Correlation of severity of chronic venous disease with capillary morphology assessed by capillary microscopy.

BACKGROUND: In patients with lipodermatosclerosis caused by chronic venous disease of the lower limb, the skin capillaries show proliferation and convolution. To our knowledge, no previous attempt has been made to correlate the clinical severity of venous disease based on the CEAP classification with the capillary morphology changes. The purpose of this study was to correlate the clinical severity with the capillary morphology changes in patients with chronic venous disease by using capillary microscopy and to explore the significance of atypical capillary morphology in patients with uncomplicated varicose veins. METHOD: Patients attending the vascular clinic for management of chronic venous disease were examined clinically and by duplex ultrasonography scans, and they were assigned to the appropriate CEAP clinical stage (C1, n = 15; C2, n = 20; C3, n = 15; C4a, n = 15; C4b, n = 15; C5, n = 15). Also studied were 10 control subjects with no arterial or venous disease of the lower limb. In part 1 of the study, a capillary microscope was used to obtain digital images of the skin microcirculation in the gaiter region. The capillary density and capillary convolutions were counted in a 2.4 mm2 region of skin. In part 2 of the study, a further 33 C2 and C3 patients were studied to provide more detailed information on a small subgroup with unusual capillary morphology. RESULTS: In part 1 of the study, the capillary count was similar in controls and patients in CEAP stages C2 to C4a, but decreased in patients of groups C4b and C5 (median count: C2, 15; C4b, 4; and C5, 7). The median number of the capillary convolutions was 1 per capillary in patients of groups C1 to C3 and controls; C4a had 4 convolutions, C4b had 7, and C5 had > or = 10. In part 2 of the study, an expanded group of 66 C2 and C3 patients was analyzed, of whom 14 had a mean capillary loop count of more than two. Biologic markers of inflammation were investigated for their correlation with capillary convolution, but no relationship was found. CONCLUSIONS: Among patients with venous disease, increased capillary convolution is strongly associated with the more severe stages (lipodermatosclerosis and healed ulceration). The significance of atypically increased capillary convolutions in a small subgroup of C2/C3 patients remains unknown.

Symptoms of chronic venous disease and association with systemic inflammatory markers.

PURPOSE: We recorded symptoms reported by patients with chronic venous disease (CVD) of the leg and correlated these with systemic inflammatory markers. METHODS: This was an observational study in a cohort of 132 adult patients with CVD attending the vascular clinic of a teaching hospital. Patients were excluded in whom recent surgery, illness, or concomitant medication may have influenced measurements of systemic inflammatory mediators. Patients with CEAP clinical stages C(2) to C(5) only were considered for inclusion in the study. CEAP clinical stage was established for each patient, and duplex ultrasound scanning was used to assess extent of venous disease in the lower limbs. Blood was taken from a foot vein, and the following inflammatory mediators were measured with enzyme-linked immunosorbent assay: von Willebrand factor, intercellular adhesion molecule 1, vascular cell adhesion molecule 1, soluble (s)E-selectin, sP-selectin, L-selectin, VEGF, and cytokines interleukin (IL)-1 alpha, IL-1 beta, IL-6, and tumor necrosis factor-alpha. Symptoms were recorded by patients using a visual analog scale (VAS) for the symptoms of pain, cramps, heaviness, paresthesia, and feeling of swelling. RESULTS: The greatest VAS symptom scores were observed in the less severe disease stages: C(2) median pain score, 2.8 units (interquartile range [IQR], 0.1-5); C(3), 4.5 (IQR, 3.4-5.5), C(4), 0.5 (IQR, 0-3.0); C(5), 0 (IQR, 0-4). Symptom scores were similar in patients with primary and recurrent venous disease after previous surgery and in patients with superficial venous reflux and deep venous reflux. No correlation was found between the measurements of inflammatory mediators and the symptoms assessed with the VAS. CONCLUSION: We found no correlation between symptoms reported by patients and the internationally agreed clinical stages of venous disease of C(2) to C(5). Neither was there any correlation between levels of inflammatory mediators and patient symptoms. Symptoms reported by patients with CVD cannot be explained by anatomic distribution of venous disease in the lower limb veins or by the systemic inflammatory response in venous disease.