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Botanicals for Chronic Venous Insufficiency

Article  in  Alternative and Complementary Therapies · December 2007

DOI: 10.1089/act.2007.13609

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10.1089/act.2007.13609

Botanicals for Chronic

Venous Insufficiency
Kathy Abascal B.S., J.D., R.H. (AHG), The mainstay of allopathic treatment for CVI is the use of com-
and Eric Yarnell, N.D. pression therapy to control edema and venous hypertension.2 In
Europe, botanicals are commonly added to this as adjunctive ther-
apy, and have shown great benefit. Given the prevalence of the dis-
Abstract order, poor patient follow-through with compression therapy, and
the complete lack of established drug protocols for CVI, botanicals

C
hronic venous insufficiency (CVI) is a disorder that af- should be much more widely prescribed in the United States for
fects 5–35% of the United States population. CVI arises patients who have this disorder.
in a state of chronic venous hypertension that alters the Most of the herbs used for CVI are rich in interesting flavonoids
permeability of the skin’s microcirculation. Leakage of protein and other substances that protect capillaries. The herbs’ mecha-
and other matter from the blood vessels leads to edema and in- nisms of action vary, but all of these substances activate venous
flammation-induced tissue injury. The end result is fibrotic and and lymphatic return. The use of herbs in CVI is supported by re-
edematous skin, with damage to capillaries involved in nutrient search showing that they improve venous tone, venous blood
supply and gas exchange. The mainstay of allopathic treatment flow, capillary permeability, and lymphatic drainage.
of CVI is compression therapy to control edema and venous hy-
pertension. In Europe, botanicals are commonly added to this
Butcher’s Broom Root
as adjunctive therapy for CVI, and have shown great benefit.
The botanicals used include Ruscus aculeatus (butcher’s broom) Ruscus aculeatus (butcher’s broom) is a prickly, berry-produc-
root, Aesculus hippocastanum (horse chestnut) seed, Centella asi- ing shrub in the Liliaceae family. It has a wide growth range
atica (gotu kola) herb, Vitis vinifera (grape) leaf, and oligomeric (from Egypt and Turkey through the Mediterranean countries
proanthocyanidins such as Pycnogenol.® up through France, Spain, and England) and prefers to grow on
the outskirts of dry woods. It thrives on moist, uncultivated
ground, especially where the soil contains chalk. The berries are
Introduction
reported to be somewhat toxic. Although the plant could easily
Chronic venous insufficiency (CVI) is a disorder that affects be cultivated in many parts of the United States, most of the
5–35% of the United States population.1,2 The major clinical fea- butcher’s broom available in commerce is imported. Butchers at
tures of CVI are dilated veins, edema, leg pain, and changes in one time used branches of the shrub to clean meat stalls and
the skin of the legs. Edema begins in the ankle region and as- keep flies at bay, giving rise to its common name. The whole
cends up the leg as fluid continues to accumulate. The leg pain plant contains steroidal saponins known as ruscinogens, which
or discomfort is usually described as heaviness or aching, and are the compounds deemed most active in butcher’s broom, but
often occurs after prolonged standing. The discomfort may be only the dried rhizomes are used medicinally.
relieved by elevating the leg(s). When the deep venous system Ancient Greek physicians used butcher’s broom as a laxative and
is involved, venous claudication or intense leg cramping with diuretic. In Europe, a decoction of the root in wine was used as a
ambulation may occur. Advanced CVI can cause lymphedema diuretic, to remove urinary obstruction, kidney stones, and renal
and slow-healing ulcers.2 “gravel.” The plant was also used to regulate menses and amelio-
CVI arises in a state of chronic venous hypertension that alters rate jaundice and headache, and a poultice of the berries was used
the permeability of the skin’s microcirculation.2 The movement of to help heal broken bones and dislocated joints. In South America,
protein and other matter from the blood vessels into the intersti- the root was roasted, ground, and drunk like coffee for prostate tu-
tium causes injury to nutrient and exchange capillaries, white mors. Today, the plant is little used for most of these indications.
blood cell chemotaxis, and inflammation-induced injury. The end Instead, butcher’s broom is now frequently used to relieve symp-
result is fibrotic and edematous skin. toms of CVI such as edema of the ankles, itching, tension and

