Which varicose vein

patients need treatment

Prof. Cees H.A. Wittens, MD PhDHead of Venous SurgeryMaastricht University Medical CenterUniklinik Aachen

1

VE C

European Venous Centre; Aachen-Maastricht

Epidemiology

70% of the western population has C0-1*

Not reimbursed

25% has C2-3*

Reimbursed ? (about 0.1% Nat. Health care budget)

5% has C4-6*

Reimbursed

*Source: Bonn

Vein I 2

VE C

European Venous Centre; Aachen-Maastricht

Which varicose vein (C1-3)

patients need treatment

What is the justification:

Cosmetic?

QoL gain alone?

C1-3 (improve and get normal)

C4-6 (improve but never get normal)

Prevention of progression?

Anno 2013 Cost benefit

Reimbursement

Qaly’s

(Quality adjusted life years)

3

VE C

European Venous Centre; Aachen-Maastricht

Prevention of progression

Treatment of early stage CVD slows

progression (to ulceration)

symptomatic C2: 100 treatments prevent 1

ulcer

C4: 8 treatments prevents 1 ulcer

Reduced incidence of venous ulcers

Source: Nelzén,

Swedish experience

Progression is directly related to age!! Bonn Vein

Edinburgh Vein

Bochum

French

San Diego

Polish

Tübinger

Progression; many studies

Bonn Vein 5

VE C

European Venous Centre; Aachen-Maastricht

Progression; Bochum studies

BO I: 10-12 years/old

BO II: 14-16 years/old

BO III: 18-20 years/old

BO IV: 29-31 years old

GSV or SSV incompetence preludes clinical signs

6

VE C

European Venous Centre; Aachen-Maastricht

Progression; Hemodynamics

Correlation with hemodynamic

pathology

More refluxing segments = higher C

class

67.3% of C2 patients have saphenous

reflux

Source: Labropoulos, Bochum Vein I study, San Diego study

7

VE C

European Venous Centre; Aachen-Maastricht

Progression; Bonn Vein II

Progression is more severe in patients

with saphenous reflux:

31.8% in 6 years with saphenous reflux (4.8%/y)

19.8% in 6 years without saphenous reflux (3 %/y)

8

VE C

European Venous Centre; Aachen-Maastricht

Epidemiology: progression decreased

(Europe)

In Europe varicose vein treatment

frequency is stable over the years

causing the venous ulcer incidence to

be reduced.

Prevalence of ulcers is lower in older

studies: 2.7% in the 70s (Framingham, Tubingen studies)

Edinburgh Vein Study (2000): 0.6% ulcers

Bonn Vein Study I (2005): 0.7% ulcers

9

VE C

European Venous Centre; Aachen-Maastricht

Netherlands

USA

Epidemiology: progression is decreasing in

the USA : why?

Goal AVF:

50% reduction of venous Ulcers

Awareness of venous disease

Treat C2 patients earlier!

Netherlands

USA

Conclusions

Progression is related to aging

Progression is worse in C2 patients with

incompetent GSV or SSV

Circumstantial evidence shows that:

C2 patients with incompetent GSV or SSV

should be treated to prevent progression to

venous ulceration.

11

VE C

European Venous Centre; Aachen-Maastricht