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POINT OF VIEW - Venous symptoms: is everything clear?

Typically, most patients present to the doctor because they have symptoms. Careful questioning may reveal that the cause is non-venous despite the presence of a prominent varicose vein. Pain on the first step in the morning suggests a muscular-skeletal-joint disorder. Sharp, shooting, stabbing pains suggest nerve entrapment. Heel pain a calcaneal spur and burning foot pains or numbness diabetes. Easy?

This article was authored by: Chris Lattimer FRCS, MS, PhD Honorary Consultant & Senior Lecturer in Vascular Surgery, Ealing Hospital & Imperial College, London, UK (credit: Imperial College)

In reality venous symptoms may be more obtuse. Nocturnal itching, tingling and restless legs may represent the typical symptoms of healing after prolonged gravitational stress the previous day. Heaviness, ache and oedema can occur in patients without varicose veins or venous disease. This may be termed occupational oedema or physiological venous insufficiency (drainage insufficiency). Any healthy subject who stands for too long will develop discomfort and pain which is likely to have a multi-factorial aetiology. In obesity with other co-morbidities, the venous nature of any symptoms become less obvious.

Are large ugly varicose veins that do not cause pain considered a cosmetic problem? After prolonged standing of course they will cause symptoms. So the decision to treat on current NHS rationing criteria is easy. In a young lady who is very conscious of her appearance it would be cruel to deny treatment because of the immense psychological stress that these veins may cause to her body image. Is this psychological symptom worthy of NHS rationing criteria? Depending on the degree, a counter argument is that if minor veins are treated, and the patient is pre-occupied with body image, then this may lead on to reshaping and adjustments to other parts.

Darkening of the gaiter region, congestion and swelling of the ankle and the appearance of a corona phlebectatica paraplantaris may be entirely without symptoms. Here the family doctor or relative is often the primary driver to seek treatment. Perhaps correctly this is with the aim to prevent future venous ulceration. In contrast, patients can have terrible gravitational pain after an hour without overt venous signs. A duplex study may reveal gross saphenous incompetence and its treatment result in instantaneous relief.

Varicosities themselves may cause pain. Occult phebitis, direct pigmentation over the veins (PIH, post-inflammatory hyperpigmentation) and the pain experienced during advancement of an endothermal ablation fibre or a phlebectomy in some patients provides evidence that veins are sensitive structures. The exact opposite, the complete lack of pain in these circumstances, is equally true. This suggests that venous pain is very variable and differs between individuals.

Interestingly, patients present at all stages of the clinical CEAP classification from C0 with pain to C4b without pain. Therefore, it appears that pain may not be a significant factor in venous disease progression. Conversely, it may be of benefit. Like the diabetic neuropathic foot, pain may be an advantage because it forces the subject to take remedial action. This includes leg raising, compression, change in occupation and seeking treatment. Are those patients without pain more likely to develop into the later stages of venous disease and even to ulceration? If this is the case, surely the focus should be on patients without pain because they are devoid of the stimulus necessary to precipitate anti-gravitational action.

Several questionnaires have been validated extensively to assess quality of life, including pain. But are they fit-for purpose? These questionnaires do not have a close correlation with clinical or haemodynamic severity. Furthermore, given the variability in symptoms and patient circumstance, and the global score they provide, they are heavily biased towards patients with symptoms. It is common nature for a doctor to judge the patients symptoms with greater weight if they have gross skin changes and to dismiss those with unaffected legs.

Currently, the aim of treatment in venous disease is to alleviate venous symptoms. If venous disease progression and ulceration is to be prevented perhaps the focus should shift towards the screening and treatment of the symptomless patients who lack the innate defence mechanisms against the relentless force of gravity.

Chris Lattimer

Chris Lattimer FRCS, MS, PhD Honorary Consultant & Senior Lecturer in Vascular Surgery Ealing Hospital & Imperial College, London, UK