304
ALTERNATIVE & COMPLEMENTARY THERAPIES—DECEMBER 2007 305

cramping of the legs, and related symptoms. Both animal and The human studies of butcher’s broom in CVI are shown in Table
human studies support this plant’s benefit in CVI, and the German 1. All of the studies showed the plant to have a positive effect, and in
Commission E has affirmed the value of butcher’s broom as an ad- one multicenter study butcher’s broom efficacy in CVI was rated as
junctive treatment for this condition.3 “excellent” by 81.6% of the treating physicians and as “good” by the

Table 1. Studies on Butcher’s broom in Chronic Venous Insufficiency (CVI)

Study # of Type Product Focus Result Length
participants
Cappelli 40 Double-blind, 2 capsules of CVI, Itching, edema, and 2 months, with a
et al.a crossover, (16.5 mg varicosities paraesthesia reduced 15-day washout
placebo-controlled, ruscinogens, and 2-month
prospective 75 mg hesperidin crossover
& 50 mg ascorbic
acid) 3 times/day
Rudofskyb 141 + 20 Randomized, 2 capsulesh 3 CVI Continuous decreases 2 weeks wash-
healthy double-blind, times/day for 4 in foot and ankle out followed by
volunteers multicenter weeks; 2 capsules volume, decrease in 12 weeks treat-
2 times/day for 8 leg swelling, improved ment
weeks venous pumping
Haas 20 Placebo-controlled, 1 capsule (150 mg CVI stages I Significantly in- 14 days
et al.c double-blind ruscus & 150 mg and II, patients creased fibrinolyt-
methylhesperidin scheduled for ic activity of
chalcone) 3 surgery removed great
times/day saphenous vein
Kiesewetter 30 Random selection, 3 x 2 ruscus capsules CVI Reduced circumferences 5 months
et al.d noncontrolled for 5 weeks then of lower legs, malleoli
2 x 2 capsules/day; & subjective complaints;
amount of ruscus greater rheologic improv-
not stated ement in patients with
advanced stages of CVI
Beltramino 80 Open-label, random- 2 capsules/day of CVI (heavy, tired, Significant reduction of 90 days
et al.e ized, multicenter 150 mg ruscus, swollen or painful symptoms, reduction in
150 mg hesperidin legs) limb circumference;
methylchalchone, physicians & patients
& 100 mg ascorbic had more favorable
acid; control was opinion of ruscus
2 tablets of 500 mg than of rutoside
hydroxyethyl
rutoside/day
Le Devehat, 60 + 7 Randomized, 2 capsules/day of CVI; blood samples Improved blood 4 weeks
et al.f healthy double-blind, 150 mg ruscus, drawn from foot viscosity disturbances
volunteers placebo-controlled 150 mg hesperidin before & after caused by venous
methylchalchone, provoked venous stasis
& 100 mg ascorbic stasis
acid
Seydewitz 36 Randomized, 3 capsules Stage IV varicosities Increase in enzyme 4 weeks
et al.g double-blind, (150 mg ruscus with stage I or stage activity in the
placebo-controlled & 150 mg tri- II CVI, scheduled proximal segment of
methylhesperidinch- for vein stripping. the vein, distinctly
alcone) higher incidence of
subjective reduction
of symptoms

aRef. 5; bRudofsky G. Efficacy of Ruscus extract in venolymphatic edema using foot volumetry. In:Vanhoutte PM, ed. Return Circulation and Norepinephrine Paris: John Libbey Eurotext,
1991;cRef. 6; dKiesewetter H, Scheffler P, Jung F, et al. Effect of Ruscus extract in chronic venous insufficiency stage I, II, and III. In: Vanhoutte PM, ed. Return Circulation and Norepinephrine
Paris: John Libbey Eurotext, 1991; eBeltramino R, Penenory A, Buceta AM. An open-label, randomized multicenter study comparing the efficacy and safety of Cyclo 3 Fort versus hydroxyethyl
rutoside in chronic venous lymphatic insufficiency. Angiology 2000;51:535–544; fLe Devehat C, Khodabandehlou T, Dougny M. The effects of Cyclo 3 Fort treatment on hemorheological
disturbances during a provoked venous stasis in patients with chronic venous insufficiency. Clin Hemorheol 1994;14:S53–S63; gSeydewitz V, Berg D, Welbers P, Staubesand J. Biochemical
investigations on the action of Ruscus extract and trimethylhesperidinchalcon (TMHC). In:Vanhoutte PM, ed. Return Circulation and Norepinephrine Paris: John Libbey Eurotext, 1991.
hNot clearly stated but appeared to be using a capsule containing 150 mg of ruscus, 150 mg of hesperidin methylchalchone, and 100 mg of ascorbic acid.
306 ALTERNATIVE & COMPLEMENTARY THERAPIES—DECEMBER 2007

