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Quality of life assessment before and after surgery for lower limb varicose veins

Fernanda Appolonio Rocha Esdras Marques Lins Catarina Coelho de Almeida Ronaldo Campelo Dias Junior Pedro Alberto Livino da Silva Claudia Almeida Gameleira Mary Gleyce de Melo Gomes Falcão José Wellington dos Santos Barros About the authors

Resumo

Contexto

As varizes dos membros inferiores representam uma das doenças mais prevalentes na população mundial e resultam em grande impacto na qualidade de vida dos pacientes devido às limitações nas atividades diárias e no desempenho funcional. Vários autores têm ressaltado a importância da avaliação da qualidade de vida na abordagem de pacientes portadores de doença venosa crônica.

Objetivos

Avaliar a qualidade de vida antes e após o tratamento cirúrgico de pacientes portadores de varizes dos membros inferiores.

Métodos

Através de estudo de antes e depois, foram avaliados 92 portadores de varizes dos membros inferiores submetidos a tratamento cirúrgico. Os pacientes foram divididos em grupos de acordo com a faixa etária e a classificação clínica CEAP. A qualidade de vida foi avaliada através do questionário VEINES QOL/SYM, aplicado no pré-operatório e 60 dias após a operação.

Resultados

Do total de 92 indivíduos analisados, 82,6% (76) eram mulheres. Com relação à idade, a média foi de 45,7±12,11. A classe CEAP 2 foi a mais encontrada, em 57,6% dos pacientes. Foi encontrada diferença significativa entre os escores antes e após a cirurgia para os pacientes na faixa etária entre 30 e 40 anos. Não houve diferença entre os escores nos momentos pré e pós-operatório entre os grupos CEAP.

Conclusões

Não foi encontrada diferença na qualidade de vida antes e após a cirurgia na maioria dos pacientes do estudo.

Palavras-chave:
qualidade de vida; varizes; insuficiência venosa

Abstract

Background

Lower limb varicose veins are one of the most prevalent diseases in the global population. The disease is chronic and has a great impact on patients’ quality of life, limiting daily activities and functional performance. Several authors have emphasized the importance of including quality of life assessment in management of patients with chronic venous disease.

Objectives

To evaluate quality of life before and after surgical treatment of patients with varicose veins.

Methods

A before and after study design was employed. Ninety-two people with varicose veins of the lower limbs were treated surgically. Patients were divided into subsets according to age and CEAP clinical classification. Quality of life was assessed using the VEINES QOL/SYM questionnaire, administered during the preoperative period and 60 days after the operation.

Results

The sample comprised 92 subjects, 82.6% (76) of whom were women and mean age was 45.7±12.11 years. CEAP class 2 was the most frequent clinical classification, in 57.6% of patients. There was a significant difference in scores before and after surgery among patients aged from 30 to 40 years. There was no difference between preoperative and postoperative scores between different CEAP groups.

Conclusions

No difference in quality of life was observed after surgery in most of the patients in the present study.

Keywords:
quality of life; varicose veins; venous insufficiency

INTRODUCTION

Chronic venous disease (CVD) of the lower limbs (LL) is extremely common and has variable presentations. It is characterized by venous system dysfunction secondary to venous hypertension caused by valve incompetence and/or obstruction of venous flow. In addition to esthetic compromise, CVD can cause symptoms that result in complications and sequelae, which can have a negative influence on patients’ quality of life.11 Castro e Silva M. Diagnóstico e tratamento da doença venosa crônica. J Vasc Bras. 2005;4:S185-94.

