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302 Chapter 33/Classifi cation and Treatment of Recurrent Varicose Veins
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TABLE 33.1 REVAS Classifi cation Form
Date of examination
Day Month Year
Patient Name:
—First name or given name
—Last name or family name
T Topographical sites of REVAS
Since more than one territory may be involved several boxes may be
ticked
g Groin 䊐
t Thigh 䊐
p Popliteal fossa 䊐
l Lower leg including ankle and foot 䊐
o Other 䊐
S Source(s) of Refl ux
Since more than one source may be involved several boxes may be
ticked
0 No source of refl ux 䊐
1 For pelvic or abdominal 䊐
2 Saphenofemoral junction 䊐
3 Thigh perforator(s) 䊐
4 Saphenopopliteal junction 䊐
5 Popliteal perforator 䊐
6 Gastrocnemius vein(s) 䊐
7 Lower leg perforator(s) 䊐
R Refl ux (Degree of Refl ux)
Only one box can ticked
PROBABLE Clinical signifi cance R+ 䊐
UNLIKELY Clinical signifi cance R− 䊐
UNCERTAIN Clinical signifi cance R? 䊐
N Nature of sources
Only one box can be ticked
N classifi es the source as to whether or not it is the site of previous
surgery and describes the cause of recurrence.
N Ss is for same site 䊐
Only one box can be ticked
Technical failure 䊐
Tactical failure 䊐
Neovascularization 䊐
Uncertain 䊐
Mixed 䊐
N Ds is for different (new) site 䊐
Only one box can be ticked
Persistent 䊐
(Known to have been present at the time of previous surgery)
New 䊐
(Known to have been absent at the time of previous surgery)
Uncertain/not known 䊐
(insuffi cient information at the time of previous surgery)
C Contribution from persistent incompetent saphenous trunks
Since more than one territory may be involved several boxes may be
ticked
AK great saphenous (above knee) 䊐
BK great saphenous (below knee) 䊐
SSV small saphenous 䊐
O Other 䊐
N Neither 䊐
Comment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
F Possible contributory factors
Several boxes may be ticked
gF General factors
Family history 䊐
Obesity 䊐
Pregnancy 䊐
Oral contraceptive 䊐
Lifestyle factors 䊐
Pregnancy since the inital operation 䊐
Professional activity 䊐
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 䊐
sF Specifi c factors
Several boxes may be ticked
Primary deep vein refl ux 䊐
Post thrombotic syndrome 䊐
Iliac vein compression 䊐
Congenital vascular malformation 䊐
Lymphatic abnormality 䊐
Calf pump dysfunction 䊐
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 䊐
family history, obesity, pregnancy, oral contraceptive, lifestyle factors (pregnancy since the initial operation, professional activity, other). sF (specifi c factors): primary deep
venous incompetence, post-thrombotic syndrome, iliac
vein compression, congenital vascular malformation,
lymphatic abnormality, calf pump dysfunction, other.
Compression
Compression in varicose veins is frequently recommended and improves both symptoms and signs, but it does
not cure the disease.
TREATMENT
Methods
Drugs
In varicose veins phlebotonic drugs are prescribed mainly
to improve edema and symptoms. The most commonly used
are fl avanoids, but others exist.
Interventional Procedures
They share the same goals:
• To eliminate refl ux from deep to superfi cial systems
when they do exist
• To eliminate varices
• In some specifi c cases, to suppress deep vein
abnormality to prevent new recurrences
The fi nal objective is multiple: decrease the ambulatory
venous pressure, prevent worsening of chronic venous
Treatment 303
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A
B
D
disorders, avoid further recurrences, and of course, improve
the patients in terms of cosmetic appearance, symptoms, and
signs.
Sclerotherapy
Sclerotherapy has been used for a very long time
for treating REVAS, but ultrasound-guided sclerotherapy
(USGS) has improved the technique. Different protocols
have been used but no comparative study is available.
Recently foam USGS has entered the ring, but no consensus
exists on the techniques, doses, concentrations, or sclerosing
agents. Nevertheless one of the main advantages of sclerotherapy with or without foam is that the process is simple
and repeatable.
C
FIGURE 33.1 REVAS related to a nonfl ush resection of the sapheno-
femoral junction in a patient with an incompetent terminal valve. A. Patient
view. B. Same patient. Refl ux at the saphenofemoral junction through the
saphenous stump illustrated by inducing a Valsalva maneuver during a
dynamic popliteal phlebography. C. Same patient. Color duplex ultrasound.