other 18.4%.4 Even though the products used and the quality of the In one study, veins from patients treated with butcher’s
studies vary, a clear picture emerges from clinical and in vitro studies broom prior to vein-stripping surgery showed greater fibri-
showing that butcher’s broom improves venous circulation, perhaps nolytic activity than did the veins of placebo controls.6 In an-
most strongly when that circulation is deficient. However, some re- other trial, patients with CVI and healthy subjects were given
searchers caution that if butcher’s broom is to have benefit, CVI butcher’s broom in a random, double-blind fashion, and were
should not have progressed to a point at which the activity of alpha- then subjected to treatment simulating venous stasis. By com-
adrenergic receptors in the venous wall has been compromised.5 parison with the healthy subjects, the patients with CVI had

Case Study
A 53-year-old postmenopausal woman with low-normal blood pressure had a history of gastric-bypass surgery and arthroscopic surgery on
both knees, and had seasonal affective disorder (SAD) for which she was taking a serotonin-specific reuptake inhibitor (SSRI)–type antidepressant.
Her upper body was slender, and she had a small waist and flat stomach. However, her legs were quite stocky and swollen, as also were the tops
of her feet and toes. Her ankle bones were not visible, and the skin from the midcalf to the ankle of both legs was a mottled red, and pitting
edema was present.
Even the smallest scratch on the patient’s legs caused leakage of a clear fluid that persisted for hours, completely wetting her socks. The leakage
could eventually be stopped by applying continuous pressure. The patient did a lot of physical work, loved to garden, and felt fine as long as she
was moving. She could not sit for more than very short periods because resting caused her cramping or pain, which was worsened when she
elevated her legs. She had had restless leg syndrome in the past and described her current symptoms as entirely different from those of the
syndrome. Her greatest pain came from her right ankle and radiated over the top of the foot. Her physician had told her that she would simply
have to get used to her current circumstances. She had been prescribed full-leg compression stockings, which provided her with some relief, but
which apparently fit poorly, with the tops of the stockings tending to slide down from the patient’s waist to her hips, for which reason she no
longer used them.
The patient’s diet was small and not optimal. She primarily ate Lean Cuisine meals, little meat or fish, and not many vegetables, although she did
consume a spinach drink and 100% vegetable juice. She ate few sweets but did consume some nuts and seeds, used alcohol only minimally, and
drank water liberally. She was not taking any supplements. As her naturopathic physicians, we discussed the need for her to increase her intake of
flavonoids and other antioxidants by eating as many fruits and vegetables as possible. She was unwilling to take tinctures and unable to spend a
great deal of money on supplements.
Initial treatment involved:

• Pycnogenol®a—100 mg once daily

• Ruscus aculeatus (butcher’s broom)—470 mg (1 capsule)/day
• Aesculus hippocastanum (horse chestnut) cream—This consisted of horse chestnut seed and bark extract standardized to 20% aescin, and
which also contained butcher’s broom, Hamamelis virginiana (witch hazel), Quercus alba (white oak), Commiphora myrrha (myrrh) gum, and
Rosmarinus officinalis (rosemary) extracts, with parabens as a preservative. The treatment was gentle topical application to the lower limb
twice daily.

