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 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

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.

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

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.

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.

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, class III compression stockings are also indicated for stages_C3 to_C6 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 (CEAP_C4): In the case of skin changes, symptomatic care, lipid replenishing, scaling therapy, additional anti-eczematous external therapy, see below. eczema.

Stage (CEAP C5 and_C6): 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.

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. For this reason, appropriate fleece or absorbent dressings should be placed underneath.

Phytotherapy offers a number of preparations that have been proven in studies to reduce edema and inflammation, 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 e.g. Venostasin retard®, Venoplant retard®, Aescorin forte®, Noricaven®.

Butcher 's broom root: 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, 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 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.

Pinebark 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 catechin 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 8-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 unclear to date.

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

s.a. Asparagi rhizoma