Chronic venous insufficiency (overview) I87.2

Authors: Prof. Dr. med. Peter Altmeyer, Alexandros Zarotis

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Last updated on: 28.12.2021

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Synonym(s)

chronic venous congestion; Chronic venous insufficiency; Chronic Venous Insufficiency; CVI; Insufficiency chronic venous; Varicose vein formation; venous insufficiency; venous insufficiency chronic of the legs

Definition
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Chronic reflux disorder of the venous blood with venous hypertension in standing position as well as consecutive oedema formation in the ankle area. The consequences are chronic, with increasing persistence irreversible changes in the veins, skin, subcutaneous fatty tissue and muscle fascia(dermatoliposclerosis - or dermatolipofasciosclerosis).

CVI includes the various forms of primary varicosis and postthrombotic syndrome and their sequelae.

Classification
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Classification of clinical severity according to the CEAP classification:

  • C = clinical signs
  • E = Etiological classification (congenital, primary, secondary)
  • A = Anatomical distribution (superficial, deep, perforating vein, alone or in combination)
  • P = Pathophysiological dysfunction (reflux or obstruction, alone or in combination).

The clinical symptoms (see CEAP classification above, "C" = "clinical signs") are classified as follows:

  • C0 = No visible or palpable signs of venous disease
  • C1 = spider veins and/or reticular varices, no visible or palpable signs of CVI
  • C2 = Varicose veins
  • C3 = Varicosis with edema
  • C4 = Varicosis with trophic skin changes (hyperpigmentation, eczema, lipodermatosclerosis, atrophy blanche)
  • C5 = Varicosis with healed ulcer
  • C6 = Varicosis with florid ulcer

Classification of chronic venous insufficiency (n. Widmer)

  • Stage I: reversible oedema, corona phlebectatica, perimalleolar bulbous veins
  • Stage II: persistent oedema, haemosiderosis, dermatosclerosis, lipodermatosclerosis, atrophie blanche, stasis dermatitis
  • Stage III: Ulcus cruris (florid or healed)

Occurrence/Epidemiology
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Prevalence in the general population is between 3 and 11%. In a serial examination of 4530 persons (Tübingen study) aged between 20 and 70 years, stage I CVI was detected in 73% of the persons. The incidence of stage II and III CVI was 13 and 15%, respectively. The male/female ratio was reported to be 1:1.5. Risk factors (contribute to weakening of connective tissue and/or increase in venous pressure):

  • Familial predisposition
  • Genetic factors
  • Activities involving prolonged standing/sitting
  • Overweight
  • Age
  • Pregnancies

Etiopathogenesis
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Either mechanical obstruction of venous return, e.g. by deep vein thrombosis, or by valve insufficiencies of the deep vein system, the Vv. perforantes or the superficial vein system, as well as the insufficiency of the additional pumping mechanisms (skin pump, joint pumps, muscle pumps, abdomino-thoracic two-phase pump).

See below intrafascial venous insufficiency and extrafascial venous insufficiency, transfascial veins, primary varicosis and secondary varicosis.

Manifestation
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Average age at development of the full clinical picture: 40 to 50 years.

Clinical features
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Subjective sensation of heaviness or tension, and drawing or dull pain in the legs with oedema of the ankles and lower legs, especially on standing or long walking; relieved by lying down. Local tenderness of trophically disturbed parts. Nocturnal cramps of the calves.

Diagnosis
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Anamnesis, inspection, palpation, standard venous examination program ( Perthes test, Trendelenburg test, Mahorner-Ochsner test, Valsalva test).

Functional tests: ultrasound Doppler examination, light reflection rheography, plethysmographic procedures ( venous occlusion plethysmography), phlebography, phlebodynamometry.

Therapy
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Stage (CEAPC2 toC6): The focus is on consistent compression therapy with elastic short-stretch bandages (Pütter technique) until decongestion and maintenance. Class II compression stockings are indicated here, class III compression stockings are also indicated for stagesC3 toC6 of CVI.
Exclusion of deep vein thrombosis of the leg (ultrasound Doppler examination, phlebography) In postthrombotic syndrome lifelong compression is necessary. In case of valve insufficiency and proven venous insufficiency, initiation of venous sclerotherapy or venous surgery according to the extent and location. Targeted physiotherapeutic exercise therapy often improves the immobility that accompanies CVI. Recent studies show promising results with conservative improvement of venous function.

Stage (CEAPC4): In the case of skin changes, symptomatic care, lipid replenishing, scaling therapy, additional anti-eczematous external therapy, see below. eczema.

Stage (CEAP C5 andC6): The compression therapy may be intensified in the centre of the ulcer with adapted foam pads. After diagnosis, periulcerous sclerotherapy if necessary. In addition, especially in the case of chronic congestion and therapy-resistant ulcers, there is an indication for ulcer excision (shave excision) and grinding of the depression. Furthermore, phase-specific ulcer therapy, see also wound treatment.