In a telephone conversation with us after 1 week, the patient reported that she was taking Pycnogenol every other day because of its cost,
and that disliked the horse chestnut cream, complaining that it ran and was green, sticky, and messy. Her treatment was thereupon modified to
consist of:

• Pycnogenol: 100 mg every other day

• Butcher’s broom: 470 mg (1 capsule)/day
• Horse chestnut, 250 mg seed extract standardized to 20% aescin, 1 capsule/day

In a visit made 3 weeks after modification of her therapy, the patient reported making an effort to include more vegetables and fruit in diet, and
felt that she was improving. At another visit at 5 weeks after modification of the patient’s treatment, her ankle and calf circumferences had
decreased and the tops of her feet and toes were no longer swollen. Her ankle bone was now visible. However, her leg continued to leak fluid
when scratched, and still showed some pitting edema. She reported feeling much better and being able to fit into pants that she had previously
become unable to wear because her knees and calves were too large (she wears loose men’s pants). She continued to have pain when sitting or
being still, and reported that the pain increased when she elevated her legs. She agreed to try a pair of air boots and subsequently reported that
they enabled her to sit comfortably and completely without ankle pain. However, the boots are of a single size designed to fit all wearers (“one-
size-fits-all”) and she described them as sometimes being too snug for her. Her skin was still mottled but had not worsened or shown signs of
skin or tissue breakdown.

Initial 5 weeks Initial 5 weeks

Right ankle 10.75" 10" Right calf 17.25" 16.5"
Left ankle 10.25" 9.75" Left calf 15" 14.5"

aPycnogenol is an extract from French maritime Pinus maritimus (pine bark), manufactured by Horphag Research, Geneva, Switzerland.
ALTERNATIVE & COMPLEMENTARY THERAPIES—DECEMBER 2007 307

hematologic abnormalities (e.g., disturbances in parameters of

blood viscosity) that were exacerbated in conditions of venous
stasis,7 and butcher’s broom significantly reduced these abnor-
malities. A number of in vitro studies of animal veins confirm
that butcher’s broom and its ruscinogens have a vasoconstrictive
effect and reduce vascular permeability.8 In other studies,
butcher’s broom protected human endothelial cells from hy-
poxia,9 and in yet another study exhibited significant antielas-
tase activity in vitro.10 A review of 24 pharmacologic studies
concluded that butcher’s broom should be the treatment of
choice for CVI.11
Butcher’s broom is generally considered a safe herb, although
it does occasionally cause gastrointestinal (GI) distress.3,12 Side
effects have not been noted in most clinical studies of butcher’s
broom. However, one study of 124 patients with hemorrhoids
noted a 2.4% incidence of GI symptoms (primarily epigastric
burning and pain), 13 and in a study of lymphedema, 3.5% of
the participants experienced significant nausea and abdominal
pain.14 In addition, recent reports in the French medical litera-
ture suggest that butcher’s broom may cause lymphatic colitis
in some patients.15–17 We have not been able to review these
reports, but we suggest that practitioners discontinue the use of
butcher’s broom if severe or persistent GI symptoms occur with
its use. It might also be wise to advise patients not to comb-
ine butcher’s broom with nonsteroidal anti-inflammatory Ruscus aculeatus (butcher’s broom) root.
medications that may cause lymphatic colitis and other adverse
GI effects.

Table 2. Dosing and Potential Safety Concerns of Herbs Used to

Treat Chronic Venous Insufficiency
Herb Dose Potential safety concerns
Ruscus aculeatus Dried root: 300–450 mg/day; in most studies, May cause GI upset, should be taken with meals; may
(butcher’s broom) root butcher’s broom is paired with trimethylhesperidin cause lymphatic colitis (rare), should not be combined
chalcone and ascorbic acid (see Table 1) with NSAIDs.
Tincture: 2–3 mL t.i.d Theoretical: May interact with MAO-inhibiting drugs
(there are no references supporting theory); herb’s
action may be decreased when combined with alpha-
adrenergic- or calcium-antagonists; not sufficiently
studied in pregnancy but appears to be safe based on
existing data
Aesculus hippocastanum Dried seed: 250–300 mg b.i.d. (100 mg aescin/day) Should be used with caution in chronic kidney failure;
(horse chestnut) seed Fresh seed: 120–180 mg q.i.d, should not be applied apply topically to broken or
(120 mg of aescin/day); dose may be cut in half ulcerated skin; may cause GI upset and should be
after the first 8-week period taken with meals
Tincture: 2–3 mL t.i.d. Theoretical: Concern that the herb may affect the
actions of anticoagulant drugs
Pycnogenol,® a extract from 50–350 mg/day Not recommended in pregnancy or lactation; may
maritime pine or grape seeds cause mild GI upset
Theoretical: concern that, as an immune enhancer, the
herb should not be combined with immunosuppres
sive therapies
Centella asicatica (gotu kola) herb Dried herb: 90–180 mg/day No known contraindications
Tincture: 2–4 mL t.i.d
Vitis vinifera (red grape) leaf Dried herb, 370–720 mg/day No known contraindications

