Treatment Strategies for Patients with Lower Extremity Chronic Venous Disease (LECVD)

CMS evidence review | evidence_type=Technology Assessment | record_type=technology_assessment | document_id=104 | year=2017

Lower extremity chronic venous disease (LECVD) is a heterogeneous term that encompasses a variety of conditions that are typically classified based on the CEAP classification, which defines LECVD based on Clinical, Etiologic, Anatomic, and Pathophysiologic parameters. This review focuses on treatment strategies for patients with LECVD, which is defined as patients who have had signs or symptoms of lower extremity (LE) venous disease for at least 3 months. Patients with LECVD can be asymptomatic or symptomatic, and they can exhibit a myriad of signs including varicose veins, telangiectasias, LE edema, skin changes, and/or ulceration. The etiology of LECVD includes venous dilation, venous reflux, (venous) valvular incompetence, mechanical compression (e.g., May-Thurner syndrome), and post-thrombotic syndrome. Because severity of disease and treatment are influenced by anatomic segment, LECVD is also categorized by anatomy (iliofemoral vs. infrainguinal veins) and type of veins (superficial veins, perforating veins, and deep veins). Finally, the pathophysiology of LECVD is designated typically as due to the presence of venous reflux, chronic unresolved thrombosis, and/or obstruction. LECVD is common in the United States, where 25 million people have varicose veins, 2.5 million people have chronic venous insufficiency/incompetence, and the annual prevalence of venous thromboembolism (VTE, including both pulmonary embolism [PE] and deep vein thrombosis [DVT]) is approximately 1 million people. While the majority of patients with LECVD are asymptomatic, serious complications can occur, including LE amputation, acute and chronic VTE, chronic thromboembolic pulmonary hypertension, and mortality. A serious and common issue with LECVD is the formation of venous leg ulceration, affecting approximately 600,000 patients in the United States, and placing a burden on patients in terms of quality of life, pain, and social isolation. Furthermore, costs for the care of LECVD have increased substantially in the last few decades, with estimates in the United States of between $150 million and $1 billion per year.

Issue: Lower extremity chronic venous disease (LECVD) is a heterogeneous term that encompasses a variety of conditions that are typically classified based on the CEAP classification, which defines LECVD based on Clinical, Etiologic, Anatomic, and Pathophysiologic parameters. This review focuses on treatment strategies for patients with LECVD, which is defined as patients who have had signs or symptoms of lower extremity (LE) venous disease for at least 3 months. Patients with LECVD can be asymptomatic or symptomatic, and they can exhibit a myriad of signs including varicose veins, telangiectasias, LE edema, skin changes, and/or ulceration. The etiology of LECVD includes venous dilation, venous reflux, (venous) valvular incompetence, mechanical compression (e.g., May-Thurner syndrome), and post-thrombotic syndrome. Because severity of disease and treatment are influenced by anatomic segment, LECVD is also categorized by anatomy (iliofemoral vs. infrainguinal veins) and type of veins (superficial veins, perforating veins, and deep veins). Finally, the pathophysiology of LECVD is designated typically as due to the presence of venous reflux, chronic unresolved thrombosis, and/or obstruction. LECVD is common in the United States, where 25 million people have varicose veins, 2.5 million people have chronic venous insufficiency/incompetence, and the annual prevalence of venous thromboembolism (VTE, including both pulmonary embolism [PE] and deep vein thrombosis [DVT]) is approximately 1 million people. While the majority of patients with LECVD are asymptomatic, serious complications can occur, including LE amputation, acute and chronic VTE, chronic thromboembolic pulmonary hypertension, and mortality. A serious and common issue with LECVD is the formation of venous leg ulceration, affecting approximately 600,000 patients in the United States, and placing a burden on patients in terms of quality of life, pain, and social isolation. Furthermore, costs for the care of LECVD have increased substantially in the last few decades, with estimates in the United States of between $150 million and $1 billion per year. Other Material: Other Material 1 Questions: Questions Technology Assessment: Download technolody assessment Download appendices