The incidence of CVD increases considerably from the third decade of life onwards. In Brazil, an epidemiological study conducted by Maffei22 Maffei FHA. Varizes dos membros inferiores: epidemiologia, etiopatogenia e fisiopatologia. In: Maffei FHA, Lastória S, Yoshida WB, Rollo HÁ, editores. Doenças vasculares periféricas. Rio de Janeiro: Medsi; 1995. p. 939-49. found a 35.5% prevalence of varicose veins and severe forms of CVD. This rate increases with age: the disease affects 3% of men and 20% of women in the 30-40 years age group, while at 70 years of age, 70% of the population have some degree of venous disease.22 Maffei FHA. Varizes dos membros inferiores: epidemiologia, etiopatogenia e fisiopatologia. In: Maffei FHA, Lastória S, Yoshida WB, Rollo HÁ, editores. Doenças vasculares periféricas. Rio de Janeiro: Medsi; 1995. p. 939-49.,33 Maffei FHA, Magaldi C, Pinho SZ, et al. Varicose veins and chronic venous insufficiency in Brazil: prevalence among 1755 inhabitants of a country town. Int J Epidemiol. 1986;15(2):210-7. http://dx.doi.org/10.1093/ije/15.2.210. PMid:3721683.
http://dx.doi.org/10.1093/ije/15.2.210...

Although surgical treatment is a widely used therapeutic option for CVD, there are few studies evaluating its impact on the quality of life (QoL) of patients who undergo surgery. There are reports of QOL assessment after surgical treatment, but in relation to other factors, such as venous hemodynamics,44 Uema RT, Dezotti NRA, Joviliano EE, Dalio MB, Moriya T, Piccinato CE. A prospective study of venous hemodynamics and quality of live at least five years after varicose vein stripping. Acta Cir Bras. 2013;28(11):794-9. http://dx.doi.org/10.1590/S0102-86502013001100009. PMid:24316748.
http://dx.doi.org/10.1590/S0102-86502013...
use of preoperative ultrasonography,55 Blomgren L, Johansson G, Bergqvist D. Quality of life after surgery for varicose veins and the impact of preoperative duplex: results based on a randomized trial. Ann Vasc Surg. 2006;20(1):30-4. http://dx.doi.org/10.1007/s10016-005-9285-z. PMid:16378147.
http://dx.doi.org/10.1007/s10016-005-928...
and comparisons of treatment techniques.66 Argyriou C, Papasideris C, Antoniou GA, et al. The effectiveness of various interventions versus standard stripping in patients with varicose veins in terms of quality of life. Phlebology. 2018;33(7):439-50. http://dx.doi.org/10.1177/0268355517720307. PMid:28720052.
http://dx.doi.org/10.1177/02683555177203...

As a tool for assessing the quality of life (QOL) of patients with LL varicose veins, questionnaires can be administered both before and after treatment. There are many different questionnaires for QOL assessment, of which the VEINES-QOL/Sym is one of the most widely used because it has good clinimetric properties and an objective and inexpensive methodology that can be applied in any type of setting and can complement conventional clinical assessment.77 Leal FJ, Couto RC, Pitta GBB, et al. Tradução e adaptação cultural do Questionário Aberdeen para Veias Varicosas. J Vasc Bras. 2012;11(1):34-42. http://dx.doi.org/10.1590/S1677-54492012000100007.
http://dx.doi.org/10.1590/S1677-54492012...

8 McDaniel MD, Nehler MR, Santilli SM, et al. Extended outcome assessment in the care of vascular diseases: revising the paradigm for the 21st century. J Vasc Surg. 2000;32(6):1239-50. http://dx.doi.org/10.1067/mva.2000.109747. PMid:11107103.
http://dx.doi.org/10.1067/mva.2000.10974...

9 Lamping DL, Schroter S, Kurz X, Kahn SR, Abenhaim L. Evaluation of outcomes in chronic venous disorders of leg: development of a scientifically rigorous, patient-reported measure of symptoms and quality of life. J Vasc Surg. 2003;37(2):410-9. http://dx.doi.org/10.1067/mva.2003.152. PMid:12563215.
http://dx.doi.org/10.1067/mva.2003.152...
-1010 Moura RMF, Gonçalves GS, Navarro TP, Britto RR, Dias RC. Adaptação transcultural do questionário VEINES/QOL-SYM: avaliação da qualidade de vida e sintomas na doença venosa crônica. J Vasc Bras. 2011;10(1):17-23. http://dx.doi.org/10.1590/S1677-54492011000100004.
http://dx.doi.org/10.1590/S1677-54492011...

