Which varicose vein patients need treatment

1. Which varicose vein
patients need treatment
Prof. Cees H.A. Wittens, MD PhD
Head of Venous Surgery
Maastricht University Medical Center
Uniklinik Aachen
1
VE C
European Venous Centre; Aachen-Maastricht

2. Epidemiology
 70% of the western population has C0-1*
 Not reimbursed
 25% has C2-3*
 Reimbursed ? (about 0.1% Nat. Health care budget)
 5% has C4-6*
 Reimbursed
*Source: Bonn
Vein I 2
VE C
European Venous Centre; Aachen-Maastricht

3. Which varicose vein (C1-3)
patients need treatment
 What is the justification:
 Cosmetic?
 QoL gain alone?
 C1-3 (improve and get normal)
 C4-6 (improve but never get normal)
 Prevention of progression?
 Anno 2013  Cost benefit
 Reimbursement
 Qaly’s
(Quality adjusted life years)
3
VE C
European Venous Centre; Aachen-Maastricht

4. Prevention of progression
 Treatment of early stage CVD slows
progression (to ulceration)
symptomatic C2: 100 treatments prevent 1
ulcer
C4: 8 treatments prevents 1 ulcer
Reduced incidence of venous ulcers
Source: Nelzén,
Swedish experience

5.  Progression is directly related to age!!
 Bonn Vein
 Edinburgh Vein
 Bochum
 French
 San Diego
 Polish
 Tübinger
Progression; many studies
Bonn Vein 5
VE C
European Venous Centre; Aachen-Maastricht

6. Progression; Bochum studies
BO I: 10-12 years/old
BO II: 14-16 years/old
BO III: 18-20 years/old
BO IV: 29-31 years old
GSV or SSV incompetence preludes clinical signs
6
VE C
European Venous Centre; Aachen-Maastricht

7. Progression; Hemodynamics
 Correlation with hemodynamic
pathology
 More refluxing segments = higher C
class
 67.3% of C2 patients have saphenous
reflux
Source: Labropoulos, Bochum Vein I study, San Diego study
7
VE C
European Venous Centre; Aachen-Maastricht

8. Progression; Bonn Vein II
 Progression is more severe in patients
with saphenous reflux:
 31.8% in 6 years with saphenous reflux (4.8%/y)
 19.8% in 6 years without saphenous reflux (3 %/y)
8
VE C
European Venous Centre; Aachen-Maastricht

9. Epidemiology: progression decreased
(Europe)
 In Europe varicose vein treatment
frequency is stable over the years
causing the venous ulcer incidence to
be reduced.
 Prevalence of ulcers is lower in older
studies: 2.7% in the 70s (Framingham, Tubingen studies)
 Edinburgh Vein Study (2000): 0.6% ulcers
 Bonn Vein Study I (2005): 0.7% ulcers
9
VE C
European Venous Centre; Aachen-Maastricht
Netherlands
USA

10. Epidemiology: progression is decreasing in
the USA : why?
 Goal AVF:
 50% reduction of venous Ulcers
 Awareness of venous disease
 Treat C2 patients earlier!
Netherlands
USA

11. Conclusions
 Progression is related to aging
 Progression is worse in C2 patients with
incompetent GSV or SSV
 Circumstantial evidence shows that:
 C2 patients with incompetent GSV or SSV
should be treated to prevent progression to
venous ulceration.
11
VE C
European Venous Centre; Aachen-Maastricht