Massive refl ux induced by a Valsalva maneuver. D. Same patient,
scheme.
Surgery
Procedures can be classifi ed into three groups according
to their objective, and should be used in combination.
The fi rst group gathers techniques that aim to eliminate
refl ux from deep to superfi cial systems. At the saphenofemoral or saphenopopliteal junctions, the site usually has been
previously operated, and according to the extent of postoperative fi brosis, redo surgery may be diffi cult. It is
recommended to approach the deep vein fi rst in order to
avoid dissection of scar tissues, lymphatic nodes, and cavernoma. Flush ligation of the stump and patch interposition is
recommended.
9
The second procedure of this group consists of perforator
ligation. When severe cutaneous and subcutaneous changes
304 Chapter 33/Classifi cation and Treatment of Recurrent Varicose Veins
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C
A
B
FIGURE 33.2 REVAS related to neovascularization in a patient who had a fl ush resection of the saphenofemoral
junction. A. Patient view. B. Same patient. Refl ux at the saphenofemoral junction through multiple small caliber channels by inducing a Valsalva maneuver during a dynamic popliteal phlebography. C. Same patient, duplex scanning.
Refl ux induced by a Valsalva maneuver is identifi ed in several small caliber channels. D. Same patient, scheme.
are present, subfascial endoscopic perforator surgery (SEPS)
is the favored technique.
The second group includes procedures that aim to eliminate or obliterate the refl uxing varices. According to the
location and type of varicose veins, various techniques can
be used: stab avulsion and phlebectomy are the most used
techniques, and stripping or endovascular obliteration (laser,
radiofrequency) usually are reserved for treating the residual
saphenous trunk.
D
The third group is represented by procedures whose goal
is to suppress deep vein refl ux, as several studies demonstrated that primary extended deep incompetence (refl ux
grade 4 according to Kistner) frequently is associated with
REVAS.
30,31
Embolization and Coils
In patients whose varices are fed by pelvic or gonadal
refl ux this procedure has now replaced direct ligation.
17
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Results
Compression and Drugs
We have no specifi c data on the effi cacy of compression
treatment and drugs in patients with REVAS.
Sclerotherapy
The effi cacy of sclerotherapy using one protocol has
been reported on a large series (253 legs) with a follow-up
of 3.1 ± 1.7 years (range 1.5–5.7 years).
18
The cumulative obliteration rate was sustained at >90%
and there was a signifi cant decrease in the venous dysfunction score. Unfortunately the endpoint of sclerotherapy sessions is not given.
No data have yet been published with foam techniques.
Surgery
Surprisingly very few data are available on the results
provided by redo surgery in patients investigated preoperatively with DS.
I reported a series of 145 limbs with a fi ve- to six-year
follow-up.32 All had major refl ux from the deep system
feeding recurrent varices that were treated by surgery. Postoperative sclerotherapy was performed in all patients during
the fi rst two years. An external audit revealed a global objective improvement of 85%, but there was better improvement
of signs and symptoms than cosmetic appearance.
The results of two studies using an interposition patch for
treating recurrence at the saphenofemoral junction (SFJ)
have been published. Creton,5 using this procedure without
resection of the groin cavernoma but with combined resection of varices (saphenous trunks and/or tributaries), had
only 4.2% recurrences at the SFJ at 4.9 years mean followup (range 3 to 7 years) in 119 extremities. Nevertheless,
22.6% of patients had diffuse varices, with a new site of
incompetence between the deep and femoral systems.
De Maeseneer9 has compared the results at fi ve years of
two nonrandomized groups with and without patch in a prospective study. All patients had recurrent SFJ incompetence.
The results were signifi cantly better in terms of absence
of recurrent thigh varicosities and neovascularization in the
patch group.
Embolization
At six months follow-up, 90% of 215 patients treated by
embolization of gonadal and pelvic veins were signifi cantly
improved in both signs and symptoms.
17
Indications for Treating REVAS
Patients with REVAS can be roughly divided into two
groups:
• Patients complaining of symptoms or esthetic concerns,
or presenting with signs of chronic venous disease (C2–
C6). In all cases these patients need to be investigated
by DS.