The VEINES-QOL/Sym is a disease-specific self-administered questionnaire with 26 items covering symptoms, performance in activities of daily living, time of day when symptoms are most intense, changes in disease state over the previous year, and psychological impact. The questionnaire produces two scores, one estimating the impact of CVD on QOL, the VEINES-QOL, and another representing the severity of CVD symptoms, the VEINES-Sym. The higher the score, the better the patient’s quality of life.99 Lamping DL, Schroter S, Kurz X, Kahn SR, Abenhaim L. Evaluation of outcomes in chronic venous disorders of leg: development of a scientifically rigorous, patient-reported measure of symptoms and quality of life. J Vasc Surg. 2003;37(2):410-9. http://dx.doi.org/10.1067/mva.2003.152. PMid:12563215.
http://dx.doi.org/10.1067/mva.2003.152...
,1010 Moura RMF, Gonçalves GS, Navarro TP, Britto RR, Dias RC. Adaptação transcultural do questionário VEINES/QOL-SYM: avaliação da qualidade de vida e sintomas na doença venosa crônica. J Vasc Bras. 2011;10(1):17-23. http://dx.doi.org/10.1590/S1677-54492011000100004.
http://dx.doi.org/10.1590/S1677-54492011...

The objective of this study was to evaluate the impact of surgical treatment on the QOL of patients with LL varicose veins, using the scores of the VEINES QOL/Sym questionnaire, administered before and after surgery.

METHODS

A before and after study was conducted with all patients who underwent surgical treatment for LL varicose veins at the Vascular Surgery Service run by the Instituto de Medicina Integral Professor Fernando Figueira (IMIP), Recife, PE, Brazil, from December 2013 to July 2014 (sampled consecutively). All of the participants signed free and informed consent forms after being provided with information about the study.

The number of patients enrolled on the study (n = 92) was determined using a formula for sample size calculation based on use of a data collection instrument comprised of categorical items, which is the case of the VEINES/QOL-SYM questionnaire.

The Formula 1 used was:

n = c E 2 i = 1 k c i E 2 i = 1 k c i o 1 + 1 N x c E 2 i = 1 k c i E 2 i = 1 k c i o 1 (1)

where: cE = effective number of categories on the data collection instrument; ciE = number of categories in the ith item; k = number of items on the data collection instrument; ciO = total number of categories in the ith item; N = size of population.

A total of 92 patients who underwent surgery for LL varicose veins were assessed. Patients were enrolled on the study at the time of indication of surgical treatment by a vascular surgery specialist, after clinical and ultrasonographic examination. The inclusion criteria were patients at C2 to C6, who were symptomatic and had varicose veins observed during physical examination and on Doppler ultrasonography, with or without saphenous reflux. Patients under the age of 18 years or with clinical comorbidities that contraindicated the surgical procedure were excluded.

Patients were examined standing upright by a trained examiner who classified their lower limbs according to the severity of CVD, using the CEAP classification. When the patient had CVD in both lower limbs, the higher CEAP score was used for analysis.

The surgical technique employed was varicectomy, ligature of perforating veins with reflux (using the conventional technique, with direct access after marking the site with ultrasound guidance), and resection of the saphenous arch, with or without saphenectomy. Saphenectomy was indicated in cases of reflux combined with dilatation of the great or small saphenous veins. All procedures were performed by the same team of surgeons.

All patients wore elastic compression stockings (20-30 mmHg), mid-thigh length (7/8) during the postoperative period and were prescribed an anti-inflammatory (nimesulide) for 5 days and analgesics (dipyrone or paracetamol) to be taken only if in pain.

