Chronic venous insufficiency (overview) I87.2

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

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Last updated on: 29.10.2020

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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 screening of 4530 persons (Tübingen study) who were between 20 and 70 years old, stage I CVI was detected in 73% of the persons. The frequency of stages II and III of CVI was 13 and 15%. The male/female ratio is given as 1:1.5.

Risk factors:

(contribute to the weakening of the connective tissue and/or increase of the venous pressure)

  • Family burden
  • 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 clinical picture: 40 to 50 years.

Clinical features
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Subjective feeling of heaviness 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. Nightly calf cramps.

Diagnosis
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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: Avoid long standing and sitting - better walking and lying! Avoid heat.

Concluding procedures, here especially the treatment with leeches, Hirudo medicinalis

Leeches are attached to the congested limb above the corresponding varicose vein, the sucking act lasts from 20 minutes to 2 hours, and the leech sucks 3-6 ml of blood. The saliva of the leech contains, among others, hirudin, calin, hyaluronidase, eglin, bdellin, apyrase, collagenase, destabilase, hementin and organase. These cause the wound to continue bleeding for about 12 hours and thus leak another 20 - 30 ml of blood. Therefore, appropriate fleece or absorbent compresses should be used.

Phytotherapy offers some preparations proven in studies which lead to a reduction of oedema and inflammation, to an increase in venous vascular tone and lymphatic drainage with simultaneous sealing of the capillaries. These phytotherapeutics may, for example, be indicated 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 the lower leg edema at a daily dose of 360 and 720 mg, respectively, could be demonstrated to the same extent as with compression stockings.

Hippocastani semen: Horse chestnut extracts(Aesculus hippocastanum) are known as vein therapeutics. Highly concentrated extracts of 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 antiexudative effect due to its vasoconstrictive, astringent, vein toning and anti-inflammatory action. 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 broom root: Furthermore, butcher's broom root, Ruscus aculeatus, is available for the treatment of chronic venous insufficiency. The butcher's broom root contains steroidal saponins and the efficacy determining substances ruscin, ruscoside. These stimulate alpha-adrenergic receptors of smooth muscle cells in the vascular wall. Studies in animals show the following effects: increase of venous tone, capillary sealing, antiphlogistic, diuretic. The effect is proven by scientific studies. (Note: Commission E has given a positive evaluation to the butcher's broom root for the treatment of haemorrhoids). Preparations: Phlebodril Venecapsules®, Cefadyn Film Tablets®. Cave: The berries of the piercing butcher's broom itself are poisonous, they cause gastrointestinal discomfort and somnolence.

Meliloti herba (sweet clover) (proven by scientific studies; positive monograph by Commission E and ESCOP. Meliloti herba contains coumarin, flavonoids and saponins (commercial product: Meli Rephastasan®).

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

Pine bark extracts (no monograph available from Commission E). Pine bark extracts (mostly extracted from the French maritime pine, Pinus paster) are also used for the treatment of CVI. The drug contains the efficacy determining catechin active ingredient pycnogenol (leucoccianidol). The administration of 50 mg/day of the standardised pine bark extract led to a noticeable reduction in oedema in an 8-week randomised, placebo-controlled study involving 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 edema (commercial product: Pycnogenol®)

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 the same as the clinical diagnosis "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 joint 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: E149-155

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 hematomas in flap plasty. 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. Drug discovery: 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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Last updated on: 29.10.2020