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Age and varicose veins

Age does not impact outcomes following VV procedures

The most common complication for both age groups was paresthesia, followed by deep venous thrombosis
Patients ≥65 years old were treated with a significantly higher percentage of minimally invasive procedures compared with the patients <65 years old (62.3% vs 52.1%; p<0.001)

Patients older than 65 years appear to benefit from appropriate varicose vein (VV) procedures and this group of patients should not be denied interventions on their varicose veins and venous insufficiency on the basis of their age only, according to the outcomes from study that included more than 3,700 patients. The paper, ‘Age is not a barrier to good outcomes after varicose vein procedures’, was published in the Journal of Vascular Surgery venous and Lymphatic Disorders.

The study analysed prospectively captured anatomic, procedural, and outcome data for all patients from the national Vascular Quality Initiative (VQI) Varicose Vein Registry (VVR). The researchers searched the VQI VVR database for all patients undergoing varicose vein procedures between January 2015 and July 2016, and compared pre- and post-procedural CEAP classification, Venous Clinical Severity Score (VCSS) and patient-reported outcomes (PROs) between patients <65 years and ≥65 years old.

In total, the researchers report on 4,841 varicose vein procedures performed from January 2015 to May 2016. There were 3,441 procedures performed in 2,691 patients (3,631 limbs) in the group <65 years old and 1,400 procedures performed in 1,068 patients (1,467 limbs) in the group ≥65 years old. Bilateral procedures were performed in 190 patients <65 years old and in 67 patients ≥65 years old. The total number of veins treated in each age group was 6,147 in the younger group and 2,366 veins treated in the older group.

Of 4,841 procedures, 45.3% (n=2,195) of procedures had early follow-up (within three months), 16.9% (n=820) of procedures had late follow-up and 37.7% (n=1,826) of procedures were missing follow-up.

Outcomes

The group <65 years had a higher percentage of female patients, an overall higher BMI, a higher percentage of whites, and these patients were more likely to have a history of bilateral varicose vein procedures and to be receiving anticoagulation.

The most common preprocedural CEAP classification was C3 in both groups. Patients <65 years old presenting to clinic had C3 disease 40% (n=1,329) of the time, followed by C2 disease in 34.17% (n=1,135) of procedures and C4a disease in 14.09% (n=468). Patients in the group ≥65 years presenting to clinic had 33.92% (n=466) with C3 disease, 25.40% (n=349) with C2 disease and 23.22% (n=319) with C4a disease. Only 4.09% (n=136) of procedures performed in patients <65 years had active ulceration, whereas a higher percentage, 7.13% (n=98) of procedures performed, were for active ulceration in the group ≥65 years old.

The most frequent varicose vein procedure in the VVR during the period examined was a truncal only procedure (48.9% for patients <65 years, 51.6% for those patients ≥65 years), followed by truncal plus cluster procedures for both age groups (39.6% of patients <65 years, 36% for patients ≥65 years). The least common procedure for patients <65 years old was a cluster plus perforator procedure. The least common procedure performed on patients ≥65 years old was truncal plus perforator procedure.

Of all procedures performed, every anatomic segment was treated individually or in conjunction with treatment of truncal, cluster, and perforators in each age group. Patients ≥65 years old were treated with a significantly higher percentage of minimally invasive procedures compared with the patients <65 years old (62.3% vs 52.1%; p<0.001).

For all procedures performed in patients <65 years old, 57.4% had an improvement (95% improved or stable); and for procedures performed in patients ≥65 years old, 52% had an improvement (92% improved or stable). VCSS and PROs score improvement was also examined in all patients who had a preprocedural and postprocedural assessment. VCSS improvement of 3.83 (CI, 3.67-3.98; p<0.001) was seen in patients <65 years old undergoing procedures and of 3.72 (CI, 3.46-3.98; p<0.001) in patients ≥65 years old undergoing procedures.

PROs score improvement was seen in both age groups, with a mean improvement of 9.96 (confidence interval [CI], 9.61-10.31; p<.001) for procedures performed in patients <65 years old and 9.07 (CI, 8.58- 9.56; p<0.001) for procedures in patients ≥65 years old. In comparing the mean improvement between age groups in regard to VCSS and PROs scores, the researchers report that there was no difference for VCSS (3.83 vs 3.72; p=0.42); however, with PROs scores (9.96 vs 9.07; p< 0.004), the patients <65 years old had a higher mean improvement.

The complications recorded in the VQI VVR are systemic and leg specific and are captured at different time points. Systemic complications were documented during the periprocedural period and were overall low and not statistically different for patients <65 years and ≥65 years of age, 0.70% and 0.79%, respectively (p=0.742).

Leg-specific complications were documented during the early (0-3 months) follow-up appointment. Leg-specific complications were also low at <2% for each leg complication. The overall rate of any leg complication for patients <65 years of age was 6.71% (n=101) and 6.17% (n=39) for patients ≥65 years of age. The most common complication for both age groups was paresthesia, followed by deep venous thrombosis. The only leg complication that was statistically different between age groups was wound infection (0.20% vs 0.95%; p=0.015), although this occurred extremely infrequently.

“These data demonstrate that not only do patients ≥65 years of age have improvement of clinical outcomes and PROs, this group has just as much of a positive response as their younger counterparts in regard to VCSS,” the authors write. “Importantly, this benefit does not come with a higher risk of complications, and in fact the group of older patients had no associated increased risk of complications with the exception of wound complications. Ultimately, these results have the potential to directly affect federal policy on Medicare coverage in this population of vulnerable patients.”

“There was no significant difference in the improvement in CEAP class and VCSS between patients younger and older than 65 years,” the authors concluded. “Although patients <65 years old had a statistically significant mean improvement in PROs compared with the patients ≥65 years old, it remains unclear whether this is a clinically significant result. Given these findings, patients older than 65 years appear to benefit from appropriate varicose vein procedures and should not be denied interventions on their varicose veins and venous insufficiency on the basis of their age only.”

To access this paper, please click here