Although the VEINES-QOL/Sym (Venous Insufficiency Epidemiological and Economic Study) questionnaire can be self-administered, in this study it was administered by a duly trained interviewer in the form of an interview, because of the educational profile of the patients treated at this service (a large proportion of illiteracy and low-educational level). Questionnaires were administered before the surgical procedure (at the time of hospital admission) and again 60 days (±7 days) after surgery.

For the statistical analysis, patients were stratified by CEAP classification and also by age group.

Initially, all variables were analyzed descriptively. Quantitative variables were analyzed using ranges, means, standard deviations, and medians. Qualitative variables were expressed as absolute and relative frequencies.

The Kolmogorov-Smirnov test was used to test the normality of data. The Wilcoxon non-parametric test was used to compare data from before and after surgery, because the assumption of normally distributed data was rejected. Comparisons between two groups were made using the Mann-Whitney non-parametric test. The level of significance was set at 5%.

The study was approved by the Research Ethics Commission at Xxxx, under decision number. 3946-14.

RESULTS

A total of 118 patients were recruited, 19 of whom were excluded because they had clinical conditions that contraindicated the surgical procedure (Figure 1 – Flow chart). None of the patients operated were lost to follow-up.

Figure 1
Flow chart of selection of patients for the study.

A total of 92 patients were assessed, aged from 22 to 71 years (45.71±12.11 years; median: 43.50 years), 76 (82.6%) of whom were female. CEAP clinical class 2 was the most common, in 57.6% (n = 53) of the sample. The clinical and epidemiological data are summarized in Table 1.

Table 1
Data on patients and procedures.

Patients’ quality of life was assessed using the VEINES-QOL/Sym questionnaire before and after surgery. For both the VEINES-QOL and the VEINES-Sym, higher scores indicate better outcomes.99 Lamping DL, Schroter S, Kurz X, Kahn SR, Abenhaim L. Evaluation of outcomes in chronic venous disorders of leg: development of a scientifically rigorous, patient-reported measure of symptoms and quality of life. J Vasc Surg. 2003;37(2):410-9. http://dx.doi.org/10.1067/mva.2003.152. PMid:12563215.
http://dx.doi.org/10.1067/mva.2003.152...
Table 2 lists descriptive statistics for the scores at the two data collection points. We observed that overall the patients did not exhibit significant differences in QOL between preoperative and postoperative scores, either in terms of improvement of symptoms or of improved QOL.

Table 2
Descriptive statistics for preoperative and postoperative VEINES SYM and VEINES QOL scores for the whole sample.

It was observed that patients with ages in the range of 30 to 40 years did exhibit significant increases in VEINES-SYM and VEINES-QOL scores for the postoperative period, indicating improved symptoms and improved QOL after surgery in this subset of patients. There were no statistically significant changes in the other age groups (Table 3). The Kruskal-Wallis nonparametric test demonstrated that the age groups did not exhibit significant differences at the preoperative (p = 0.269) or postoperative data collections (p = 0.578).

Table 3
Descriptive statistics for preoperative and postoperative VEINES SYM and VEINES QOL scores, by age group.

There were no statistically significant differences in VEINES-SYM and VEINES-QOL scores from preoperative to postoperative results when patients were divided into groups according to CEAP clinical classification (Table 4). The Kruskal-Wallis nonparametric test demonstrated that the CEAP groups did not exhibit significant differences on VEINES-SYM at the preoperative (p = 0.626) and postoperative (p = 0.400) data collections.

Table 4
Descriptive statistics for preoperative and postoperative VEINES SYM and VEINES QOL scores, by severity of clinical status.

Patients classified as C6 have been excluded from Table 4 because of the small n (n = 2), which prevented adequate statistical analysis. These patients’ scores did increase during the postoperative period.

None of the subsets exhibited worse QOL postoperatively.

