-41% of the variability in post-operative scores for disease specific quality of life tools, generic quality of life tools, and clinical severity scores.

iv. The AVULS trial recruited 101 patients. Simultaneous treatment leads to improved clinical outcomes at up to 1 year and early quality of life improvement. Delayed treatment has a significantly increased risk of requiring further treatment (Odds Ratio 27.78, Relative Risk 18.36, p<0.0001). 95% of patients declining randomisation opted for simultaneous treatment. v. New Technology Outcomes ⁃ The eSCOPE study recruited 70 patients in Europe with good technical outcomes. ⁃ The VVCVV trial (ongoing) has recruited 85 patients, with significantly reduced procedural pain found with mechanochemical ablation.

Conclusions Varicose veins are a widespread problem with effective treatment that leads to a significant improvement in quality of life. Education and communication between community and hospital-based medicine is lacking. Predictive modelling of varicose vein symptoms remains difficult due to the multifactorial nature of the disease. Simultaneous treatment of varicosities during endovenous truncal ablation produces improved outcomes and is the option of choice for most patients. Early data on new technologies show they provide less painful procedures with similar outcomes as the established modalities.