THE
STANDARD
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Volume 1, No. 4
Venous Disorders: More than a cosmetic concern
Thomas G. Guilliams Ph.D.
For many years, veins have been thought to function only as passageways for blood to flow
back into the heart. This has given way in recent years to an understanding that the venous
system performs many functions that are vital to the whole circulatory network; such as
their capability of constricting and dilating, storing large volumes of blood for use in
other areas of the circulation, and even to regulate cardiac output. The alteration of
venous blood flow can result in a number of conditions including: Chronic venous
insufficiency (CVI), varicose veins, venous thrombosis, pulmonary embolism (a complication
of deep vein thrombosis (DVI)), hemorrhoids, lower limb edema, and venous ulcers. These
conditions are considered by many to be 'incurable'. We hope to show here that various
natural ingredients have a profound effect on these conditions and their related
symptoms.
Venous insufficiency has a complex pathology, having a dramatic impact on the quality of
life of the patient (1). In fact chronic venous disease of the lower limbs is one of the
most common conditions affecting humankind (2), with as many as 8 million Americans suffering
from these conditions (3). A recent article reviewed the increasing incidence of deep vein
thrombosis and found that between 1966 and 1990 the incidence of DVI was about 1 per 1000 annually,
which was "virtually equivalent to the incidence of stroke" (4). While some might think that such
problems are simply cosmetic, the underlying pathology can lead to a number of serious consequences.
The primary cause of venous disease is increase distention of the vessel walls, which seems
to have a genetic component. Other factors would include hormone imbalance (especially pregnancy),
certain oral contraceptives (5), prolonged hydrostatic load (extended periods of standing),
or abdominal pressure on veins. Symptoms would include the pigmentation of the skin in the
affected area, dermatitis, hemorrhages or thrombophlebitis. Tissue hypoxia and local edema can
then lead to inflammation and infection, which will favor the likelihood of leg ulcers
(between 400,000 and 500,000 patients in the U.S. (6)). Such is the spiral of untreated
venous conditions of the lower limbs.
Patients with CVI are often told to simply elevate the effected leg
above heart level for 30 minutes several times daily. This will help
reduce the edema and improve the circulation in the small vessels nearest
the skin. In more advanced cases, various forms of compression are
required to improve leg circulation. Compression stockings are very
common in the treatment of CVI and varicose veins, and have been shown
to increase blood flow in the deep veins, diminish venous reflux, as well
as improve ulcer healing. Unfortunately, compression stockings have low
compliance. This is due in part to the uncomfortable nature of wearing
them, cosmetic considerations, as well as the difficulty in putting them
on correctly. Patients with massive edema can use intermittent pneumatic
compression pumps, which compress the leg to a preset pressure,
periodically throughout the day. Again compliance is a key issue.
The use of drug therapy is limited in the treatment of CVI and
varicose veins. Infected leg ulcers are usually treated as other
open skin infection, topically or orally. The use of topical
and/or oral enzyme treatment to improve healing may be warranted.
The use of diuretics is not uncommon for advanced cases of edema,
although usually restricted to a short period of time. Most other
drugs are secondary to improving wound healing or cosmetically related.
Injection therapy designed to sclerose the vein can be used
to treat most varices. This is done by injecting sclerosant
(something like sodium tetradecyl sulfate) into an 'empty vein'
to promote scaring, and disuse of that particular vein. This
procedure does not normally require hospitalization, and may need
to be repeated several times until fully accomplished. Tissue
scaring and skin discoloration are common side effects with this
procedure, results which are dramatically reduced using concomitant
oral enzyme preparations (7). Spider veins (Idiopathic
telangiectases) can be treated in a similar manner (sclerotherapy)
with good results.
The complete removal of an incompetent vein is often referred
to as vein stripping. Since the advent of bypass grafting of
the coronary and peripheral arteries, every effort is made
to preserve the saphenous veins (8). Some studies have shown
that the risk of recurrent varicose veins may be associated
with surgery of superficial insufficiency (9). There are few
studies that have assessed the beneficial effects of surgery
on objective end-points and in a random and controlled way.
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Fig 1 The major veins of the leg. Blood is intended to be pumped upward
through the veins of the leg by muscular action exerted on the veins (A)
. When distention causes the valves, which prevent blood from flowing
downward, to become incompetent; varicosities result (B).
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A fundamental element of the diet for patients suffering from
venous insufficiencies is fiber. Low-fiber diets tend to make the
stools smaller and harder, making them more difficult to pass.
This strain increases the abdominal compression on the major veins,
increasing the pressure and the likelihood of varicosities and
edema in the legs. Difficult bowel movements also increase the
likelihood of hemorrhoids. By increasing the soluble fiber content
of the diet, which may include the addition of psyllium, pectin,
or guar gum fiber supplements; the patient will greatly decrease
the abdominal pressure required to expel the stool. Increasing the
amount of water will also greatly help in this respect.
A second dietary consideration would be the consumption of flavonoids.
