Varicose vein syndrome (chronic venous insufficiency)

Disorders of the veins most amenable to herbal therapy are those associated with varicosities. These are characterized by abnormally dilated, tortu- ous, readily visible, usually superficial veins, primarily of the extremities. The condition is often associated with aching discomfort or pain, depend- ing on its severity and the presence of thrombus-associated inflammation, loss of endothelium, and edema. The superficial veins of the leg are most frequently affected because of the effects of gravity on venous pressure. Approximately 20 percent of adults develop varicose veins; the condition is more common in women, a reflection of the elevated venous pressure in the lower legs during pregnancy. 52

Chapter six: Cardiovascular system problems 109 It is now recognized that varicose vein syndrome is largely the result

of the action of lysosomal enzymes that destroy the network of proteogly- cans in the elastic tissue of the veins. This facilitates the passage of elec- trolytes, proteins, and water through the venous walls, thereby producing edema. The enzymes also act not only to reduce the strength of the vessel walls but also to cause them to dilate. The result is valvular incompe- tence, blood flow that tends to stagnate, and development of complica- tions including thrombophlebitis and ulceration. 53

Therapy for varicose vein syndrome has as its objectives: • relief of existing edema;

• prevention of edema by reducing vessel permeability; • reduction of blood stasis by increasing venous tonus; • inhibition of the action of lysosomal enzymes; and • neutralization of inflammatory and sclerotic processes.

In this connection, it must be noted that herbal treatment of varicose veins should not be expected to reverse changes in organic structures that have resulted from years of chronic varicosity. It may, however, provide some relief from the unpleasant symptoms by increasing capillary resistance, improving venous tonus, and even inhibiting the action of lysosomal enzymes.

Most of the phytomedicinals used to treat varicose vein syndrome are isolated chemicals or mixtures thereof, such as rutin, hesperidin, diosmin, and coumarin. These will not be discussed here.

Horse chestnut seed By far the most effective plant drug employed for varicose vein syndrome is horse chestnut seed. The large, nearly globular, brown seeds of Aesculus

hippocastanum L. (family Hippocastanaceae) or of closely related species such as the American horse chestnut or Ohio buckeye, A. glabra Willd., are probably known to every schoolchild because they have been widely used in children’s games. Superstitious adults in many countries carry them in their pockets to prevent or to cure arthritis and rheumatism. Because of their attractive red, yellow, or white flower clusters, the relatively large trees that bear them are widely cultivated.

Horse chestnut seeds contain a complex mixture of triterpenoid saponin glycosides designated aescin. This may be fractionated into an easily crystallizable mixture known as β-aescin and water-soluble compo- nents referred to as α-aescin. Flavonoids, including quercetin and kaemp-

ferol, and the coumarin aesculetin are also present in the seed. 54 Aescin has the ability to reduce lysosomal enzyme activity as much as 30 percent, apparently by stabilizing the cholesterol-containing mem- branes of the lysosomes and limiting release of the enzymes. The com- pound also restricts edema by reducing the transcapillary filtration of

110 Tyler's herbs of choice: The therapeutic use of phytomedicinals water and protein and has some beneficial diuretic effect. In addition, it

has been shown to increase the tonus of the veins, thus improving return blood flow to the heart. 53 As can be seen from the earlier discussion, all of these actions would prove beneficial for the treatment of varicose veins and venous insufficiency.

Horse chestnut seeds are normally utilized in the form of an aqueous- alcoholic extract that is dried and adjusted to a uniform concentration of 16–21 percent triterpene glycosides, calculated as aescin. The efficacy of horse chestnut seed extract (HCSE) in reducing edema in patients with chronic venous insufficiency has been reported in several clinical tri-

als. 54 A recent study compared the two modalities now commonly used to reduce edema: (1) standard mechanical compression with bandages and stockings is inconvenient, uncomfortable, and subject to poor patient compliance, and (2) the medicinal agent approach uses a venoactive sub- stance, in this case HCSE, which exerts an inhibitory action on capillary protein permeability.

This randomized, partially blind, placebo-controlled clinical study involved 240 patients with a duration of twelve weeks. The medicinal agent group received 50 mg aescin twice daily, and the results were determined by measuring lower leg volume. Both those receiving compression therapy and HCSE therapy experienced a 25 percent reduction in mean edema volume, indicating that the two different modalities were equally effective. 55

In the treatment of varicose veins, the initial oral dosage of HCSE is equivalent to 90–150 mg of aescin; following improvement, this may

be reduced to 35–70 mg aescin equivalent daily. As of this writing, stan- dardized horse chestnut extracts or dosage forms prepared from them are not commercially available in the United States. Extemporaneous preparation of a hydroalcoholic extract is possible, but standardization is difficult.

A number of ointments and liniments containing horse chestnut extract are available in Europe. Some of these are endorsed by the manu- facturers not only for local application to superficial varicose veins but also for treatment of hemorrhoids. Because evidence regarding the trans- dermal absorption of aescin is lacking and hemorrhoids are related to both arterial and venous circulation, the efficacy of such preparations,

particularly in the treatment of hemorrhoids, is doubtful. 56 Neither horse chestnut extract nor the aescin contained in it is recognized by the FDA as an effective ingredient in hemorrhoid preparations.

German Commission E has approved the use of horse chestnut seeds for the treatment of chronic venous insufficiency of various origins as well as pain and a feeling of heaviness in the legs. It is also recommended for varicose veins and postthrombotic syndrome. The herb is antiexudative and acts to increase tonus of the veins. Side effects are uncommon, but

Chapter six: Cardiovascular system problems 111 gastrointestinal irritation may occur. 57 Isolated cases of renal and hepatic

toxicity as well as anaphylactic reactions have been reported following intravenous administration, but these appear to be exceptional. 58

Butcher’s broom The rhizome and roots of Ruscus aculeatus L., a fairly common, short evergreen shrub of the family Liliaceae, have acquired some reputa- tion recently as a useful treatment of varicose vein syndrome. Much less studied chemically and clinically than horse chestnut, the herb contains

a mixture of steroidal saponins, particularly the modified cholesterol derivatives ruscogenin and neoruscogenin. Animal studies indicate that the activity of these saponins is in part linked to their stimulation of the

postjunctional α 1 - and α 2 -adrenergic receptors of the smooth muscle cells of the vascular wall, which results in an increased tonus of the veins. 59 In Europe, the herb is available in capsules or tablets containing about 300 mg each of a dried extract. Ointments and suppositories for the treatment of hemorrhoids are also available. 60 Butcher’s broom capsules are available in the United States. Although toxicity has not been reported, much additional work must be carried out before the efficacy of butcher’s broom can be established with certainty.

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chapter seven

Nervous system disorders

Varicose vein syndrome (chronic venous insufficiency)