A study of epidemiological factors and clinical profile of primary varicose veins
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0975-2870.192169
Keywords: Epidemiology, primary varicose veins, varicose veins
Varicose veins are defined as dilated, tortuous, subcutaneous veins ≥3 mm in diameter measured in the upright position with demonstrable reflux.[1] Varicose veins do not threaten life and are seldom disabling, but it causes a considerable demand on medical care.[2] It is the cause of morbidity and loss of precious work hours and a significant financial burden on the health-care system. It is a penalty we pay for adoption of the erect posture. It affects 10–20% of population in the Western world but in India, it is 5%.[3] They can be primary where the defect lies in the walls or the valves of superficial venous system/perforating veins. Secondary varicose veins are due to the obstruction in venous flow such as deep vein thrombosis (DVT), pregnancy, and tumor. Various predisposing factors of varicose veins have been implicated such as pregnancy, prolonged standing, obesity, old age, chronic rise in intra-abdominal pressure, and athletics. Heredity also plays an important role.[4] The aims of this study are to study the epidemiological factors such as age, sex, area of residence, posture, and to study the clinical profile according to the CEAP classification of varicose veins.
A prospective observational study with a sample size of sixty patients was undertaken at a Teaching Medical College and Hospital and Research Center. The period of study was July 2013–September 2015. Patients with features of varicose veins and its complications were included in the study while patients with secondary varicose veins due to DVT, pregnancy, and venous flow obstruction were excluded from the study. Clinical history of all the patients was taken. Clinical examinations and color Doppler were performed. The collected data were analyzed using Chi-square test and IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0. (IBM Corp., Armonk, NY).
In our study, 70% of patients were males, and 30% of patients were females [Figure 1].
Age of the patients ranged from 19 to 70 years. Maximum patients were in age group of 45 to 54 years (21.67%) [Figure 2].
The numbers of patients were maximum in the body mass index (BMI) range 18.6–25 kg/m 2. However, the majority of the patients 31 were overweight and obese [Figure 3].
In our study, 44 patients (73%) had a history of prolonged standing out of with 17 had history of mainly standing, 6 had history of standing and walking, 12 had history of standing and sitting, 9 had history of standing, walking, and sitting. Sixteen patients had history of sitting posture out of which 9 had history of mainly sitting and 7 had history of sitting and walking [Figure 4].
Fifty-four patients had unilateral lower limb varicose veins while six patients had bilateral lower limb [Figure 5].
Out of 60 patients, 38 patients had the involvement of only great saphenous vein (GSV), while only short saphenous vein (SSV) was involved in 8 patients. Both GSV and SSV were present in 14 patients [Figure 6].
Among the patients examined, 33% of patients belonged to C2 class, and 17% of patients belonged to C5 class [Figure 7].
Out of 60 patients examined, 47 patients had incompetent saphenofemoral junctions (SFJs) on clinical examination while 13 patients had competent SFJ [Figure 8].
On color Doppler study, 55 patients had incompetent SFJ while only 5 patients had competent SFJ. On clinical examination [Figure 9]:
On color Doppler study [Figure 10]:
This study was done to seek a better knowledge about the epidemiology of the varicose veins in the local population which visited this hospital. No similar study has been reported in India. The study also aims to spread awareness about the lifestyle which leads to the development of varicose veins and to take measure to avoid them. Varicose veins are more common in the Western countries as compared to India [5] which results in considerable morbidity and costs to the health services. In our study, 70% of patients were males and 30% patients were females. The study of Lee et al., Edinburgh Vein Study shown the prevalence of 40% in men and 32% in women.[6] Our findings are in accordance with the study of Vashist et al. which showed 64% of males and 36% of females.[7] The marked female preponderance of varicose veins in the Jerusalem sample may be related to the fact that the prevalence of overweight (BMI 2–8 g/cm 2 or more) in the study population was 1–4 times as high among women as among men. In the USA, the corresponding sex ratio is 1.1 if overweight is defined as 10% or more above standard weight and 1–7 if it is defined as 20% or more above standard weight.[4] Age of the patients ranged from 19 to 70 years. Maximum patients were in age group of 45–54 years (21.67%). The finding is in accordance with Edinburgh Vein Study.[6] Our study showed that majority of patients 51.67% were either overweight or obese while 40% had normal BMI and 8.33% were underweight. Our findings correlate with the findings of Kröger et al. which showed that increase in BMI was one of the most important determinants of the development of varicose veins.[8] A study by Selçuk Kapısız et al. showed that obesity and lack of exercise are one of the contributory factors in the development of varicose veins.[9] Seventy-three percent patients had a history of prolonged standing. Prolonged standing is defined as standing for 60% of work day. When work posture was added to the analysis of variance, using data for gainfully employed people aged 20–64, this variable was found to have a significant specific effect in each sex, somewhat stronger among women. The inclusion of work posture in the analysis of variance produced little change in the specific effects of the other variables.[4] Our results support the notion that prolonged standing can contribute to the development of varicose veins. This is a widely accepted belief for which little reliable and convincing evidence exists.[4],[10] However, we also conclude that not only the prolonged standing but also sitting posture also causes varicose veins. In our study, 62% of patients resided in an urban area while 38% of patients lived in the rural area. In our study, 54 patients had unilateral lower limb varicose veins while 6 patients had bilateral. In a study by Staniszewska et al.,[11] majority of patients had unilateral lower limb varicose veins which correlate with our study. In our study, 60% of patients had involvement of GSV, 17% patients had SSV while 23% patients had involvement of both GSV and SSV. In our study, 20 were in CEAP C2, 15 cases in CEAP C3 and 15 cases in CEAP C4 and 10 cases in C5. In the study of de Andrade et al.,[12] it was observed that severity was related to the number of incompetent perforating veins in each limb and to association of superficial veins, especially with SSV incompetency. The absence of reflux in perforating veins alone was predominant in patients with C2, which correlates with our study. In a study by Staniszewska et al.,[11] the majority of patients had varicosities in C2 class. However, only the clinical classification (C) holds the importance. The CEAP classification can only be used to describe patients and not to evaluate the results of treatment. It provides adequate information in communications between practitioners in different fields and is also helpful in the thorough patient counseling. In our study, SFJ incompetency in 78% of patients was detected by Brodie–Trendelenburg's test. Color Doppler identified 92% of patients with SFJ incompetency. Sensitivity was 93.07%. Specificity was 100% which closely correlates with the study of Vashist et al. in which 72% patients were detected to have SFJ incompetence on clinical tests while 80% of patients were found to have SFJ incompetence on color Doppler.[7] Their sensitivity was 90%, and specificity was 100%. In our study, 104 perforators were detected by clinical tests while 138 perforators were detected by color Doppler. In the study by Vashist et al., 104 perforators were detected by clinical tests while 100 perforators were detected by color Doppler.[7]
Our study finds that not only prolonged standing but also sitting posture can cause varicose veins. Obesity and increasing age are other risk factors. Classifying the varicose veins has an impact on the course of the disease and preventing its complications. We also conclude that color Doppler is superior to clinical examination in the evaluation of superficial and perforator veins incompetence. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]
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