GI, gastrointestinal; NSAIDS, nonsteroidal, anti-inflammatory drugs; MAO, monoamine oxidase.

aPycnogenol is an extract from French maritime Pinus maritimus (pine bark), manufactured by Horphag Research, Geneva, Switzerland.
308 ALTERNATIVE & COMPLEMENTARY THERAPIES—DECEMBER 2007

The authors of one book caution against the use of butcher’s for venous edema and has been approved by the German Commis-
broom in patients using alpha-adrenergic antagonist therapy for sion E for CVI including heaviness, nocturnal leg cramping, itch-
benign prostatic hypertrophy (BPH) or hypertension, and against ing, and swelling of the legs.3 A recent Cochrane Review of the use
the plant’s use in patients taking monoamine oxidase (MAO)–in- of horse chestnut found it to be an efficacious and safe short-term
hibiting medications.18 The authors cite no references for these rec- treatment for CVI.25
ommendations, but they may be based on the theoretical possibility Two of the main constituents of horse chestnut are aesculin, a
that the tyramine contained in butcher’s broom might precipitate coumarin derivative, and aescin. Aescin comprises the total
a hypertensive crisis, reduce the effectiveness of alpha-adrenergic- saponin content of the seeds, which actually consists of more
blocking antihypertensive drugs, or reduce the effectiveness of than 30 derivatives of triterpenoids, protoaescigenin, and bar-
treatment of BPH. While one in vitro study showed that alpha- ringtogenol C. It also contains a number of flavones. The
adrenergic agents and calcium-antagonists reduced the venocon- renowned German phytotherapist R.F. Weiss stated that the
strictive effect of butcher’s broom, no studies have shown that antiedematous effect of horse chestnut was 600 times that of
butcher’s broom diminished the action of those drugs. rutin in animals.27
In fact, in one very small study, butcher’s broom reduced edema of In studies, horse chestnut was found to be antiedematous28 and to
the ankles and legs edema caused by calcium-channel–blocker ther- improve vein function, inhibit vasodilation, modulate inflammation,
apy for hypertension. Although the description of this latter study is and act as an antioxidant.3 The herb reduced lysosomal enzymes that
poor, 4 of the 9 patients nevertheless had complete improvement with break down mucopolysaccharides (e.g., hyaluronidase) in the region
butcher’s broom, and no adverse effects were noted. While caution is of the capillary wall, and inhibited the filtration of small molecules,
needed when combining herbs and pharmaceutical medications, it electrolytes, and water into the interstitium by reducing vascular per-
is also important to remember that botanicals can counteract the ad- meability.29 In one study horse chestnut inhibited induced leg edema
verse effects of drugs and sometimes improve their actions. Many in patients with CVI.30
cases of edema are found in patients who are also hypertensive, and The ABC Clinical Guide to Herbs lists 18 studies of the use of
butcher’s broom should not automatically be ruled out as a treatment horse chestnut in CVI.31 These range in duration from 6 to 12
for patients who are medicated for hypertension. weeks and uniformly show a reduction in ankle circumference
The abovementioned authors also caution against the use of and improvement in symptoms. In an observational study of
butcher’s broom in pregnancy and lactation, owing to lack of proof of more than 5000 patients, horse chestnut reduced all of the symp-
its safety in these circumstances18; however, most authors who write toms investigated, including pain, tiredness, tension and
on the topic consider butcher’s broom safe in pregnancy and lacta- swelling of the leg, and itching, and had the advantage over com-
tion.3,12 Although not large enough to be conclusive, an open study of pression stockings of better patient compliance.32 In one system-
20 pregnant women taking butcher’s broom daily for venous insuffi- atic review of clinical trials, horse chestnut reduced leg volume,
ciency followed both fetal and post-birth indices, finding no embry- reduced the likelihood of leg pain by 4-fold, and reduced itching
otoxic effects, and post-birth indices were normal in all instances.19 and edema by 1.5-fold. It was found to be safe and to have no
