Chronic venous insufficiency (overview) I87.2

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

CVI includes the various forms of primary varicosis and post-thrombotic syndrome and their sequelae.

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)

Prevalence in the general population is between 3% and 11%. In a screening study of 4530 people (Tübingen study) aged between 20 and 70 years, stage I CVI was detected in 73% of people. The frequency of stage II and III CVI was 13% and 5% respectively. The ratio of men to women is given as 1:1.5. Risk factors (contribute to weakening of the connective tissue and/or increase in venous pressure):

• family history
• genetic factors
• Activities with prolonged standing/sitting
• overweight
• age
• pregnancies

Either mechanical obstruction of venous return flow, e.g. due to deep vein thrombosis or valve insufficiency of the deep venous system, the perforating veins or the superficial venous system as well as insufficiency of the additional pump 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.

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

Subjective feeling of heaviness or tension as well as pulling or dull pain in the legs with ankle and lower leg edema, especially when standing or walking for long periods; alleviated by lying down. Local sensitivity to pressure in trophically disturbed areas. Nocturnal calf cramps.

Medical history, 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.

stage (CEAP_C2 to _C6): 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, and class III compression stockings are also indicated for stages _C3 to _C6 of CVI.
Exclusion of deep vein thrombosis (ultrasound Doppler examination, phlebography). In post-thrombotic syndrome, lifelong compression is necessary. In the case of valve insufficiencies and proven venous insufficiencies, vein sclerotherapy or vein surgery should be initiated depending on the extent and localization. Targeted physiotherapeutic exercise therapy often improves the immobility that accompanies CVI. Recent studies show promising results with conservative improvement of venous function.

Stage (CEAP _C4): If skin changes occur, symptomatic skin care, moisturizing, desquamating therapy, additional external anti-eczematous therapy, see below Eczema.

Stage (CEAP _C5 and C6₎: Compression therapy may be increased in the center of the ulcer with adapted foam pads. If necessary, periulcerous sclerotherapy after diagnosis. In addition,shave excision of the ulcer and grinding of the degeneration is indicated, particularly in cases of chronic congestion and treatment-resistant ulcers. Furthermore, phase-appropriate 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 surgically removed. It is also possible to cover the area around the ulcer, for example with zinc pastes or zinc ointments (e.g. R001), to protect against maceration by exudate.
• Antiseptic local therapy: compresses with octenidine (e.g. Octenisept) or polihexanide (Serasept, Prontoderm) prevent secondary bacterial colonization. Local antibiotics make little sense due to the selection of germs and the high risk of sensitization. Internal antibiotic therapy should be carried out for secondary infections in accordance with the antibiogram. Dye-containing solutions for dry brushing should not be used.
• Epithelialization: Hydrocolloid dressings are also used to protect the newly formed epithelium. Alternative: Simple fatty gauze dressings (e.g. Jelonet, Oleo-Tuell).
• In the absence of epithelialization, split-thickness skin grafts or mesh graft grafts are used. Keratinocyte transplants have yet to prove themselves in routine ulcer therapy.
  Excessive granulation tissue can impede epithelialization: therefore, careful surgical ablation, foam compression and cauterization with silver nitrate.

Order therapy: Avoid standing and sitting for long periods - better walking and lying down! Avoid 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 training for 20-30 minutes. Mind-body medicine, yoga (shoulder stand, headstand), breathing therapy, lymphatic drainage, kinesiotaping.

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

Draining procedures, in particular treatment with leeches(Hirudo medicinalis).

Leeches are applied to the congested extremity over the corresponding varicose vein. The suction act takes 20 minutes to 2 hours, during which the leech sucks 3-6 ml of blood. The leech's saliva contains hirudin, calin, hyaluronidase, eglin, bdellin, apyrase, collagenase, destabilase, hementin and organase. These cause the wound to continue to bleed for around 12 hours, causing another 20-30 ml of blood to leak out. Therefore, apply appropriate fleece or absorbent dressings.

Phytotherapy offers a number of preparations that have been proven in studies to reduce edema and inflammation and increase venous vascular tone and lymphatic drainage while simultaneously sealing the capillaries. These phytotherapeutics may be indicated, for example, if compression therapy is contraindicated:

Red vine leaves: (commercial preparation e.g. ^Antistax® extra). For chronic venous insufficiency grade I and II, a daily dose of 360 and 720 mg respectively has been shown to reduce lower leg edema to the same extent as compression stockings.

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

Butcher 's broomroot: Butcher's broom root ( 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 substances ruscin and ruscoside, which determine its effectiveness. These stimulate alpha-adrenergic receptors of the smooth muscle cells in the vascular wall. Animal studies show the following effects: increased venous tone as well as capillary-sealing, antiphlogistic and diuretic effects. The effect has been proven by scientific studies. (Note: Commission E has positively evaluated butcher's broom root for the treatment of hemorrhoids). Preparations: Phlebodril ^venous capsules®, Cefadyn film-coated tablets®. Cave: The berries of the butcher's broom itself are poisonous, they cause gastrointestinal complaints and somnolence.

Meliloti her ba (sweet clover) (proven by scientific studies; positive monograph by Commission E and ESCOP) Meliloti herba contains coumarin, flavonoids and saponins (commercial preparations: Meli Rephastasan®). The drug is used homeopathically in various dilutions, e.g. as ^Veno-loges® N injection solution.

Pine bark extracts (no monograph available from Commission E). Pine bark extracts (mostly obtained from the French maritime pine, Pinus paster) are also used for the treatment of CVI, among other things. The drug contains the active ingredient pycnogenol (leucocianidol), which determines its efficacy. The administration of 50 mg/day of the standardized pine bark extract led to a noticeable reduction in oedema in an eight-week, randomized, placebo-controlled study with 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 so far unclear.

Japanese string tree(Sophorae japonicae flos): Study situation unclear.

Cf. a.: Asparagi rhizoma