• Subjects attending a routine follow-up. The decision
whether to undertake DS or not depends on the
presenting complaint and physical fi ndings. In practice
DS is almost always done.
Asymptomatic Patients
When hemodynamic abnormalities are found in asymptomatic patients without severe signs who are not concerned
by their minor varices as cosmetic problems the decision to
treat depends of the severity of the noninvasive fi ndings. In
all cases follow-up is required knowing that abnormal DS
fi ndings precede symptoms and signs.
Symptomatic Patients
In symptomatic patients presenting with recurrent varices
and hemodynamic anomalies, treatment must be considered.
At the REVAS conference in 1998 we agreed that there was
no consensus for recommending sclerotherapy, surgery, or a
combination of both when active treatment was needed.
Seven years later one cannot provide either grade A or B
recommendations.
Sources of Refl ux
Concerning the treatment of sources of refl ux, surgery
was considered the best option in patients where a major
refl ux was identifi ed at the SFJ, but there is no evidence that
USGS does not give the same results. If redo surgery is
undertaken a silicone or PTFE patch on the common femoral
vein is recommended.
In the presence of recurrent refl ux at the saphenopopliteal
junction, sclerotherapy generally is used since redo surgery
is sometimes diffi cult, but again there is no evidence that
one method is better than the other.
Thibault reported early favorable results when treating incompetent perforators with USGS.
popular when dealing with recurrent varices fed by leg or
thigh perforators, but in patients with ulcer SEPS it is the
recommended method.
Major pelvic refl ux is a good indication for embolization,
but minor refl ux can be treated as a fi rst step by USGS.
The Varicose Network
When a persistent incompetent saphenous trunk is present,
pin stripping or endovenous procedures (laser, RF) or USGS
are possible options according to the experience and habits
33
This method is
306 Chapter 33/Classifi cation and Treatment of Recurrent Varicose Veins
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of the practitioner. For other varices USGS and stab avulsion
are appropriate.
Ferrara11 relies on preprocedural bandage effi cacy to
compress the recurrent veins for treating patients with
sclerotherapy.
Associated Deep Refl ux
In patients with primary deep vein refl ux grade 4 and C
4b–6, valvuloplasty must be considered in active patients
reluctant to wear lifelong compression or with recurrent
1
ulcer.
GUIDELINES FOR PROSPECTIVE STUDIES
In order to know the prevalence and annual incidence of
REVAS we need prospective studies well documented in
detail from the outset of surgical treatment as in Kostas’
16
series.
These studies may give information on:
• The value of routine postoperative scanning in the early
detection of persisting refl ux;
• The relationship between hemodynamics and clinical
recurrence;
• The possible role of compression therapy and/or
complementary postoperative sclerotherapy in
preventing recurrence;
To identify what is the best method, when REVAS has
occurred, prospective randomized studies using different
treatments are needed. These studies may use both the
updated CEAP and REVAS classifi cation and a quality of
life questionnaire.
CONCLUSION
REVAS is a frequent condition frustrating both patients
and physicians that has been poorly evaluated. In order to
build a scientifi cally convincing evidence base and to achieve
a greater degree of comparability between studies, an international consensus on conformity is required.
References
1. Perrin M, Guex JJ, Ruckley CV, dePalma RG, Royle P, Eklof B et al.
Recurrent varices after surgery (REVAS), a consensus document, Cardiovasc Surg. 2000. 8: 233–245.
2. Beresford T, Smith JJ, Brown L, Greenhalgh RM, Davies AH. A com-
parison of health-related quality of life of patients with primary and
recurrent varicose veins, Phlebology. 2003. 18: 35–37.
3. Blomgren L, Johansson G, Dahlberg-Akerman A, Norén A, Brundin
C, Nordström E, Bergqvist D. Recurrent varicose veins: Incidence, risk
factors and groin anatomy, Eur J Vasc Endovasc Surg. 2004. 27:
269–274.
4. Creton D. Surgery of great saphenous vein recurrences: The presence
of diffuse varicose veins without a draining residual saphenous trunk
is a factor of poor prognosis for long-term results, JP. 2002. 2:
83–89.
5. Creton D. Surgery for recurrent saphenofemoral incompetence using
expanded polytetrafl uoroethylene patch interposition in front of the
femoral vein: Long-term outcome in 119 extremities, Phlebology.
2002. 16: 93–97.
