|Year : 2021 | Volume
| Issue : 1 | Page : 58-62
A study of chronic venous insufficiency in relation with body mass index and diameter of saphenofemoral junction and great saphenous vein
Jayesh Patel, Pratiksha Shah, Fenil Gandhi
Department of Vascular Surgery, Shree Krishna Hospital, Anand, Gujarat, India
|Date of Submission||30-Apr-2020|
|Date of Decision||05-May-2020|
|Date of Acceptance||31-May-2020|
|Date of Web Publication||20-Feb-2021|
Department of Vascular Surgery, Shree Krishna Hospital, Anand, Gujarat
Source of Support: None, Conflict of Interest: None
Introduction: Chronic venous insufficiency (CVI) is a condition that occurs when the venous wall and/or valves in the lower limb veins are not functioning effectively, making it difficult for the blood to return to the heart from the lower limb. Over time, it can lead to pain, swelling, skin changes over the lower limb, and ulcers around the ankles. Some common etiological factors of CVI include obesity, more than 50 years of age, family history of CVI, smoking, and pregnancy. The combination of obesity and other genetic and environmental factors creates a higher risk for the development of CVI. Objective: The objective was to study the relation between body mass index (BMI) and CVI at its various stages using the clinical, etiological, anatomical, and pathophysiologic (CEAP) classification of CVI. In addition, it was to study whether there was a notable increase of diameter seen in saphenofemoral junction and great saphenous vein (GSV) as the BMI increases and in patients of CVI. Materials and Methods: It was a study conducted on 100 consecutive patients; data were collected from the vascular surgery outpatient department where patients presented with venous disease. The grade of the venous disease was recorded using the CEAP criteria. BMI was calculated for each patient. Based on the BMI, the patients were classified into underweight, normal, overweight, and obese. The mean, standard deviation, P value, and percentage of each stage of venous disease in each group were calculated accordingly and studied. Results: A total of 100 patients were undertaken for the study, out of which 78 were male and 22 were female. The clinical stage according to the CEAP criteria, BMI, diameter of the saphenofemoral junction, and diameter of the GSV was recorded for each patient. Clinical stage (CEAP criteria) was discovered to become more advanced as the BMI increased. According to the data, 50% of underweight patients reported of CVI, 53% of normal weight patients reported of CVI, 72% of overweight patients reported of CVI, and 87% of obese patients reported of CVI. Furthermore, it was noted that there was an increase in the diameter of the GSV as the BMI increased, although no change was seen in the diameter of the saphenofemoral junction. Conclusion: Lower limb venous flow parameters differ significantly among normal, overweight, and obese individuals. The CEAP clinical stage of venous disease is more advanced in obese patients than in nonobese patients with comparable anatomical patterns of venous incompetence. This could possibly be a result of raised intra-abdominal pressure leading to greater reflux, increased vein diameter, and venous pressures. In addition, an increase in diameter was noted in the GSV, however no change in diameter was observed at the saphenofemoral junction, as the BMI of the patients increased. Hence, the findings support the mechanical role of abdominal adipose tissue, which may potentially lead to elevated risk for both, venous thromboembolism and CVI.
Keywords: Body mass index, clinical, chronic venous insufficiency, etiological, anatomical and pathophysiologic criteria, mean ± standard deviation, obesity, P value, varicose veins
|How to cite this article:|
Patel J, Shah P, Gandhi F. A study of chronic venous insufficiency in relation with body mass index and diameter of saphenofemoral junction and great saphenous vein. Indian J Vasc Endovasc Surg 2021;8:58-62
|How to cite this URL:|
Patel J, Shah P, Gandhi F. A study of chronic venous insufficiency in relation with body mass index and diameter of saphenofemoral junction and great saphenous vein. Indian J Vasc Endovasc Surg [serial online] 2021 [cited 2021 Feb 25];8:58-62. Available from: https://www.indjvascsurg.org/text.asp?2021/8/1/58/309716
| Introduction|| |
Chronic venous insufficiency (CVI) is one of the most important conditions seen in vascular surgery, although it remains underdiagnosed due to the several factors contributing to its development. CVI is the impairment of the vessels in the lower limb, leading to improper return of the blood causing increase in pressure in the veins of the lower extremity. Venous insufficiency is strongly associated with venous ulceration, and hence, chronic CVI can result in difficult-to-heal and recurrent venous ulcers. The complications of CVI impair the ability of a person to be involved in social or routine occupational activities and also result in an economic burden on the patient and family due to the loss of work hours.
