The lymphatic system can compensate for the increase in fluid outflow into the surrounding tissues in the early stages of the disease. Studies of the mechanism of tissue injury at the different stages of CVD show how changes in venous pressure and hemodynamic forces particularly fluid shear stress, the force exerted on venous walls that is predominantly linked to blood speed lead to cellular and biochemical disorders.
Leukocytes, due to their ability to respond to physical stimulation, are now known to play a key role in the resultant tissue injury that leads to the development of CVD symptoms, varicose veins, edema, and ulcers. A key event in CVD is valve failure, which leads to increased venous hypertension, maintains a vicious circle of inflammatory events, and causes eventual venous complications. Both general practitioners and specialist doctors have to deal with CVD.
Specific tools capable of assessing the full spectrum of CVD, its signs and symptoms, impact on QOL, and treatment effects are key to the efficient management of the disease. Assessment tools in CVD can be categorized into two classes those for symptoms and those for CVD-related signs and are summarized below 20 :. The scoring system by P.
Updating guidelines in chronic venous disease: what is needed? - MedicographiaMedicographia
Carpentier is a patient-administered diagnostic tool combining 4 criteria worth 1 mark each, which allows leg symptoms to be ascribed to CVD if the threshold level is equal to or greater than 3. Blanchemaison, which includes questions about the frequency of symptoms, helps predict the risk of developing CVD. Of the various instruments that are available to physicians to measure symptoms such as pain, the most widely validated is the cm visual analogue scale. This type of scale provides patients with an easy and rapid means to express the intensity of their pain and has numerous applications, including in CVD.
Other types of scale, such as numerical rating scales, are usually graded from 0 to 4, 0 to 5, or 0 to These scales allow the measurement of pain both during the medical visit and retrospectively, and are also used in the evaluation of treatment in CVD. The tools used to assess patient-reported outcomes consist mainly of QOL scales that may be either generic or disease-specific.
CIVIQ has been used extensively, as reported in numerous studies some of which included large samples of patients. All four specific questionnaires above were used in conjunction with the item Medical Outcome Study health survey Short Form MOS SF , a generic health-related QOL instrument whose validity, reproducibility, and responsiveness to changes over time have been well demonstrated.
These instruments may be used to evaluate any stage of CVD in patients, although they are imperfect in the early stages. Vein diameter can be measured on duplex scan investigation. Numerous techniques are available for the assessment of venous ulcers, ranging from the simple use of tracings to more sophisticated methods requiring the use of cameras, videos, and computers.
With either treatment of the greater saphenous vein, the tributary veins at the femoral saphenous junction are spared, leaving a long saphenous stump. Currently, two of the most frequently cited causes of restripping are inadequate sectioning of saphenous vein tributaries at the saphenous junction and leaving too long a saphenous stump. Despite this, it would seem that the 5-year results using these techniques are at least similar to and in fact often better than those of traditional stripping. Another great addition to these techniques is foam sclerotherapy, which gives the same excellent results at remarkably low cost.
Guideline developers have used a bewildering variety of systems to rate the quality of the evidence underlying their recommendations.
Some are facile, some confused, and others sophisticated but complex. The recent documents that reported recommendations in CVD used several systems. Selection of RCTs is done by classifying trials as level A low risk of bias , level B moderate risk of bias , or level C high risk of bias.
A total of 10 Cochrane reviews have been published in CVD since In European guidelines on CVD management, studies were classified as: grade A at least two RCTs with large sample sizes,meta-analyses combining homogeneous results , grade B RCTs with small sample sizes, single RCT , or grade C other controlled trials, nonrandomized controlled trials. Table I. These recent ACCP guidelines have made specific changes with recommendations and suggestions linked to objective grades. This new approach provides a system for rating the quality of evidence and the strength of recommendations that is explicit, com- prehensive, transparent, and pragmatic.
Management of venous leg ulcers in general practice – a practical guideline
That is why it is widely used in North America: 25 organizations have already adopted it, and it is increasingly being adopted by other organizations worldwide. The task of building international guidelines is challenging, particularly in the venous field. This is because of the large spectrum of disease manifestations and either the lack of validated methods or the weak consensus for methods that have been adopted for assessing symptoms, signs, and QOL, not to mention the resource constraints that vary considerably from region to region.
Even if much still remains to be done to get the high-quality scientific studies needed to support the development of guidelines, we are at a point where a lot of progress in standardization, classification, fundamental research, and assessment methods has been made in a short time. Let us hope that we can continue to advance in the same way. References 1. Nomenclature of the veins of the lower limbs: an international interdisciplinary consensus statement. J Vasc Surg. Nomenclature of the veins of the lower limbs: extensions, refinements, and clinical application.
Duplex ultrasound investigation of the veins in chronic venous disease of the lower limbs—UIP Consensus Document.
Part II. Eur J Vasc Endovasc Surg. Reporting standards on venous disease: an update. Revision of the CEAP classification for chronic venous disorders: consensus statement. Venous severity scoring: An adjunct to venous outcome assessment. Comerota AJ. Chronic venous disorders of the leg: epidemiology, outcomes, diagnosis and management.
Venous Insufficiency Epidemiologic and Economic Studies. Int Angiol.
Diagnosis, Investigations, Management, and Progression
Prevalence of varicose veins and chronic venous insufficiency in men and women in the general population: Edinburgh Vein Study. J Epidemiol Community Health. Chronic venous insufficiency and venous ulceration. J Gen Intern Med. International Task Force. The management of chronic venous disorders of the leg: an evidence-based report of an international task force.
The French venous disease surgery: epidemiology, management, and patient profiles. Quality of life in venous disease. Thromb Haemost. Quality of life in patients with chronic venous disease:SanDiegopopulation study. Quality of life in chronic venous insufficiency. An Italian pilot study of the Triveneto Region. Leg ulcer point prevalence can be decreased by broad-scale intervention: a follow-up cross-sectional study of a defined geographical population.
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Prevalence of venous leg ulcer: the importance of the data collection method. Jawien A. Unmet needs in the assessment of symptoms and signs related to chronic venous disease. Application to Daflon mg. Allegra C, Carlizza A. Oedema in chronic venous insufficiency: physiopathology and investigation. Allegra C. Patients with chronic venous disease—related symptoms without signs: prevalence and hypotheses. Clinical and hemodynamic significance of corona phlebectatica in chronic venous disorders.