6. De Maeseneer MG. The role of postoperative neovascularisation in
recurrence of varicose veins: From historical background to today’s
evidence, Acta Chirurgica Belgica. 2004. 104: 281–287.
7. De Maeseneer MG, Tielliu IF, Van Schil PE, De Hert SG, Eyskens EJ.
Clinical relevance of neovascularization on duplex ultrasound in long
term follow-up after varicose vein operation, Phlebology. 1999. 14:
118–122.
8. De Maeseneer MG, Giuliani DR, Van Schil PE, De Hert SG. Can
interposition of a silicone implant after sapheno-femoral ligation
prevent recurrent varicose veins, Eur J Vasc Endovasc Surg. 2002. 24:
445–449.
9. De Maeseneer MG, Vandenbroeck CP, Van Schil PE. Silicone patch
saphenoplasty to prevent repeat recurrence after surgery to treat recurrent saphenofemoral incompetence: Long-term follow-up study, J Vasc
Surg. 2004. 40: 98–105.
10. Edwards AG, Donaldson D, Bennets C, Mitchell DC. The outcome of
recurrent varicose veins surgery, Phlebology. 2005. 20: 57–59.
11. Ferrara F, Bernbach HR. La sclérothérapie des varices récidivées,
Phlébologie. 2005. 58: 147–150.
12. Fischer R, Linde N, Duff C. Cure and reappearance of symptoms of
varicose veins after stripping operation—A 34 year follow-up, JP.
2001. 1: 49–60.
13. Fischer R, Linde N, Duff C, Jeanneret C, Chandler JG, Seeber P. Late
recurrent saphenofemoral junction refl ux after ligation stripping of the
greater saphenous vein, J Vasc Surg. 2001. 34: 236–240.
14. Frings N, Nelle A, Tran Ph, Fischer R, Krug W. Reduction of neorefl ux
after correctly performed ligation of the saphenofemoral junction. A
randomized trial, Eur J Vasc Endovasc Surg. 2004. 28: 246–252.
15. Geier B, Olbrich S, Barbera L, Stücker M, Mumme A. Validity of
the macroscopic identifi cation of neovascularization at the saphenofemoral junction by the operating surgeon, J Vasc Surg. 2005. 41:
64–68.
16. Kostas T, Loannou CV, Toulouopakis E, Daskalaki E, Giannoukas AD,
Tsetis D, Katsamouris AN. Recurrent varicose veins after surgery: A
new appraisal of a common and complex problem in vascular surgery,
Eur J Vasc Endovasc Surg. 2004. 27: 275–282.
17. Leal Monedero J, Zubicoa Ezpeleta S, Castro Castro J, Calderón Ortiz
M, Sellers Fernández G. Embolization treatment of recurrent varices
of pelvic origin, Phlebology. 2006. 21: 3–11.
18. McDonagh B, Sorenson S, Gray C, Huntley DE, Putterman P, King T
et al. Clinical spectrum of recurrent postoperative varicose veins and
effi cacy of sclerotherapy management using the compass technique,
Phlebology. 2003. 18: 173–185.
19. Stücker M, Netz K, Breuckmann F, Altmeyer P, Mumme A. Histomorphologic classifi cation of recurrent saphenofemoral refl ux, J Vasc
Surg. 2004. 39: 816–822.
20. van Rij AM, Jiang P, Solomon C, Christie RA, Hill GB. Recurrence
after varicose vein surgery: A prospective long-term clinical study with
duplex ultrasound scanning and air plethysmography, J Vasc Surg.
2003. 38: 935–943.
21. van Rij AM, Jones GT, Hill GB, Jiang P. Neovascularization and
recurrent varicose veins: More histologic and ultrasound evidence, J
Vasc Surg. 2004. 40: 296–302.
22. Winterborn RJ, Foy C, Earnshaw JJ. Causes of varicose vein recurrence: Late results of a randomized controlled trial of stripping the long
saphenous vein, J Vasc Surg. 2004. 40: 634–639.
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23. Wong JKF, Duncan JL, Nichols DM. Whole-leg duplex mapping for
varicose veins: Observation on patterns of refl ux in recurrent and
primary legs, with clinical correlation, Eur J Vasc Endovasc Surg.
2003. 25: 267–275.
24. Browse NL, Burnand KG, Irvine AT, Wilson NM. Disease of the veins.
London: Arnold. 1999. 191–248.