There are numerous risk factors that lead to CVI. Some examples include, more than 50 years of age, pregnancy, genetics, smoking, standing for long hours, obesity, and iatrogenic. Obesity is hypothesized to be one of the most important factors that contribute to the development of CVI. Obesity I, II, and III significantly affect the development of metabolic syndromes and several cardiovascular conditions. Excess body weight is also related to alterations in the coagulation system, including impaired fibrinolytic activity and elevated plasma concentrations of clotting factors. These alterations in endothelial function and coagulation are thought to be relevant not only for arterial but also for venous thrombosis. Factors contributing to the development of deep vein thrombosis as per Virchow's triad of hypercoagulability, stasis, and venous injury contribute to the development of CVI. Hormonal supplemental usage in women and smoking in men adds to the risk of deep vein thrombosis and resultant CVI.
Clinical history, detailed physical examination, and noninvasive vascular investigations are the three essential factors in evaluating the incompetence of the venous system. There are very limited studies done assessing the correlation between body mass index (BMI) and CVI in India; hence, it is a topic worth addressing.
| Materials and Methods|| |
This was a study where 100 consecutive patients presenting to the vascular surgery outpatient department with venous disease were undertaken. This study used the clinical, etiological, anatomical, and pathophysiological (CEAP) criteria (CEAP classification) to aid in the assessment of the patients. Furthermore, BMI was calculated for each patient [Table 1]. The patients were then categorized into underweight, normal, overweight, and obese according to the BMI. The percentage of each stage of venous disease in each group was then studied. The study was conducted from January 2018 to September 2018.
|Table 1: Clinical, etiological, anatomical, and pathophysiologic classification|
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- All patients presenting with varicose veins.
- Patients with a past history of deep vein thrombosis
- Patients with history of surgery/trauma over the lower limb in case of C5 and C6 disease.
Consent was obtained from the patients asking for their permission to use their details for the study. All the personal information was kept confidential and in no manner manipulated. No harm was done to the patients. The patients' details were solely used for this study only and no other research studies.
| Results|| |
The study comprised a total of 100 patients, among whom there were 78 male and 22 female. The clinical stage according to the CEAP criteria, BMI, diameter of saphenofemoral junction, and diameter of great saphenous vein (GSV) was recorded for each patient. All the variables were studied based on percentages, mean ± standard deviation (SD), and P values. P < 0.05 was considered statistically significant. Among the 100 patients, 0 patients reported in C1 class, 20 patients in C2 class, 9 patients in C3 class, 28 patients in C4 class, 15 patients in C5 class, and 28 patients in C6 class [Table 2]. According to the BMI classification, 2 patients were underweight (<18.5), 15 patients were normal (18.5–22.9), 11 patients were overweight (23.0–24.9), and 72 patients were obese (≥25) [Table 3]. The numbers greatly differed when the patients were grouped according to the clinical stage (CEAP criteria) in correlation with BMI [Table 4].
|Table 2: Total number of patients according to clinical, etiological, anatomical, and pathophysiologic classification criteria|
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|Table 4: Total number of patients according to clinical, etiological, anatomical, and pathophysiologic classification criteria in correlation with body mass index|
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There was a distinguishable difference found in the percentage of underweight and normal weight patients having CVI compared to overweight and obese patients. According to the data, 50% of underweight patients reported of CVI, 53% of normal weight patients reported of CVI, 72% of overweight patients reported of CVI, and 87% of obese patients reported of CVI [Table 5]. In addition, the collective P value was 0.001, which proved that as the BMI increases, the probability of developing CVI also increases in the patients [Table 6].