This group of phytochemicals is responsible for the color of most
fruits, especially the berries. Increasing the intake of fresh fruits
such as cherries, raspberries, blackberries, currents, blueberries
(or bilberries), hawthorn berries, etc will greatly increase venous,
capillary, and arterial tonicity. Flavonoids are also excellent as
antioxidants for the lipid membranes along these vessels, preventing
them from loosing their tone and becoming brittle from oxidative damage.
Foods that increase the fibrinolytic activity of the blood have
been shown to be helpful, as fibrin is often deposited near varicose
veins. Decreased fibrinolytic activity is associated with increase
risk of thrombus formation, thrombophlebitis, and pulmonary embolisms.
Foods such as onions, garlic, ginger and cayenne will increase
fibrinolytic activity as well as promote other benefits to the
overall circulation.
The Horsechestnut tree (Aesculus hippocastanum L.)
has been planted through the northern hemisphere as an ornamental
and shade tree, although it is native to the Balkan peninsula. The
seed is primarily used medicinally, having as its major known
active component the group of saponins known as aescin (or escin).
Other components include, quinones, flavones, sterols, and a variety
of fatty acids. The extract of the seeds of Horsechestnut, and
specifically aescin, have antiinflammatory, antiedema, antiexudative,
and venotonic activity (10). Many of these activities have been
described since about 1960 and have been the focus of many studies
related to chronic venous insufficiencies and varicose veins.
One of the modes of action associated with aescin appears to be
mediated by prostaglandin F alpha, attributing an anti-exudative
activity (11). Its anti-edema properties are attributed to its
ability to decrease transcapillary filtration (12). Several enzymes
that decrease the tone of vessels (hyaluronidase and several
lysosomal proteoglycan destructing
enzymes) are inhibited by escin or horsechestnut extracts (13,14).
This venotonic activity has been confirmed in animal models (15,17),
as well as human vessel in vitro studies on saphenous veins (16).
A review article published in 1996 (18) summarizes a case observation
study of more than 800 practitioners and more than 5,000 patient with
chronic venous insufficiency, treated with a standardized horsechestnut
extract. They conclude that "all the symptoms investigated- pain,
tiredness, tension and swelling in the leg, as wess as itching and
the tendency toward
edema- all improved markedly or disappeared completely." They conclude
it to be a therapeutic 'pillar', and include that it is additionally
beneficial because compliance is much higher than compression stockings.
These conclusions can be seen in double-blind placebo controlled studies
using standardized horsechestnut extract at 50 mg aescin, twice daily
(19,20,21).
The safety and efficacy of this natural product is sure
to be recognized in greater measure in the United States as more information
continues to confirm these phenomenal results.
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Fig 2 Protecting every Layer of the Vein: Naturally and Synergistically
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Butcher's Broom (Ruscus aculeatus L.) is a short evergreen shrub,
native to the Mediterranean region. It is the root (rhizomes)
of this plant, also referred to as box holly or knee holly,
that is used medicinally. This plant has recorded medicinal
use as early as the first century, but has been a focus of
studies in venous disease primarily in the past 40 years.
Like horsechestnut, saponins play a major role in the activity
of butcher's broom. In this case it is the saponins ruscogenin
and neoruscogenin. They apparently function as vasoconstricting
agents through the a-adrenergic receptors, a property that is
diminished by decreased temperature (22). Extracts of butcher's
broom have also been shown to inhibit elastase, an enzyme
involved in the decreased tone of veins (13). Several experiments
with animal models have confirmed the microcirculatory, venous
constricting, and the anti-edema (inhibition of venous permeability)
effects of butcher's broom extracts
(23,24,25,26).
Several human studies have confirmed its effective use for
venous insufficiencies alone, as well as in combination with
the flavonoids and ascorbic acid
(27,28,29).
Results included
rather immediate changes in symptoms and direct measurements (28),
improvement of venous tone as measured by venous occlusion
plethysmography (27), and a decrease in capillary filtration rate,
tissue volume of the foot and ankle, and a reduction of the blood
volume in the lower leg (29). Dosages range from 100 mg of extract
per day, all the way to 100mg of the extract
(standardized to 9-11% ruscogenin) taken 3 times per day. Again
butcher's broom is considered extremely safe and has minimal
adverse reactions.
The fresh-dried leaves of the Gotu Kola plant (Centella asiatica L.)
have been used medically for a variety of concerns throughout China,
East Asia, and Africa for many years. The saponin component again,
in this case asiaticoside and others, are thought to be the most
active components. Like aescin, the triterpenic fraction of Gotu Kola
extracts is able to inhibit some of the lysosomal enzymes thought to
participate in the etiology of varicosities and venous
insufficiencies (30).
Other factors attributed to Gotu kola is its ability to enhance connective
tissue, increasing the tone of vessels. This activity has been confirmed
in several clinical trials, in which edema, pain, decreased capillary
permeability, and improved microcirculation were all improved significantly
without adverse effects
(31,32,33,34).