25. Merchant RF, Pichot O, Myers KA. Four-year follow-up radiofrequency obliteration of great saphenous refl ux, Dermatol Surg. 2005.
31: 129–134.
26. Uhl JF, Verdeille S, Martin-Bouyer Y. Three-dimensional spiral CT
venography for the pre-operative assessment of varicose patients,
VASA. 2003. 32(2): 91–94.
27. Stonebridge PA, Chalmers N, Beggs I, Bradbury AW, Ruckley CV.
Recurrent varicose veins: A varicographic analysis leading to a new
practical classifi cation, Br J Surg. 1995. 82: 60–62.
28. Porter JM, Moneta GL. International consensus comittee on chronic
venous disease. Reporting standard in venous disease: An update, J
Vasc Surg. 1995. 21: 635–645.
29. Perrin M, Allaert FA. Intra- and inter-observer reproducibility of the
recurrent varicose veins after surgery (REVAS) classifi cation, Eur J
Vasc Endovasc Surg. 2006.
30. Almgren B, Eriksson I. Primary deep vein incompetence in limbs with
varicose veins, Acta Chir Scand. 1989. 155: 445–460.
31. Guarnera G, Furgiuele S, Di Paola FM, Camilli S. Recurrent varicose
veins and primary deep venous insuffi ciency: Relationship and therapeutic implications, Phlebology. 1995. 10: 98–102.
32. Perrin M, Gobin JP, Grossetete C, Henri F, Lepretre M. Valeur de
l’association chirurgie itérative-sclérothérapie après échec du traitement chirurgical des varices, JMV. 1993. 18: 314–319.
33. Thibault PK, Lewis WA. Recurrent varicose veins. Part 2: Injection of
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CHAPTER
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34
Use of System-Specifi c Questionnaires and
Determination of Quality of Life after Treatment
of Varicose Veins
MERYL DAVIS and ALUN H. DAVIES
INTRODUCTION
Varicose veins are one of the most common conditions
in the Western world. In the United Kingdom approximately
100,000 varicose vein operations are performed per annum.
Long saphenous vein surgery accounts for 90%, with recurrent surgery accounting for 20% of procedures.
Results from the Edinburgh Vein Study estimated the
prevalence of trunk varices to be one third in men and
women aged 18 to 64 years.2 Spider and reticular veins were
noted in 80% of the population. This study was unusual in
that it identifi ed a signifi cantly higher prevalence of truncal
veins in men compared with women; a possible explanation
for this was that previous studies relied on self-assessment
of varicose veins and this resulted in bias because women
are more likely to consult for this condition than men. In the
United States a longitudinal study of a community reported
the prevalence of any varicose veins as 25.9% and 12.9% in
women and men, respectively.
Lower limb venous disease not only causes morbidity but
is expensive; it is estimated that 2% of national health care
resources are spent on treatment.4 Evidence on the effectiveness of various interventions for venous problems is not
clear and the assessment of patient outcome is lacking.5 The
standard method of assessment incorporates quality of life
questionnaires.
3
1
Quality of Life
Quality of life as defi ned by the World Health Organization is a state of complete physical, mental, and social wellbeing, and not merely the absence of disease. However Price
described quality of life as the impact of an illness and its
treatment on disability and daily living.
6
Quality of life
assessment is of value in demonstrating the benefi t of interventions in patients and can be used to measure the benefi t
gained and plan future treatment.
The criteria for an ideal quality of life measure are:
• Equally applicable to any disease process or outcome
• Equally applicable across all levels and degrees of
invalidity
• Proven validity with a high level of convergence within
patient groups when applied across geographic, linguistic, and cultural boundaries
Improving quality of life has become a major focus of interest in medicine; however, most outcome measures assess
much narrower concepts such as impairment and disability.
In 1984 a defi nition of quality of life offered was “the extent
to which our hopes and ambitions are matched by our experience.”8 This defi nition tries to reduce the gap between
patients’ expectations and actual results.
Currently there is no single quality of life tool that fulfi lls
this criteria; this means that a generic tool has to be adopted.
Options include the Nottingham Health Profi le (NHP),
EuroQol (EQ), Frenchay Activities Index (FAI), or McGill
Short Form Health Survey (SF-36). The International Quality
of Life Assessment (IQOLA) project was an undertaking to
translate and adapt the SF-36 questionnaire and validate it
in all major languages, thereby making it an international
scale of health-related quality of life.