|Table 5: Percentage of patients having chronic venous insufficiency according to the body mass index|
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|Table 6: Correlation between the body mass index and patients having chronic venous insufficiency|
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Furthermore, a comparison was performed between the clinical Stage (CEAP criteria) and the diameter of the saphenofemoral junction and the GSV. An increase in size by ≥6 mm was considered to be significant. The mean, SD, and P values were calculated comparing along each group. There was no significant increase in diameter noted, as the clinical stages got more severe, leading to CVI [Table 7].
|Table 7: Correlation between clinical stage (clinical, etiological, anatomical, and pathophysiologic classification criteria) and diameter of saphenofemoral junction and great saphenous vein|
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Moreover, a comparison was also performed between various groups of BMI and the diameter of the saphenofemoral junction and the GSV. Again, an increase in diameter by ≥6 mm was considered to be significant. Furthermore, the mean, SD, and P values were calculated for diameter of saphenofemoral junction and GSV. There was no significance found in the increase in size of the saphenofemoral junction as the BMI increased. Although significance was noted in the increase in the diameter of the GSV with increase in the BMI, where P value was determined to be 0.002. It was noted that overweight and obese patients had an increase in the diameter of the GSV [Table 8].
|Table 8: Correlation between body mass index and diameter of Saphenofemoral junction and great saphenous vein|
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| Discussion|| |
A high BMI is a critical risk factor for CVI. In this study, patients with a BMI of >25 (kg/m2) were considered to be obese. It was established that a patient with a high BMI had a higher probability of developing CVI in comparison to a patient with a lower BMI. Another Indian study showed correlation between patients with a BMI of >30 (kg/m2) and its effects on the development of CVI. It is possible that obesity per se results in adverse changes in the structural and functional vein wall properties under the influence of the associated hemodynamic and hormonal alterations. The correlation between obesity and venous hemodynamic changes has mainly been associated to visceral obesity, which leads to an increase in the intra-abdominal pressure. The high pressure is transmitted to the end of the femoral vein, leading to distension of the vein walls, which favor stasis and venous valve dysfunction. This phenomenon occurs because the venous wall is constantly under greater tension in obese individuals.
In addition, a comparison between the various BMI groups and the diameter of saphenofemoral junction and GSV was also performed which showed that there was an increase in diameter of the GSV as the BMI increased. In CVI, the venous diameters are directly associated with venous incompetence. There are numerous factors that may lead to an increase in diameter such as age, gender, occupation, and CEAP criteria. A study performed by Kröger et al. established that as the CEAP class increase, there was a notable increase in the diameter of the GSV. Compared to the normal GSV, CVI shows thickening of the wall intima and media and a transverse greater diameter, changes in smooth muscle composition, endothelial disruption, and fibrosis. Studies have shown hypertrophic changes in the smooth muscle cells (SMCs) in the media of vein walls with remodeling of the alignment and structure of the muscles cells. Overall, the literature tends to support a higher content of SMC, which suggests that the pathological abnormalities in varicose veins are not only due to deficiency of smooth muscle but also due to the inability of the SMC to produce the necessary venous tone.
Some of the limitations found in the study were that BMI might not always be the best resource to determine a correlation between obesity and development of CVI because BMI does not determine the distribution of the body fat. Potentially, variations in the disposition of abdominal rather than peripheral adiposity could present as mechanical obstruction to the venous outflow from the lower legs and contribute to venous hypertension and disease. Venous return on its way back to the heart from the legs passes through the retroperitoneum of the abdomen where it is subjected to changes in intra-abdominal pressures. A different study can be performed which highlights the distribution of body fat and its correlation to the development of CVI. The results of this study being a single institution study cannot generalize the entire Indian population.
| Conclusion|| |
The results of this study showed that the probability of the development of CVI increases as the BMI increases. It also showed that more obese patients were found to be in the C6 classification of the CEAP criteria. In addition, an increase in diameter of the GSV was also noted in patients with a higher BMI. The presence of CVI should be identified and treated promptly in obese individuals with close follow-up in order to prevent complications.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]