These data show that the response
is dose dependent up to 60 mg three times daily. Interestingly, those
patients with normal capillary filtration rates and no edema were not
significantly affected by the Gotu kola extract treatment (34).
The use of
this herb, sometimes called Indian Pennywort, is becoming more frequent
for a number of connective tissue, vascular, and wound healing protocols.
The safe use of this herb and its extracts has been confirmed
by many studies.
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Rutin and It's Derivatives
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Rutin is a flavonoid glycoside containing quercetin as the aglycone
portion and rutinose as its sugar portion, and is found widely
distributed in the plant kingdom. Rutin has been used for many
years for its ability to decrease capillary permeability and fragility
(one of the group called vitamin P, from years ago).
A group of rutin derivatives collectively known as troxerutin
(O-(beta-hydroxyethyl)-rutosides) has become a very useful
ingredient in the treatment of chronic venous insufficiencies.
Its effectiveness and safety has been evaluated in both elderly
patients (35), as well as pregnant women
(36), with excellent
results. While the complete mechanism is not understood, troxerutin
has been reported to have both anti-erythrocyte aggregation effects
and a favorable effect on blood fibrinolytic activity (37).
These authors claim that "Abnormal increase of erythrocyte aggregation and
reduction of profibrinolytic activity are the two most frequent
biological perturbations found in chronic venous insufficiency."
This is quite exciting because this is a mechanism unlike that of
the saponin components previously described. The synergistic potential
may have great benefits in the treatment of CVI (21). Dosages of
troxerutin as a single ingredient were around 900-1000 mg per day
in divided doses (35,38).
There are a whole host of ingredients one could list that have
been used for the conditions described here. We will briefly
overview a few that may be of some benefit, this is by no means
an exhaustive or exclusive list.
Witch hazel (Hamamelis virginiana L.) has been used both
internally, but primarily externally for concerns of varicosities
(especially hemorrhoids).Among its activities are anti-inflammatory,
alpha glucosidase inhibition, elastase inhibition, as well as
anti-edema properties (39). Its use is not wide-spread and has not
been confirmed in many double-blind controlled studies.
A tea preparation of buckwheat (Fagopyrum esculentum) was used
in a double-blind, placebo-controlled clinical trial with good
results in patients with leg edema and CVI (40).
Interestingly,
buckwheat is very high in rutin and this may account for this
activity.
Most of the other natural remedies would include extracts of the
flavonoid-rich fruits such as hawthorn berries (Crataegus sp.),
blue berries or bilberries (Vaccinium sp.), currents (Ribes sp.),
etc. In general the proanthocyanadin compounds in these extracts
have been shown to reduce capillary fragility, increase venous
wall integrity and muscular tone, and prevent the break of the
extracellular matrices of blood vessel. In this respect, grape seed
extracts would be efficacious for similar reasons.
As this brief review has shown, chronic venous insufficiencies and
its associated outcomes is a serious and wide-spread problem in the
United States. Once thought of as only a cosmetic difficulty, these
conditions signal a deep underlying change in physiology of the
venous system. The prevention and treatment of these conditions has
been difficult under the current paradigm of treatments, although
the use of natural ingredients in these conditions is quite promising.
Many of the ingredients (or several
combined) are sure to become standard treatments for venous
conditions here in the United States within the next several years.
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- Helmerhorst FM, Bloemenkamp KW, Rosendaal FR, et.al.
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[PubMed]
- Alguire MD, Mathes MD
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Sixteenth Edition. p 590-593.
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[PubMed]
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[PubMed]
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[PubMed]
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[PubMed]
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[PubMed]
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[PubMed]
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[PubMed]
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[PubMed]
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permeability induced by various agents in the hamster cheek pouch.
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[PubMed]
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histamine in hamster cheek pouch.
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[PubMed]
- Bouskela E, Cyrino FZ, Marcelon G.
Possible mechanisms for the venular constriction elicited by Ruscus extract on hamster cheek pouch.
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[PubMed]
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[PubMed]
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[PubMed]
- Arpaia MR, Ferrone R, Amitrano M, et.al.
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[PubMed]
- Cesarone MR, Laurora G, DeSanctis MT, et.al.
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[PubMed]
- Pointel JP, Boccalon H, Cloarec M, et.al.
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[PubMed]
- Belcaro GV, Grimaldi R, Guidi G.
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[PubMed]
- Belcaro GV, Rulo A, Grimaldi R.
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[PubMed]
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Gerontology 1994;40(1):45-52.
[PubMed]
- Sohn C, Jahnichen C, Bastert G.
Effectiveness of beta-hydroxyethylrutoside in patients with varicose veins in pregnancy.
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[PubMed]
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Febrinolysis and hemorheology in chronic venous insufficiency: a double blind study of troxerutin efficiency.
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[PubMed]
- Unkauf M, Rehn D, Klinger J, et.al.
Investigation of the efficacy of oxerutins compared to placebo in patients with chronic venous insufficiency treated with
compression stockings.
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[PubMed]
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Standard Treatment:
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