DISCUSSION

Patients were stratified by the CEAP clinical classification because patients with lower clinical scores theoretically have less venous compromise. The patients were also analyzed by age groups, considering that older patients tend to have more advanced venous disease with a greater impact on quality of life, since CVD is chronic and progressive.

The greater prevalence of LL varicose veins in women observed in this study is consistent with published data. It is important to point out that female sex is one of the risk factors for development of LL CVD.1111 Gil França LH, Tavares V. Insuficiência venosa crônica: uma atualização. J Vasc Bras. 2003;2:318-28.

12 Beebe-Dimmer JL, Pfeifer JR, Engle JS, Schottenfeld D. The epidemiology of chronic venous insufficiency and varicose veins. Ann Epidemiol. 2005;15(3):175-84. http://dx.doi.org/10.1016/j.annepidem.2004.05.015. PMid:15723761.
http://dx.doi.org/10.1016/j.annepidem.20...
-1313 Seidel AC, Mangolim AS, Rossetti LP, Gomes R, Miranda F Jr. Prevalência de insuficiência venosa superficial dos membros inferiores em pacientes obesos e não obesos. J Vasc Bras. 2011;10(2):124-30. http://dx.doi.org/10.1590/S1677-54492011000200006.
http://dx.doi.org/10.1590/S1677-54492011...
The mean age of the patients analyzed was over 40 years. Studies have shown that the prevalence of CVD increases with age, particularly the more severe forms (CEAP 4, 5, and 6).1414 Higginson IJ, Carr AJ. Measuring quality of life: using quality of life measures in the clinical setting. BMJ. 2001;322(7297):1297-300. http://dx.doi.org/10.1136/bmj.322.7297.1297. PMid:11375237.
http://dx.doi.org/10.1136/bmj.322.7297.1...

15 Seidl EMF, Zannon CMLC. Qualidade de vida e saúde: aspectos conceituais e metodológicos. Cad Saude Publica. 2004;20(2):580-8. http://dx.doi.org/10.1590/S0102-311X2004000200027. PMid:15073639.
http://dx.doi.org/10.1590/S0102-311X2004...

16 Bergan JJ, Schmid-Schonbein GW, Smith PD, Nicolaides NA, Boisseau MR, Eklof B. Chronic venous disease. N Engl J Med. 2006;355(5):488-98. http://dx.doi.org/10.1056/NEJMra055289. PMid:16885552.
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-1717 Lins EM, Barros JW, Appolonio F, Lima EC, Barbosa M Jr, Anacleto E. Perfil epidemiológico de pacientes submetidos a tratamento cirúrgico de varizes de membros inferiores. J Vasc Bras. 2012;11(4):301-4. http://dx.doi.org/10.1590/S1677-54492012000400008.
http://dx.doi.org/10.1590/S1677-54492012...

Measures of QOL are used as indicators to evaluate the efficacy and impact of specific treatments and also to compare different therapeutic procedures, although other criteria, such as analysis of change in CEAP class, are also used.1818 Barros BC, Araujo AL, Magalhães CE, Barros RL, Fiorelli SK, Gatts RF. Eficácia do tratamento cirúrgico das varizes com preservação de veia safena interna. Rev Col Bras Cir. 2015;42(2):111-5. http://dx.doi.org/10.1590/0100-69912015002008. PMid:26176677.
http://dx.doi.org/10.1590/0100-699120150...
In clinical practice, QOL assessment is an important tool, particularly as an outcome variable that can be used to determine the impact that a disease and its treatments have on a person’s life.1414 Higginson IJ, Carr AJ. Measuring quality of life: using quality of life measures in the clinical setting. BMJ. 2001;322(7297):1297-300. http://dx.doi.org/10.1136/bmj.322.7297.1297. PMid:11375237.
http://dx.doi.org/10.1136/bmj.322.7297.1...
,1515 Seidl EMF, Zannon CMLC. Qualidade de vida e saúde: aspectos conceituais e metodológicos. Cad Saude Publica. 2004;20(2):580-8. http://dx.doi.org/10.1590/S0102-311X2004000200027. PMid:15073639.
http://dx.doi.org/10.1590/S0102-311X2004...