Instruments used to measure quality of life are classifi ed
into generic and disease-specifi c instruments. Generic instruments allow comparison across populations of patients with
different diseases, whereas disease-specifi c instruments are
sensitive to key dimensions of quality of life that are affected
by specifi c diseases. Therefore combining the two is the
preferred strategy when examining quality of life.
7
9
The Vein Book
309
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Copyright © 2006, Elsevier Inc.
310 Chapter 34/Use of System-Specifi c Questionnaires and Determination of Quality of Life after Treatment of Varicose Veins
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TABLE 34.1 The Venous Clinicial Severity Score
Characteristic Absent = 0 Mild = 1 Moderate = 2 Severe = 3
Varicose veins None Few Multiple Extensive
Edema None Evening ankle edema Afternoon above ankle edema Morning edema above ankle
Pigmentation None Limited and old Diffuse gaiter area Wider distribution
Pain None Occasional Daily Limiting activities
Infl ammation None Mild Moderate Severe
Induration None <5 cm <lower third of leg All of lower leg
Acute ulcers (number) None 1 2 >2
Duration of ulceration No <3 months >3 months >1 year
Diameter of ulcer No <2 cm 2–6 cm >6 cm
Compression used Nil Occasionally Most days Every day
Maximum Score 30
Measurement of Outcome
In developing an outcome measure the concepts of valid-
ity, reliability, and responsiveness are vital.
Validity is the extent to which a questionnaire measures
what is intended. This usually is assessed by comparing a
new measure with an established one (this is known as criterion validity). In the absence of a gold standard, construct
validity can be measured; this allows comparison of a new
tool with objective or clinical fi ndings.
Reliability is the degree to which measurements on the
same individual are similar under different conditions. Testretest comparisons are the most appropriate method for
assessing reliability if the instrument is intended as an evaluative tool. Reliability can also be assessed using internal
consistency; this checks the extent to which similar questions give consistent replies.
10
Responsiveness considers whether the tool is sensitive to
assess measurable change. If meaningful comparisons are to
be made then a standardized measure of responsiveness is
required. The standardized response mean allows such a
comparison (this represents the mean change in score over
two points in time divided by the standard deviation of the
score differences).
11
SYSTEM-SPECIFIC QUESTIONNAIRES
Correct and consistent clinical diagnosis and subsequent
classifi cation are vital before addressing the post-treatment
phase with disease-specifi c questionnaires. The CEAP
(Clinical-Etiology-Anatomic-Pathophysiologic) classifi cation was developed in 1994 and was translated into several
languages and adopted worldwide by the vascular
community.
The CEAP system, however, is not easily translated into
a quantifi able scoring system; for this a Venous Clinical
Severity Score (VCSS) and a Venous Segmental Disease
Score (VSDS) was proposed.12 In summary the VCSS grades
10 clinical characteristics from absent to severe (see Table
34.1). The VSDS assesses the anatomical and pathophysiogical characteristics of CEAP. The scores are allocated to
11 venous segments with refl ux and/or obstruction based
on venous imaging. In addition a Venous Disability Score
(VDS) has been published with the intention of measuring
the degree of impairment in daily activities.
To allow the comparison of different treatments or results
from different publications there is a need for standardization of the severity of the venous disease being studied.
These scoring systems are an adjunct to the current armamentarium and are to be recommended for use in future
venous outcome assessment studies. These studies are as yet
to be applied to a large multicenter study of patients with
varicose veins.
Currently there are three system- or disease-specifi c
instruments for measurement of health-related quality of life
in patients with chronic venous disease of the lower limb
that can be applied to patients with varicose veins (see
Table 34.2).
Disease-Specifi c Studies
Aberdeen Varicose Vein Score
This initially was designed as a postal questionnaire.
Published in 1993, it surveyed 373 patients with varicose
veins selected from a hospital and general practice setting.
A comparison group was made up of a random sample of
900 members of the general population selected from the
electoral register of Aberdeen. They were sent a similar
questionnaire without the condition-specifi c tool. The validity of the questionnaire was shown by a high correlation with
the SF-36 health profi le; the perceived health of patients
with varicose veins was signifi cantly lower than that of the
general population.