  • Cleaning: Removal of ointment residues with oils (e.g. oleum olivarum) after disinfecting foot baths with e.g. potassium permanganate (light pink). Crusts and necroses are removed surgically. It is also possible to cover the ulcer area with e.g. zinc pastes or zinc ointments (e.g. R001) to protect against softening.
  • Antiseptic local therapy: Envelopes with octenidine (e.g. Octenisept) or polihexanide (Serasept, Prontoderm) prevent secondary bacterial colonisation. Local antibiotics make little sense because of the selection of germs and the high risk of sensitization. An internal antibiotic therapy should be carried out in case of transmitted infections according to the antibioogram. Dye-containing solutions for dry brushing should not be used.
  • Epithelialization: Hydrocolloid dressings are used to protect the newly formed epithelium. Alternative: Simple fatty gauze dressings (e.g. Jelonet, Oleo-Tuell).
  • If epithelialisation is missing, split skin grafts or mesh grafts are used. Keratinocyte transplants still have to prove themselves in routine ulcer therapy.
    Excessive granulation tissue can impede epithelialisation: therefore, careful surgical ablation, foam compression and etching with silver nitrate.

Naturopathy
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Order therapy: avoidance of long standing and sitting - better walking and lying! Avoidance of heat. Weight reduction, reduction of salt intake, fasting days if necessary (rice and fruit days), exercise therapy - toe and leg muscle exercises to activate the muscle pump; walking exercise for 20-30 minutes. Mind-body medicine, yoga (shoulder stand, head stand), respiratory therapy, lymph drainage, kinesiotaping.

Hydro-balneo-thermo-therapy: compression therapy, hydrotherapy: treading water, knee and thigh casts, lower leg baths, body wraps, sitz baths.

Draining procedures, in particular the treatment with leeches, Hirudo medicinalis.

Leeches are applied to the congested extremity over the corresponding varicose vein. The sucking act lasts 20 minutes to 2 hours, during which the leech sucks 3-6 ml of blood. The saliva of the leech contains hirudin, calin, hyaluronidase, eglin, bdellin, apyrase, collagenase, destabilase, haemmentin and organase, among others. These cause the wound to continue bleeding for about 12 hours, resulting in another 20 - 30 ml of blood leaking out. Therefore, appropriate fleece or absorbent dressings should be placed under the wound.

Phytotherapy offers some preparations which have been proven in studies to reduce oedema and inflammation, to increase venous vascular tone and lymphatic drainage while simultaneously sealing the capillaries. These phytotherapeutics may be indicated, for example, in cases of contraindication to compression therapy.

Red vine leaves: (commercial preparation e.g. Antistax® extra). For chronic venous insufficiency grade I and II, a reduction of lower leg oedema to the same extent as with compression stockings could be demonstrated with a daily dose of 360 or 720 mg.

Hippocastani semen: Horse chestnut extracts(Aesculus hippocastanum) are well known as venous therapeutics. Highly concentrated extracts of Hippocastani sem en (the horse chestnut seed), with the efficacy-determining aescin, have been positively evaluated by Commission E for chronic venous insufficiency. The horse chestnut has an antiexudative effect due to its vascular sealing, astringent effect, at the same time venous toning and anti-inflammatory. It is administered systemically in a dosage of 2 x 50 mg dry extract per day. Preparations e.g. Venostasin retard®, Venoplant retard®, Aescorin forte®, Noricaven®.

Butcher's broomroot, Ruscus aculeatus, is also available for the treatment of chronic venous insufficiency. Butcher's broom root contains, among other things, steroid saponins such as the efficacy-determining substances ruscin and ruscoside. These stimulate alpha-adrenergic receptors of the smooth muscle cells in the vascular wall. Animal studies show the following effects: increase of venous tone, capillary sealing, antiphlogistic, diuretic. The effect has been proven by scientific studies. (Note: Commission E has positively evaluated butcher's broom root for the treatment of haemorrhoids). Preparations: Phlebodril venous capsules®, Cefadyn film-coated tablets®. Caution: The berries of the stinging butcher's broom themselves are poisonous, causing gastrointestinal discomfort and somnolence.

Meliloti herba (Stonewort) (supported by scientific studies; positive monograph by Commission E and ESCOP. Meliloti herba contains coumarin, flavonoids and saponins (commercial preparation: Meli Rephastasan®).

The drug is used homeopathically in various dilutions, e.g. as Veno-loges® N solution for injection.

Pine bark extracts (no available monograph by Commission E). Pine bark extracts (mostly extracted from the French maritime pine, Pinus paster) are used, among other things, for the treatment of CVI. The drug contains pycnogenol (leucocianidol), the catechin active ingredient that determines efficacy. Administration of 50 mg/day of the standardized pine bark extract resulted in a marked reduction in edema in an 8-week, randomized, placebo-controlled study of 21 patients with CVI. In a comparison of 360 mg Pycnogenol with 600 mg horse chestnut extract, Pycnogenol was superior in terms of lower leg oedema (commercial preparation: Pycnogenol®).