Many different questionnaires are available for assessment of QOL in patients with LL varicose veins. The VEINES questionnaire used in this study has good clinimetric properties and objective, inexpensive methodology that can be employed in any setting and complements conventional clinical assessment.1010 Moura RMF, Gonçalves GS, Navarro TP, Britto RR, Dias RC. Adaptação transcultural do questionário VEINES/QOL-SYM: avaliação da qualidade de vida e sintomas na doença venosa crônica. J Vasc Bras. 2011;10(1):17-23. http://dx.doi.org/10.1590/S1677-54492011000100004.
http://dx.doi.org/10.1590/S1677-54492011...
,1919 Van Korlaar I, Vossen C, Rosendaal F, Cameron L, Bovill E, Kaptein A. Quality of life in venous disease. Thromb Haemost. 2003;90(1):27-35. PMid:12876622.,2020 Kaplan RM, Criqui M, Denenberg JO, Bergan J, Fronek A. Quality of life in patients with chronic venous disease San Diego population study. J Vasc Surg. 2003;37(5):1047-53. http://dx.doi.org/10.1067/mva.2003.168. PMid:12756353.
http://dx.doi.org/10.1067/mva.2003.168...
In order to assess QOL, it is necessary to measure reproducible and quantifiable metrics of the disease’s functional, psychological, and social impact. The VEINES-QOL/SYM assesses symptoms, performance of activities of daily living, and the psychological impact of CVD, which is why it was chosen for the present study.

When the VEINES SYM/QOL questionnaire was developed, the CEAP classification was employed for evaluation of the severity of venous disease,99 Lamping DL, Schroter S, Kurz X, Kahn SR, Abenhaim L. Evaluation of outcomes in chronic venous disorders of leg: development of a scientifically rigorous, patient-reported measure of symptoms and quality of life. J Vasc Surg. 2003;37(2):410-9. http://dx.doi.org/10.1067/mva.2003.152. PMid:12563215.
http://dx.doi.org/10.1067/mva.2003.152...
which is the reason for choosing the same classification in this study. The CEAP classification has also been used in other studies of QOL and varicose veins.55 Blomgren L, Johansson G, Bergqvist D. Quality of life after surgery for varicose veins and the impact of preoperative duplex: results based on a randomized trial. Ann Vasc Surg. 2006;20(1):30-4. http://dx.doi.org/10.1007/s10016-005-9285-z. PMid:16378147.
http://dx.doi.org/10.1007/s10016-005-928...
,66 Argyriou C, Papasideris C, Antoniou GA, et al. The effectiveness of various interventions versus standard stripping in patients with varicose veins in terms of quality of life. Phlebology. 2018;33(7):439-50. http://dx.doi.org/10.1177/0268355517720307. PMid:28720052.
http://dx.doi.org/10.1177/02683555177203...
,2121 Tan MKH, Sutanto SA, Onida S, Davies AH. The relationship between vein diameters, clinical severity, and quality of life: a systematic review. Eur J Vasc Endovasc Surg. 2019;57(6):851-7. http://dx.doi.org/10.1016/j.ejvs.2019.01.024. PMid:30850282.
http://dx.doi.org/10.1016/j.ejvs.2019.01...

When the entire patient sample was analyzed, no significant change in QOL was observed comparing the data collected before and after surgery. A similar result has been described previously by Blomgren et al., in 2006, in a prospective randomized study in which quality of life scores did not exhibit significant improvement over a 2-year observation period after surgery.55 Blomgren L, Johansson G, Bergqvist D. Quality of life after surgery for varicose veins and the impact of preoperative duplex: results based on a randomized trial. Ann Vasc Surg. 2006;20(1):30-4. http://dx.doi.org/10.1007/s10016-005-9285-z. PMid:16378147.
http://dx.doi.org/10.1007/s10016-005-928...
This result may be because the majority of the patients in this study were classified as CEAP C2. This raises the hypothesis that the absence of any significant changes in scores after surgery could be because these patients have milder symptoms, having little influence on their QOL.

