Questions remain over venous leg symptoms despite SYM vein consensus

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Eberhard Rabe

At the 2017 European Venous Forum (29 June–1 July, Porto, Portugal), a presentation given by Eberhard Rabe (Bonn, Germany) questioned whether the SYM Vein Consensus clarified all aspects of venous symptoms. Speaking with Venous News, Rabe explains which questions still remain regarding venous leg symptoms and how the clinical community can best approach a difficult subject.   

What was the goal of the SYM Vein Consensus statement? 

In the revised CEAP classification it is stated, “Each clinical class is further characterised by a subscript for the presence of symptoms or absence of symptoms, for example, C2A or C5S. Symptoms include aching, pain, tightness, skin irritation, heaviness, muscle cramps, and other complaints attributable to venous dysfunction” (Bo Eklöf et al 2004). However, there are many open questions about the true origin of these symptoms. The goal of the SYM Vein Consensus was to answer the question of which of these subjective symptoms are specifically attributable to venous dysfunction and to find a better system of quantitative and qualitative assessment (Perrin et al 2016).

What controversies still exist with venous symptoms? 

It is a fact that leg symptoms are not specific for venous pathology (examples: leg pain in peripheral arterial occlusive disease or orthopaedic patients). Leg symptoms are, in themselves, also not diagnostic of a venous disease and deserve to be assessed and treated appropriately. The absence of symptoms does not exclude chronic venous disorders like in asymptomatic varicose vein patients. Leg symptoms might have a high probability of being venous, but venous dysfunction is not demonstrable like insome C0 patients or in a population with a sitting profession but without venous pathology.

What are some of the factors that must be considered when looking at symptoms of potential venous disease? 

There are several categories of influencing factors. Human factors that influence how both patients and practitioners describe, interpret, express and use symptoms include: language and culture; levels of tolerance to unpleasant experiences; prior experience; duration and intensity of symptoms; psychosocial gains; economic gains; the belief regarding the relationship of symptoms to a chronic venous disease; and psychological dysfunction and the influence of fear. The clinical context and the specificity of leg symptoms: leg symptoms are very common in the general population while varicose veins are also highly prevalent, especially in the elderly. Leg symptoms may also be the symptoms of other conditions not directly related to any venous dysfunction. Leg symptoms of chronic venous diseases may be confounded by coexisting conditions which have a direct effect on the manifestation of chronic venous diseases and associated symptoms.

How can one determine the strength of association of leg symptoms to chronic venous disease? 

Venous symptoms “may be suggestive of chronic venous disease, particularly if they are exacerbated by heat or dependency in the day’s course, and relieved with leg rest and/or elevation,” according to Eklöf et al (2009). A high probability appears if a relationship is straight-forward with a clear temporal and/or spatial association like in venous claudication, phlebalgia of superficial thrombophlebitis or throbbing pain associated with chronic venous ulceration. A moderate probability appears if these symptoms may be equally attributable to other causes which need to be excluded like in sensation of heavy or swollen legs which may occur in the “otherwise well” population, and also as a feature in those with other clinical conditions such as knee osteoarthritis or plantar static disturbances. A low probability appears in unspecific symptoms like “impatient legs”, mimicking a minor form of restless legs or sensation of warm feet mainly in the first ten minutes after going to bed.

What is the relationship between venous pain and CEAP? 

In several studies there is a significant correlation between venous pain or symptoms and worsening of CEAP clinical classes. This was shown for instance in the Vein Consult programme (Rabe et al 2012). In our recent paper from the Bonn Vein Study we could show that the strength of the association of symptoms increases with the C-class (Wrona et al 2015).

What scoring methods are currently used for venous pain? How could these be improved? 

The CEAP classification takes into account “presence of symptoms” simply by addition of a subscript “s” without any information given about severity and type of symptoms. The VCSS uses only one symptom—pain— graded from 0–3. In patient-reported outcomes like the generic HRQoL scale (EQ5D-5L) or the disease-specific HRQoL scales (eg. CIVIQ, VEINES-QOL/ Sym, AVVQ ao) symptoms are more or less included but well specified. In the SYM Vein Consensus a three-dimensional diagram is suggested with the features: „. Frequency: never=0, from time to time=1, several times per week=2, and every day=3; „. Daily course: never=0, only in the evening=1, in the afternoon= 2, in the morning=3; „. Severity: none=0, slightly=1, moderate=2, and severe=3. This score must still be validated before using it in randomised controlled trials.

What was the take-home message of your EVF presentation?

Leg symptoms are very important in venous diseases and usually respond very well to non-invasive or invasive treatment. However, leg symptoms may also have other causes. In a population with a 25–30% prevalence of chronic venous diseases there is logically a high overlap of venous and other common diseases. In consequence it is not always clear if a typically “venous symptom” really has a pure venous origin. Despite the controversies on venous symptoms we have to keep in mind that this problem appears also for venous signs. Oedema in chronic venous disease patients may have a non-venous origin and might be caused by anti-hypertensive drugs or by inflammation of other origins. A lower leg ulcer in a varicose vein patient is not automatically a “venous ulcer” but might be due to a wide variety of other reasons. In the end, we need to know more about leg symptoms in chronic venous disease patients and include this item in our studies. The improvement of leg symptoms is one of the main goals of our treatment.

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