Buckwheat herb (Fagopyri herba) Study situation unclear to date.

Japanese cord tree(Sophorae japonicae flos) Study situation unclear.

Tables
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CEAP Classification

Severity according to Widmer*

Clinical picture

C2 and C3

I

Corona phlebectatica, possible leg edema

C4

II

Occurrence of skin changes such as stasis dermatitis (eczema, stasis dermatitis), siderosclerosis, pachydermia, hypodermitis, hyperkeratosis, dermatosclerosis, atrophy blanche, hyperpigmentation, purpura jaune d'ocre.

C5 and C6

III

venous leg ulcer

Note(s)
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The term CVI for chronic venous insufficiency is not synonymous with the clinical diagnosis of "varicose veins or varicosis". Varicosis does not necessarily lead to chronic venous insufficiency.

Literature
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  1. Bunnell AP et al (2014) Factors Associated with Saphenous Vein Recanalization after Endothermal Ablation. Ann Vasc Surg doi: 10.1016/j.avsg.2014.09.020

  2. Carruthers TN et al.(2014) Interventions on the Superficial Venous System for Chronic Venous Insufficiency by Surgeons in the Modern Era: An Analysis of ACS-NSQIP. Vasc Endovascular Surg PubMed PMID: 25487248.

  3. Garreau C et al (1988) Evaluation of venous therapy. Venous tonics, vascular protectants and thermal cures. What are the advantages for the patient? Phlebol 41: 857-876
  4. Hesse G, Stiegler H (2003) Ultrasound diagnostic techniques in dermatologic angiology and phlebology. Dermatologist 54: 614-625
  5. Kistner RL et al (1996) Diagnosis of chronic venous disease of the lower extremities: the "CEAP" classification. Mayo Clin Proc 71: 338-345
  6. Lentner A et al (1994) Mobility in the upper and lower ankle in advanced chronic venous insufficiency. Phlebol 23: 149-155
  7. Proebstle TM (2003) Surgical therapy of venous leg ulcers. Dermatologist 54: 379-386
  8. Vanscheidt V et al (1994) Paratibial Fasciotomy. A new approach for treatment of therapy-resistant venous leg ulcers. Phlebol 23: 45-48
  9. Willa-Craps C et al (1994) Contact allergy in chronic venous insufficiency Phlebol 24: 93-97.
  10. Zygmunt JA (2014) Duplex ultrasound for chronic venous insufficiency. J Invasive Cardiol 26: E149-15
  11. Michalsen A (2012) The naturopathic treatment of chronic venous insufficiency and varicosis. ZKM 4:31-34

Literature (naturopathy)

  1. Cesarone MT et al (2006) Rapid relief of signs/symptoms in chronic venous microangiopathy with pycnogenol: a prospective, controlled study. Angiology 57: 569-576.
  2. Diehm C et al. (1996) Comparison of leg compression stocking and oral horse-chest-nutseed extract therapy in patients with chronic venous insufficiency. Lancet 347: 292-294.
  3. Guex JJ et al. (2010) Quality of life improvement in Latin American patients suffering from chronic venous disorder using a combination of Ruscus aculeatus and hesperidin methyl-chalcone and ascorbic acid (quality study). Int Angiol 29: 525-532.
  4. Kiesewetter et al. (2000) Efficacy of orally administered extract of red vine leaf AS 195 (folia vitis viniferae) in chronic venous insufficiency(stages I-II). A randomized, double - blind, placebo-controlled trial. Drug Research 50: 109-117.
  5. Pittler MH et al. (1998) Horse-chestnut seed extract for chronic venous insufficiency. A criteria-based systematic review. Arch Dermatol 134:1356-1360
  6. Reuter J et al. (2010) Which plant for which skin disease? Part 2: Dermatophytes, chronic venous insufficiency, photoprotection, actinic keratoses, vitiligo, hair loss, cosmetic indications. J Dtsch Dermatol Ges 11: 866-873.
  7. Riede F et al.(2010) The use of medical leeches for the therapy of venous stasis and hematoma in flap plastic surgery. JDDG 11: 881-889
  8. Toledo RR et al (2017) Effect of Pycnogenol on the healing of venous ulcers. Ann Vasc Surg 2017; 38: 212-219
  9. Vanscheidt W et al.(2002) Efficacy and safety of a Butcher's broom preparation (Ruscus aculeatus L. extract) compared to placebo in patients suffering from chronic venous insufficiency. Arzneimittelfoschung: 52:243-250.
  10. Koch R (2002) Comparative study of venostasin and pycnogenol in chronic venous insufficiency. Phytother Re 16: Suppl. I 1-5.

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Authors

Last updated on: 28.12.2021