Epidemiology and aetiology of C4–6 disease

Abstract

Although our understanding of chronic venous insufficiency (CVI) has improved, many important questions remain unanswered. Ensuring that patients are appropriately referred for specialist assessment and then receive evidence-based, cost-effective treatment continues to be challenging. The lifetime of risk of chronic venous ulceration (CVU) is around 1% with approximately 10% ulcers being open at any one time. The incidence skin changes disease is about 10 times greater (10%). However, many of the studies upon which these estimates are based are old and/or methodologically flawed. There is reason to believe that the incidence, prevalence and characteristics of CVI/CVU may have changed considerably over the last 10-20 years and that future change is likely. Further cross-sectional and longitudinal epidemiological studies are required to establish the size and nature of the health-care need going forward in developed and increasingly developing countries. CVI culminating CVU is primarily the result of sustained ambulatory venous hypertension, which in turn arises from superficial and/or deep venous reflux with or without deep vein obstruction. However, there are many other elements to this complex condition, for example, microvascular dysfunction; calf muscle pump efficiency; dermal inflammation; disordered fibroblast function and matrix production; failure of epithelialization; congenital and acquired thrombophilia; malnutrition, obesity and diet; and bacterial colonization. None of the currently available treatment modalities is entirely satisfactory and novel therapies based upon a clearer understanding of the disease at the psychological, genetic, mechanical, microvascular and microscopic level are required.

A Study of Leg Edema in Immobile Patients

“…However, calf muscle pump failure, as seen in the patients in this study, can result in ambulatory venous hypertension and is therefore considered to be an etiological factor in CVI. [17][18][19] Because there are few examinations that elucidate dysfunction of the muscle pump causing CVI, it is often overlooked. As shown in this study, AROM, which demonstrates mobility of the calf muscle, and the CAC ratio, which indicates the amount of calf muscle, were well preserved in the majority of the patients.…”

Manual Lymphatic Drainage in the Treatment of Chronic Venous Disease

“…Several studies show that early treatment, by exercising the muscle pump, can prevent the most severe forms of CVD [14,90]. The important role of CMPF on the progression of CVD is well established, but in many individual cases impaired calf pump function may go undetected until most severe changes become evident [91]. Therefore, assessable, accurate and non-invasive methods to evaluate CMPF are needed [30,59,[90][91][92].…”

“…Muscle pump dysfunction appears to be a major mechanism for the development of superficial venous incompetence and its complications, such as venous ulcers, and around 70% of patients with venous ulcer present calf muscle pump dysfunction [48,66,89,91,102].…”

Risk Factors in Patients with Venous Stasis-Related Skin Lesions without Major Abnormalities on Duplex Ultrasonography

“…It is well known that the venous return is achieved by the combination of competent venous valves and calf muscle pump. Therefore, even without major abnormalities on DUS, the dysfunction of the calf muscle pumps which leads to ineffective emptying of venous blood from the distal lower extremities could be a significant mechanism for venous hypertension 9) and the development of CVI. 7,16) Although often overlooked, it should be regarded as functional venous insufficiency rather than as an anatomical problem.…”

“…5) Older age and obesity are well-known risk factors for CVI. 6) In addition, any condition that impacts the calf muscle pump, such as immobility, 7,8) ankle dysfunction, or loss of muscle bulk, 9) as well as prolonged standing 10,11) can potentially result in CVI. In the current study, we reviewed patients who presented with symptoms typically seen in CVI without major abnormalities on DUS, and investigated whether these patients had any of above-described risk factors.…”