In 1999 the Aberdeen Varicose Vein questionnaire
(AVVQ) was used to determine the quality of life of patients
with varicose veins both before and after surgery.16 This was
a prospective consecutive cohort of 137 patients with primary
varicose veins (recurrent veins, deep venous disease, and an
13
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TABLE 34.2 Disease-Specifi c Studies on the Quality of Life in Patients with Chronic Venous Disease
Name and year Language Patients evaluated Summary
Aberdeen Varicose Vein English Varicose veins and chronic venous disease Grid used to score the extent of the varicosities
Questionnaire (AVVQ) 1993
Chronic Venous Insuffi ciency English Chronic venous disease Clinical and subjective symptoms used
Questionnaire (CIVIQ) 1996
Venous Insuffi ciency English Chronic venous disease Large patient database, assesses C1–C6 disease
Epidemiological and Economic French (CEAP)
Study (VEINES) 200315 French Canadian
Italian
TABLE 34.3 Aberdeen Varicose Vein Symptom Severity Scores (AVVSSS) in Patients with Primary Varicose Veins
Pre- and Postsurgery
Symptom severity score Median score Interquartile ranges Signifi cance (compared with baseline scores)
Presurgery 17.7 11.8–27.2
4 weeks postsurgery 13.8 7.9–21.3 Not signifi cant
6 months postsurgery 9.6 4.2–15.8 P < 0.001
2 years postsurgery 8.1 4.0–14.7 P < 0.001
13
14
French
ulcer history were excluded). Patients completed the SF-36,
the Aberdeen questionnaire, and a set of 25 questions focussing on the symptoms and concerns. The conclusion was that
the AVVQ was a valid measure of quality of life for patients
pre- and postsurgery. Patients were found to have a signifi cantly improved quality of life six weeks postsurgery.
Two studies emerged in 2002 where the AVVQ was used.
In a prospective study of 203 unselected patients with CEAP
2–6 who underwent saphenous vein surgery (with or without
subfascial endoscopic perforator surgery) for primary and
recurrent disease there was an improvement in diseasespecifi c quality of life at six months and at two years (86%
and 87% of patients, respectively). Also the higher the
AVVQ severity score (the worse the symptoms) before
surgery, the greater the improvement seen at two years (see
Table 34.3).
17
Another study looked at the effect of stripping on healthrelated quality of life. A prospective study recruited 66
patients who underwent varicose vein surgery with attempted
stripping of the long saphenous vein (LSV) to the knee. The
AVVQ and SF-36 were used to assess outcome. LSV surgery
led to a signifi cant improvement in disease-specifi c healthrelated quality of life for up to two years. In patients with
no deep venous refl ux, stripping of the LSV to the knee gave
additional benefi t. The effect of surgery on generic quality
of life was demonstrated only in bodily pain; patients who
underwent stripping of the LSV had a signifi cantly better
score at two years.
18
Chronic Venous Insuffi ciency Questionnaire (CIVIQ)
This questionnaire was developed from a patient database
of over 2000 subjects and was described both in French and
English. The fi rst version of the CIVIQ was tested in a crosssectional observational study on subjects recruited by general
practitioners, divided into those with and without venous
insuffi ciency. The diagnosis was made on clinical and subjective symptoms. A second analysis (CIVIQ 2) was performed using a questionnaire with a total of 20 equally
weighted items on the 1001 patients with chronic venous
disease based on four criteria: physical, psychological,
social, and pain. Subsequent to this CIVIQ was used in a
randomized, double-blind trial on 934 patients to compare
two formulations of a drug (a fl avonoid) in patients with
chronic venous symptoms.
The conclusions were that the specifi c quality of life
questionnaire for chronic lower limb venous insuffi ciency
was appropriate, reliable, and specifi c.14 It is notable
however, that this questionnaire has not been used in subsequent trials to assess quality of life in patients with chronic
venous insuffi ciency.
Venous Insuffi ciency Epidemiological and Economic
Study (VEINES)
The VEINES study was an international, prospective
cohort study that evaluated epidemiology (natural history
and risk factors) and outcomes (clinical outcomes, quality
of life, costs, health service use) in chronic venous disease.
The VEINES sample represented approximately 10 years of
data and was a prospective registration of 5688 outpatients
with chronic venous disease.
In 1998 the development and psychometric evaluation of
the questionnaire was described measuring quality of life
and symptoms (VEINES-QoL and VEINES-SYM). The 26item questionnaire included categories on chronic venous
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