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Risk factors for chronic ulceration in patients with varicose veins: a case control study.

Abstract

BACKGROUND/OBJECTIVE

Identifying which patients with varicose veins are at risk of progressing to more severe forms of chronic venous disease could help in assigning clinical priorities and targeting appropriate treatments. The aim of this study was to determine, in subjects with varicose veins, the characteristics of venous disease and other factors associated with an increased risk of ulceration.

METHODS

One hundred twenty subjects with varicose veins and an open or healed venous leg ulcer were compared with 120 controls with varicose veins and no history of venous ulcer on this case control study. Subjects were recruited from hospital settings and primary care. Each subject completed a questionnaire on lifestyle and medical history and underwent an examination comprising of clinical classification of venous disease (CEAP), duplex scanning, quantitative digital photoplethysmography, and measurement of dorsiflexion. Multiple logistic regression analyses and calculation of receiver operating characteristic (ROC) curves were performed to identify the combination of factors which most accurately predicted which patients with varicose veins will develop leg ulcers.

RESULTS

An increased risk of ulceration was associated with the severity of clinical venous disease, especially with the presence of skin changes (P < .0001). Other significant risk factors included history of deep vein thrombosis (DVT) (P = .001), higher body mass index (BMI) (P = .006), smoking (P = .009), and reflux in the deep veins (P = .0001). Ulceration was associated with reduced volume of blood displaced as reflected by photoplethysmography and a limited range of ankle movement (not wholly due to the effects of an active ulcer) (both P < .05). Multivariate analyses showed that skin changes including lipodermatosclerosis (odds ratio [OR] 8.90, 95% confidence interval [CI] 1.44-54.8), corona phlebectatica (OR 4.52, 95% CI 1.81-11.3) and eczema (OR 2.87, 95% CI 1.12-7.07), higher BMI (OR 1.08, 95% CI 1.01-1.15), and popliteal vein reflux (OR 2.82, 95% CI 1.03-7.75) remained independently associated with increased risk of ulceration while good dorsiflexion of the ankle (OR 0.88, 95% CI 0.81-0.97) and an effective calf muscle pump (OR 0.96, 95% CI 0.92-0.99) remained protective factors. ROC curve analyses indicated that a model based on clinical observation of skin changes, duplex scanning for popliteal reflux, and calf muscle pump tests would be the most accurate in determining which patients with varicose veins develop leg ulcers.

CONCLUSIONS

The results of this study confirm that, in patients with varicose veins, those with skin changes of chronic venous insufficiency and deep vein incompetence are at greatly increased risk of ulceration. However, the risks may also be increased in those who smoke, are obese, and have restricted ankle movement and reduced calf muscle pump power.

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  • Authors+Show Affiliations

    ,

    University of Edinburgh, Edinburgh, United Kingdom. Lindsay.Robertson@ed.ac.uk

    , , , , , , , , ,

    Source

    Journal of vascular surgery 49:6 2009 Jun pg 1490-8

    MeSH

    Adult
    Ankle Joint
    Body Mass Index
    Case-Control Studies
    Chronic Disease
    Female
    Humans
    Logistic Models
    Male
    Middle Aged
    Muscle, Skeletal
    Odds Ratio
    Photoplethysmography
    Predictive Value of Tests
    ROC Curve
    Range of Motion, Articular
    Risk Assessment
    Risk Factors
    Severity of Illness Index
    Skin
    Smoking
    Surveys and Questionnaires
    Ultrasonography, Doppler, Duplex
    Varicose Ulcer
    Varicose Veins
    Venous Insufficiency
    Venous Thrombosis

    Pub Type(s)

