WHAT IS A VASCULAR DISEASE?
The term Vascular Disease refers to organic and functional disorders affecting the circulatory system, i.e. the body's vast network of arteries and veins. People of all ages, genders, and races are at risk of developing vascular diseases, but certain factors can increase the risk of circulatory system pathologies. For blood vessels, factors such as age, family history, obesity, sedentary lifestyle, work, and certain underlying health conditions increase the risk of developing these diseases.
Examples of vascular diseases include:
Arterial diseases, such as peripheral artery disease (PAD), renal artery disease, popliteal entrapment syndrome, and carotid artery disease
Chronic Venous Disease (CVD) and Chronic Venous Insufficiency (CVI).
Definition of these Clinical Terms (Adapted from VEIN-TERM).
- Chronic Venous Disease (CVD): This term includes any long-duration morphological and functional abnormalities of the venous system of the lower extremities, either by symptoms and/or signs, indicating the need for investigation and/or care, ranging from varicose veins, spider veins, superficial thrombophlebitis.
- Chronic Venous Insufficiency (CVI): This term is used for advanced stages of chronic venous disease (C3 to C6 classes of the CEAP classification), which is applied to functional abnormalities of the venous system producing manifestations that include pitting edema, skin changes (such as pigmentation or fibrosis) and hypodermis, white atrophy (C4) or venous ulcers (C5-C6), that can markedly affect the quality of life.
Blood clotting disorders, including deep vein thrombosis (DVT)
Raynauds disease
Lymphedema
THE BLOOD VESSELS IN VASCULAR DISEASES
Veins are an important part of the circulatory system. Blood veins carry oxygen-poor blood back to the heart so that it can be re-oxygenated before circulating through the body again. There are superficial veins (closer to the skin's surface) and deep veins (located deeper in the muscles).
There are vascular diseases that can lead to serious complications if left untreated. Some may require immediate treatment, while others may slowly worsen over time. In any case, any disease that affects the health and function of the veins or arteries should be taken seriously. For vascular diseases, prevention (Preventive Medicine) is important, in terms of early diagnosis and treatment.
WHAT IS THE PREVALENCE OF VENOUS DISEASE?
Both Chronic Venous Disease (CVD) and Chronic Venous Insufficiency (CVI) are very common conditions in the general population, usually starting in young adulthood and increasing in frequency and severity in older people. Prevalence is highest in Western countries. Due to the current situation of under-diagnosis and under-treatment in many countries, there are no up-to-date patient registries, so the prevalence of these diseases is greatly underestimated worldwide.
WHAT ARE THE WARNING SIGNS OF A VENOUS DISEASE?
The presence of lumpy, twisted veins
Achy, heavy feelings in legs
Numbness and tingling in toes, feet, or legs
Restless legs
Areas of swelling, tenderness, and warmth
Night-time cramps
Visible varicose veins
Pain
WHAT ARE THE LIFESTYLE FACTORS THAT FAVOUR THE DEVELOPMENT OF CHRONIC VENOUS INSUFFICIENCY (CVI)?
obesity
smoking
lack of physical activity
Sitting or standing for long periods of time (standing at work)
physical strain
varicose veins
leg ulcers
diabetes and hypertension in the family history
pregnancy
History of deep vein thrombosis
CLASSIFICATION OF VASCULAR DISEASE SEVERITY
Chronic Venous Disease (CVD) -related diagnoses are classified according to the following CEAP classification (Classification System of Venous Disorders):
C0 = No visible or palpable signs of venous disease
C1 = Telangiectasia or reticular veins
C2 = Varicose veins
C3 = Oedema
C4a = Pigmentation or eczema
C4b = Lipodermatosclerosis or atrophie blanche
C5 = Healed venous ulcer
C6 = Active venous ulcer
The pathophysiology of CVD is multifactorial and characterized by venous hypertension, which triggers endothelial dysfunction and inflammation leading to microcirculatory and tissue damage, and eventually to Varicose Veins (Vvs) with dysfunctional valves and venous reflux. If not adequately treated, VVs could progress to Chronic Venous Insufficiency (CVI), leading to Venous Leg Ulcer (VLU). Studies state that endothelial dysfunction may be the central player in the link between varicose veins and Deep Vein Thrombosis (DVT).