Several authors have demonstrated the existence of a direct relationship between CVD severity and reduced QOL, predominantly in relation to the physical and functional domains.99 Lamping DL, Schroter S, Kurz X, Kahn SR, Abenhaim L. Evaluation of outcomes in chronic venous disorders of leg: development of a scientifically rigorous, patient-reported measure of symptoms and quality of life. J Vasc Surg. 2003;37(2):410-9. http://dx.doi.org/10.1067/mva.2003.152. PMid:12563215.
http://dx.doi.org/10.1067/mva.2003.152...
,2222 Kahn SR, M’lan CE, Lamping DL, Kurz X, Bérard A, Abenhaim LA. Relationship between clinical classification of chronic venous disease and patient-reported quality of life: results from an international cohort study. J Vasc Surg. 2004;39(4):823-8. http://dx.doi.org/10.1016/j.jvs.2003.12.007. PMid:15071450.
http://dx.doi.org/10.1016/j.jvs.2003.12....

23 Lamping DL. Measuring health-related quality of life in venous disease: practical and scientific considerations. Angiology. 1997;48(1):51-7. http://dx.doi.org/10.1177/000331979704800109. PMid:8995344.
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-2424 Kurz X, Lamping DL, Kahn SR, et al. Do varicose veins affect quality of life? Results of an international population-based study. J Vasc Surg. 2001;34(4):641-8. http://dx.doi.org/10.1067/mva.2001.117333. PMid:11668318.
http://dx.doi.org/10.1067/mva.2001.11733...
These studies found that people with more severe LL CVD (CEAP 4, 5, and 6) tend to have lower scores on QOL assessment questionnaires.

When the patients were analyzed by age group, the youngest patients (aged 30 to 40 years) exhibited greater postoperative improvement in QOL and a statistically significant increase in QOL was observed in this subset. One hypothesis to explain this result is that this age group has a lower prevalence of related pathologies, which would lead to increased relevance of symptoms secondary to CVD, which, after surgical treatment may undergo significant improvement and, as a consequence, of quality of life. Older people often have other pathological conditions that can also cause LL symptoms and have a negative impact on their QOL.

When patients were analyzed in subsets categorized according to their CEAP clinical classification at preoperative and postoperative assessments, the group of patients with less clinical compromise (C2 and C3) had better QOL after surgery, but the difference did not attain statistical significance. There were no significant differences in QOL before and after surgery in the other subsets.

We found a randomized prospective study55 Blomgren L, Johansson G, Bergqvist D. Quality of life after surgery for varicose veins and the impact of preoperative duplex: results based on a randomized trial. Ann Vasc Surg. 2006;20(1):30-4. http://dx.doi.org/10.1007/s10016-005-9285-z. PMid:16378147.
http://dx.doi.org/10.1007/s10016-005-928...
in the literature in which it was observed that even after surgical intervention QOL levels did not improve significantly over a 2-year period, in line with the findings of the present study.

One important issue that should be mentioned and which has been described elsewhere is that it is difficult to study CVD and QOL because of discrepancies between patients’ symptoms, clinical findings, and the results of Doppler ultrasonography. In clinical practice, it is common to see patients with CVD who have the same clinical classification, but distinct physical, functional, and social limitations.2525 Bradbury A, Evans C, Allan P, Lee A, Ruckley CV, Fowkes FG. What are the symptoms of varicose veins? Edinburgh vein study cross sectional population survey. BMJ. 1999;318(7180):353-6. http://dx.doi.org/10.1136/bmj.318.7180.353. PMid:9933194.
http://dx.doi.org/10.1136/bmj.318.7180.3...

