Complexity of venous symptoms

Dear Editor,

I have read the article published by Van der Velden et al. ¹ with great interest. In their well-defined cross-sectional study, they have evaluated the venous symptoms in patients with chronic venous disease (CVD), and non-chronic venous disease group by using VEINES-Sym of VEINES-QOL/sym questionnaire. ² Briefly, they have analyzed 122 eligible patients, of whom 63 patients have been classified as CVD and 59 patients as non-CVD namely patients with peripheral artery disease, knee and hip arthrosis, and spinal disc herniation. They have found that presence of venous symptoms is slightly more often reported in CVD group than in non-CVD group, but differences are small and statistically non-significant. Subsequently, they have concluded that these symptoms are less specific for patients with CVD and refluxing veins than is usually assumed.

In terms of clinical practice, lower limb symptoms and underlying etiology sometimes exert themselves as a big challenge. Indeed, relationship between lower limb symptoms and the presence and severity of varicose veins is weak, symptom specific and gender dependent. ³ However, the recruitment method of patients might also play in the weakness of relationship between the lower limb symptoms and varicose vein. In Van der Velden report, patients with CVD have been recruited from the dermatology clinic which might have led to selection of patients complaining with mainly esthetical or cosmetic concern or itching rather than aching legs, heavy legs or night cramps. Additionally, co-morbid conditions such as chronic renal failure and diabetes mellitus ⁴ are likely to play a role as an underlying reason in the pathogenesis of aching legs, burning sensation, swelling, or itching.

High prevalence of venous reflux or CVD in general population in elderly population ⁵ and high co-existence rate of comorbid disease especially in elderly population make the assessment of lower limb symptoms more complex. Determining which lower limb symptoms are caused by varicose veins remains a matter of individual clinical judgment.

In the real world, only certain lower limb symptoms have been related to the presence of reflux on duplex ultrasound scanning. Moreover, it has been reported that duplex ultrasound cannot be used to distinguish those patients with real venous symptoms from the rest. ⁶ Therefore, individual assessment of patients with a more detailed history of complaints and reappraisal of the venous symptoms would partially resolve the weakness of lower limb symptoms.