    Journal Article

    Language

    eng

    PubMed ID

    19497512

    Citation

    Robertson, Lindsay, et al. "Risk Factors for Chronic Ulceration in Patients With Varicose Veins: a Case Control Study." Journal of Vascular Surgery, vol. 49, no. 6, 2009, pp. 1490-8.
    Robertson L, Lee AJ, Gallagher K, et al. Risk factors for chronic ulceration in patients with varicose veins: a case control study. J Vasc Surg. 2009;49(6):1490-8.
    Robertson, L., Lee, A. J., Gallagher, K., Carmichael, S. J., Evans, C. J., McKinstry, B. H., ... Fowkes, F. G. (2009). Risk factors for chronic ulceration in patients with varicose veins: a case control study. Journal of Vascular Surgery, 49(6), pp. 1490-8. doi:10.1016/j.jvs.2009.02.237.
    Robertson L, et al. Risk Factors for Chronic Ulceration in Patients With Varicose Veins: a Case Control Study. J Vasc Surg. 2009;49(6):1490-8. PubMed PMID: 19497512.
    * Article titles in AMA citation format should be in sentence-case
    TY - JOUR T1 - Risk factors for chronic ulceration in patients with varicose veins: a case control study. AU - Robertson,Lindsay, AU - Lee,Amanda J, AU - Gallagher,Karen, AU - Carmichael,Sarah Jane, AU - Evans,Christine J, AU - McKinstry,Brian H, AU - Fraser,Simon C A, AU - Allan,Paul L, AU - Weller,David, AU - Ruckley,Charles V, AU - Fowkes,Francis G, PY - 2008/06/25/received PY - 2009/02/20/revised PY - 2009/02/23/accepted PY - 2009/6/6/entrez PY - 2009/6/6/pubmed PY - 2014/8/20/medline SP - 1490 EP - 8 JF - Journal of vascular surgery JO - J. Vasc. Surg. VL - 49 IS - 6 N2 - BACKGROUND/OBJECTIVE: Identifying which patients with varicose veins are at risk of progressing to more severe forms of chronic venous disease could help in assigning clinical priorities and targeting appropriate treatments. The aim of this study was to determine, in subjects with varicose veins, the characteristics of venous disease and other factors associated with an increased risk of ulceration. METHODS: One hundred twenty subjects with varicose veins and an open or healed venous leg ulcer were compared with 120 controls with varicose veins and no history of venous ulcer on this case control study. Subjects were recruited from hospital settings and primary care. Each subject completed a questionnaire on lifestyle and medical history and underwent an examination comprising of clinical classification of venous disease (CEAP), duplex scanning, quantitative digital photoplethysmography, and measurement of dorsiflexion. Multiple logistic regression analyses and calculation of receiver operating characteristic (ROC) curves were performed to identify the combination of factors which most accurately predicted which patients with varicose veins will develop leg ulcers. RESULTS: An increased risk of ulceration was associated with the severity of clinical venous disease, especially with the presence of skin changes (P < .0001). Other significant risk factors included history of deep vein thrombosis (DVT) (P = .001), higher body mass index (BMI) (P = .006), smoking (P = .009), and reflux in the deep veins (P = .0001). Ulceration was associated with reduced volume of blood displaced as reflected by photoplethysmography and a limited range of ankle movement (not wholly due to the effects of an active ulcer) (both P < .05). Multivariate analyses showed that skin changes including lipodermatosclerosis (odds ratio [OR] 8.90, 95% confidence interval [CI] 1.44-54.8), corona phlebectatica (OR 4.52, 95% CI 1.81-11.3) and eczema (OR 2.87, 95% CI 1.12-7.07), higher BMI (OR 1.08, 95% CI 1.01-1.15), and popliteal vein reflux (OR 2.82, 95% CI 1.03-7.75) remained independently associated with increased risk of ulceration while good dorsiflexion of the ankle (OR 0.88, 95% CI 0.81-0.97) and an effective calf muscle pump (OR 0.96, 95% CI 0.92-0.99) remained protective factors. ROC curve analyses indicated that a model based on clinical observation of skin changes, duplex scanning for popliteal reflux, and calf muscle pump tests would be the most accurate in determining which patients with varicose veins develop leg ulcers. CONCLUSIONS: The results of this study confirm that, in patients with varicose veins, those with skin changes of chronic venous insufficiency and deep vein incompetence are at greatly increased risk of ulceration. However, the risks may also be increased in those who smoke, are obese, and have restricted ankle movement and reduced calf muscle pump power. SN - 1097-6809 UR - https://www.unboundmedicine.com/medline/citation/19497512/Risk_factors_for_chronic_ulceration_in_patients_with_varicose_veins:_a_case_control_study_ L2 - https://linkinghub.elsevier.com/retrieve/pii/S0741-5214(09)00600-4 DB - PRIME DP - Unbound Medicine ER -