26 Saarinen J, Heikkinen M, Suominen V, et al. Symptoms, clinical disability scores and reflux in complicated and uncomplicated primary varicose veins. Phlebology. 2003;18(2):73-7. http://dx.doi.org/10.1258/026835503321895370.
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27 Abreu GCG, Camargo O Jr, Abreu MFM, Aquino JLB. Escleroterapia ecoguiada com espuma para tratamento da insuficiência venosa crônica grave. Rev Col Bras Cir. 2017;44:511-20.

28 Faccini FP, Ermini S, Franceschi C. CHIVA to treat saphenous vein insufficiency in chronic venous disease: characteristics and results. J Vasc Bras. 2019;18:e20180099. http://dx.doi.org/10.1590/1677-5449.009918. PMid:31191629.
http://dx.doi.org/10.1590/1677-5449.0099...

29 Viarengo LMA, Viarengo G, Martins AM, Mancini MW, Lopes LA. Resultados de médio e longo prazo do tratamento endovenoso de varizes com laser de diodo em 1940 nm: análise crítica e considerações técnicas. J Vasc Bras. 2017;16(1):23-30. http://dx.doi.org/10.1590/1677-5449.010116. PMid:29930619.
http://dx.doi.org/10.1590/1677-5449.0101...
-3030 Campbell WB, Decaluwe H, Boecxstaens V, et al. The symptoms of varicose veins: difficult to determine and difficult to study. Eur J Vasc Endovasc Surg. 2007;34(6):741-4. http://dx.doi.org/10.1016/j.ejvs.2007.07.012. PMid:17870617.
http://dx.doi.org/10.1016/j.ejvs.2007.07...

Quality of life assessment is dependent on each patient’s interpretation of the signs and symptoms of their disease and this is related to their subjective perceptions of their living conditions. The same clinical presentation can cause different functional compromise in different patients or have different emotional and social relevance.2727 Abreu GCG, Camargo O Jr, Abreu MFM, Aquino JLB. Escleroterapia ecoguiada com espuma para tratamento da insuficiência venosa crônica grave. Rev Col Bras Cir. 2017;44:511-20. The symptom lower limb pain can be a result of many different diseases and may be erroneously attributed to the presence of varicose veins, as has been described in a prior study.3131 Van der Velden SK, Shadid NH, Nelemans PJ, Sommer A. How specific are venous symptoms for diagnosis of chronic venous disease? Phlebology. 2014;29(9):580-6. http://dx.doi.org/10.1177/0268355513515859. PMid:24390751.
http://dx.doi.org/10.1177/02683555135158...

One of the main limitations of this study lies in the heterogeneous nature of the sample investigated and the treatments provided. Additionally, there were few patients in the more advanced disease classes and, as a consequence, tests to detect statistically significant differences between groups could not be employed. Additionally, no analysis was conducted of correlations between ultrasonographic findings and preoperative and postoperative scores or between CEAP class and patient age. Allocation of patients to subsets may have interfered with analysis of the data because of the low n in each group.

CONCLUSIONS

In the subset of patients aged 30 to 40 years, surgical treatment resulted in improved QOL. In the other subsets, no differences were detected in preoperative and postoperative VEINES-QOL/SYM scores.

  • How to cite: Rocha FA, Lins EM, Almeida CC, Dias Junior RC, Silva PAL, Gameleira CA, Falcão MGMG, Barros JWS. Quality of life assessment before and after surgery for lower limb varicose veins. J Vasc Bras. 2020;19:e20190108. https://doi.org/10.1590/1677-5449.190108
  • Financial support: None.
  • The study was carried out Serviço de Cirurgia Vascular, Instituto de Medicina Integral Professor Fernando Figueira (IMIP), Recife, PE, Brazil.

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    » http://dx.doi.org/10.1177/0268355513515859

Publication Dates

  • Publication in this collection
    08 May 2020
  • Date of issue
    2020

History

  • Received
    12 Aug 2019
  • Accepted
    04 Feb 2020
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