WHAT ARE THE TREATMENT RECOMMENDATIONS?
Treatment of chronic venous disease (CVD) should focus on treating venous hypertension and reducing the endothelial damage and inflammation that results from it. Venous problems can be corrected with lifestyle changes, and with conservative medical and surgical interventions. Medications, compression therapy, and exercise can improve the condition, but sometimes venous problems require more intensive treatment to restore vein health and functionality.
Chronic Venous Disease (CVD) is a complex chronic disease that will progress and have a substantial impact on the patient's quality of life (QoL) if not adequately treated. For this reason, the key recommendation for GPs is to refer patients presenting with varicose veins, or skin changes in the lower extremities that could be caused by chronic venous insufficiency, to a specialist vascular surgery service. Treatment options have improved in recent years and include compression and venoactive drug therapy, surgery and endovenous laser ablation, radiofrequency, or sclerotherapy.
Regular screening programs are recommended to detect the need for treatment early. Experts also agree that conservative treatment is useful even in the early stages of venous disease, preventing complications and progression, which can bring long-term relief to the healthcare system and positively influence the quality of life of those affected. There is also an international consensus to use Duplex Ultrasound as the gold standard for the diagnosis of Chronic Venous Disease (CVD).
WHAT ARE THE BENEFITS OF DRUGS IN VENOUS DISEASES?
Venoactive drugs (VADs), also called phlebotonics, are a heterogeneous group of synthetic or plant-derived drugs. Clinical trials have demonstrated their effects on edema (C3) as well as in alleviating venous symptoms (heavy legs, leg pain, swelling, cramps, burning, itching...) at all stages (C0s-C6s) of chronic venous disease (CVD). Numerous studies have also shown that they promote the healing of venous ulcers in combination with compression therapy, making these drugs an essential component in the treatment of these patients.
Among the most commonly used venoactive drugs are MPFF (purified micronized flavonoid fraction), diosmin, Ruscus extracts, hydroxyethylrutosides, calcium dobesilate, horse chestnut extract/escin, and red vine leaf extract. Sulodexide does not belong to the venoactive drug family, but is also used for Chronic Venous Disease (CVD).
Both MPFF and Sulodexide have been assigned a High Level of Evidence (Grade A) recommendation for use according to the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system, for maximum clinical benefits and high efficacy in improving symptoms and Quality of Life (QoL) in patients with Chronic Venous Disease (CVD). These results conclude that these drugs can prevent the progression of CVD.
WHAT ARE THE BENEFITS OF COMPRESSION FOR VENOUS DISEASE?
Compression therapy (CT) is an established treatment method for chronic venous disease. Compression therapy works by exerting external pressure on the lower extremities and preventing gravity from affecting venous flow. The aim of compression therapy is to prevent an increase in intraluminal venous pressure to reduce vascular wall tension. Compression therapy helps to increase blood circulation in the lower legs, ankles, and feet. It is an effective treatment for pain and swelling caused by conditions associated with poor circulation, such as chronic venous insufficiency and varicose veins.
The choice of an appropriate interface pressure (IP) according to the severity of symptoms is the key to effective compression therapy. Tissue properties are characterized by specific parameters that allow their optimal selection according to the severity of the Chronic Venous Disease (CVD). These include elasticity, static, and dynamic stiffness indices, as well as the surface tension generated when the textile is applied. In case of leg deformity, it is possible to manufacture compression products individually adapted to the size and shape of the limb and in these cases, standard compression stockings should not be used. Despite the obvious clinical benefits, not all patients are suitable for compression therapy and should consult their specialist physician.
WHAT IS THE CURRENT SITUATION IN MANY COUNTRIES FOR PATIENTS WITH VENOUS DISEASE?
Studies show that in many countries knowledge about Chronic Venous Disease (CVD) is not optimal and that many patients are not treated and referred to specialists according to established guidelines, even in the active stage of the disease. Furthermore, in some countries, patients do not have access to publicly funded medicines labeled as having low therapeutic utility, when this is not supported by current scientific evidence. International guidelines exist to help clinicians consider treatment options for CVD and avoid unnecessary disease progression. Better knowledge of the disease and appropriate early treatment help to reduce suffering and improve the quality of life of patients, and can also help to reduce the burden on healthcare resources for CVD.
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