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Evaluation of symptoms associated with venous disease and the expected benefit
of therapy with phlebotropic drugs is not easy because many intercurrent factors exist.
However, many double-blind, placebo-controlled studies with a washout period have been
conducted using measurable criteria for evaluation of pain and heaviness in the legs.
We will briefly summarize the studies conducted on calcium dobesilate (92–96),
Horse chestnut extract (97,98), hydroxyrutin (99–101), and micronized purified flavonoid
fraction (102–105), and to which a few meta-analyses and reviews may be added (106–115).
All these studies have confirmed the reduction in symptoms with all the different
therapeutic agents.
Measurement of quality of life was assessed during treatment with a phlebotropic
drug. It markedly improved after 6 months of treatment, in particular in symptomatic
patients, and was greater in patients in whom a reflux had not been identified (116).
Action on Edema
Several methods have been used to measure edema and study the efficacy of phlebotropic
drugs on this sign.
The simplest method is measurement of ankle circumference, as done most often
with a Leg-O-Meter
w
. This instrument, which has been validated (117), takes into account
the height at which the measurement is made. However, changes observed in ankle circum-
ference are not always correlated with changes in volume of the lower limb. This is why
methods to measure differences in leg volume are preferable. The most well-known is the
volumetric method of fluid displacement (118–119), which has been validated.
Volumetric measurement has been used to show that the most painful legs are those
in which edema exists. Furthermore, volumetric method has demonstrated that the
standing position, or even prolonged sitting with no activity of the calf muscle pump
system, produces an increase in leg volume. Moreover, such edema is correlated with the
degree of venous insufficiency (120). Thus, this accounts for the existence of leg edema
during long-distance airline travel.
Other methods have been used to assess edema in CVD: the optoelectronic method
(121), the tomographic method (122), high-resolution magnetic resonance imaging, and
X-ray absorptiometry (122).
In the literature, a certain number of randomized, controlled studies have
demonstrated the efficacy of phlebotropic drugs on edema. Let us mention studies by
Jaeger et al. (93), and Casley–Smith (94) on calcium dobesilate, Vayssairat’s study
on naphtazone (123), Diehm’s study on horsechestnut extract (124), that of Blume on
micronized purified flavonoid fraction (125), and a study by Cesarone on the effect of
hydroxyrutin (126,127) on edema associated with long-distance airline travel. They have
demonstrated a significant decrease in edema.
In Chronic Venous Insufficiency: Classes C4–C6
Few phlebotropic drugs have been studied in the treatment of chronic
venous insufficiency. The phlebotropic drug most widely studied by far in venous ulcer
and its complications is mircronized purified flavonoid fraction (128–131). A recent meta-
analysis of five clinical trials conducted with this drug on venous ulcer revealed its
beneficial action on reduction of time needed for healing of the ulcer (132).
Among phlebotropic drugs, the use of horse chestnut seed extract (123,133), and
hydroxyrutosides (134) have resulted in a reduction in both edema and symptoms of
chronic venous insufficiency, but have failed to demonstrate superiority over compression
in advanced chronic venous insufficiency (133) or in preventing venous ulcer recurrence
Kakkos et al.268
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(134). This may be because reduction in edema alone is insufficient to treat leg ulceration.
Additional factors must be influenced in order to speed ulcer healing, which the
micronized purified flavonoid fraction might be able to address. Recently much attention
has been focused on the involvement of growth factors (135), and leukocytes in the
development of venous ulceration (87). This has opened up new areas of investigation.
By reducing the likelihood of leukocyte adhesion, micronized purified flavonoid
fraction presumably acts through an anti-inflammatory mechanism (87). Thus, among the
many mechanisms at work in the pathogenesis of venous ulceration, the mechanism
involving leukocyte activation and interaction with the endothelium seems to be the one
most responsive to pharmacological treatment up to now.
Place of Phlebotropic Drugs in the Treatment of Chronic
Venous Disorders
Phlebotropic drugs have a well-established effect on edema. They also effectively decrease
the so-called symptoms of venous disease such as heaviness of the legs, pain, sensation of
swelling and nighttime cramps.
In both patients classified as having stage C0 disease and in those classified as C1s
and C2s for whom invasive therapy (sclerotherapy, surgery) does not appear warranted,
phlebotonic drugs appear to represent good first-line treatment of chronic venous disorder,
possibly in conjunction with compression therapy.
In more advanced disease stages, phlebotropic drugs have not demonstrated any
additional benefit over compression on improvement of skin changes or in ulcer healing,
except for micronized purified flavonoid fraction that may be used in conjunction with
sclerotherapy, surgery and/or compression therapy, or as an alternative treatment when
surgery is not indicated or is not feasible (114).
KEY POINTS
† Compression increases ulcer healing rates and is cost effective.
† Compression reduces the venous volume and may restore venous valve function.
† Elastic stockings are the most widely used form of compression but lose
elasticity with time and should be replaced regularly.
† Various forms of bandaging are available but multi-layer systems are the most
effective.
† To prevent ischemic complications, an ankle/arm index !0.6 is a contra-
indication for compression hosiery therapy.
† Intermittent pneumatic compression may increase the healing rate of venous
ulcers but the evidence for this is currently small.
† Exercise may improve calf muscle pump function but it is not clear if this
increases ulcer healing rates. Skin substitutes may increase healing rates but are
relatively expensive.
† Few phlebotropic drugs have been studied in the treatment of chronic venous
insufficiency and their role remains controversial.
† Phlebotropic drugs have a well-established effect on edema. They may also
effectively decrease the so-called symptoms of venous disease such as heaviness
of the legs, pain, sensation of swelling, and night-time cramps.
Conservative Treatments: Medical/Drug Therapies 269
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21
Surgical Treatment of Varicose Veins
Steven S. Kang
South Miami Heart Center, Miami, Florida, U.S.A.
The surgical treatment of varicose veins most commonly consists of ligation and strip-
ping the great saphenous vein, which eliminates or reduces venous hypertension from
truncal reflux, and avulsion of subcutaneous varicose veins. The small saphenous is less
frequently treated. The following is a description of these procedures, which are effective
and cosmetic.
GREAT SAPHENOUS VEIN LIGATION AND STRIPPING
Before being taken to the operating room, I have the patient stand to distend the veins
and use an indelible marker to draw the outlines of varicose veins (Fig. 1). I draw lines on
either side of the varicose vein so that I know the relative size. Often the saphenous vein
itself is visible or palpable about the knee and this should be marked as well.
Light general or spinal anesthesia is used although the procedure can be done with
local anesthesia in the groin with a femoral nerve block. The patient is placed supine.
Some surgeons use a tourniquet but I do not think it is necessary. The incision to expose
the saphenofemoral junction is made directly in the groin skin crease just medial to the
femoral pulse. This is more cosmetic than below the skin crease. In thin patients, it need
not be longer than two or three cm.
After dividing the saphenous fascia, blunt finger dissection will readily reveal the
saphenous vein or one of it proximal branches. A small self-retaining retractor or Army–
Navy retractors can be used. Branches are exposed sufficiently to ligate and divide them.
This allows dissection and mobilization of the saphenous vein proximally to the fossa
ovalis (Fig. 2). The junction of the saphenous and femoral veins should be clearly
visualized. A right-angled clamp then is placed across the saphenous vein a couple of
centimeters distal to the saphenofemoral junction and another clamp placed further down.
The vein is divided between the clamps. The origin of the saphenous vein then is simply
ligated with a 2–0 silk; any complicated suturing is not necessary. The clamp is removed
before cutting the suture to visualize that the ligature is flush with the femoral vein.
The remaining distal end of the saphenous vein is addressed next. It is worthwhile
to place the Army–Navy retractor in the inferior aspect of the incision to see if the
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