We reviewed two studies of the use of butcher’s broom in pregnancy- adverse effects.33 As with butcher’s broom, horse chestnut ap-
related venous insufficiency, and both showed improvement in ma- pears to be far more effective in the early stages of CVI. Thus,
ternal symptoms without any adverse effects on the fetus.19,20 Two one study found the herb effective in stage I but far less effective
other European studies, one a multicenter study of 124 patients, re- in stage III of the disease.34 Another study found that after 8
ported a similar improvement of symptoms in pregnant women.21,22 weeks, the dose of horse chestnut could be cut in half and still
While these studies do not conclusively establish the safety of maintain its effect.35
butcher’s broom in pregnancy, both animal and human studies in- In rare cases, horse chestnut may cause pruritus, nausea, and
dicate that the plant has a high degree of safety. Nevertheless, a gastric complaints. One of the herb’s constituents may slow gastric
few cases of hypersensitivity to the ruscinogens of butcher’s broom emptying. There is speculation that horse chestnut may interfere
have been reported,23 and there is one reported case of a severe al- with anticoagulants, but this may pertain only to a compound
lergic reaction to butcher’s broom.24 found in the bark and not in the seeds, which are the part of the
Butcher’s broom is a sustainable medicine, largely obtained from plant used medicinally. There are no known contraindications to
cultivated sources. The dried root is dosed at 300–450 mg per day the use of horse chestnut in pregnancy and lactation, and it has
(in most studies, butcher’s broom is paired with trimethylhes- been used in some studies involving pregnant women without re-
peridin chalcone and ascorbic acid; see Table 1). Dosing of the tinc- ports of adverse effects.31 The potential toxicity of injected aescin
ture of butcher’s broom is 2–3 mL thrice daily. has been associated with significant problems, but these are of no
relevance when using the whole plant extract orally.
Horse chestnut is a highly sustainable medicine that grows read-
Horse Chestnut Seed
ily in many temperate climates, and harvesting the seed does not
Introduced to Europe as a botanical medicine in the 1600s, Aes- harm the tree. Dosing of the dried seed is 250–300 mg twice daily
culus hippocastanum (horse chestnut), like butcher’s broom, is a (100 mg aescin daily); dosing of the fresh seed is 120–180 mg four
widely used treatment for CVI, and is gaining in popularity in the times daily (120 mg aescin daily); and dosing of the tincture is 2–3
United States for this purpose and as a treatment for varicose veins. mL thrice daily. The dose may halved after the first 8-week period
In Germany, horse chestnut is the most widely prescribed botanical of treatment.
ALTERNATIVE & COMPLEMENTARY THERAPIES—DECEMBER 2007 309

permeability and fragility, and to affect enzyme systems including

Gotu Kola
cyclo-oxygenase, and lipoxygenase.50 These findings suggest that
An herb of increasing interest and use in CVI is Centella asiatica OPCs may be useful components in the treatment of a number of
(gotu kola). There is evidence that gotu kola is effective in venous conditions including venous insufficiency, varicose veins, capillary
insufficiency and, given the apparent ability of the herb to promote fragility, and diabetic retinopathy.
wound healing, adding gotu kola to a regimen containing either When individual OPC molecules bind together, they yield what
butcher’s broom or horse chestnut (or both) may prove synergistic are collectively called procyanidolic oligomers (PCOs). These have
in preventing or healing venous ulcers. a broad range of pharmacologic activity through increasing vita-
Most of the clinical studies have been on the isolated total triter- min C levels, decreasing capillary permeability and fragility, scav-
penic fraction of gotu kola. In a test using a vacuum suction cham- enging free radicals, and inhibiting destruction of collagen. The
ber that produces swelling when applied to the ankle skin, subjects last-named effect occurs through the crosslinking of collagen fibers,
with CVI had a relatively slow reabsorption of the fluid compared preventing free-radical damage, inhibiting enzymatic cleavage of
to controls. However, after taking gotu kola for 2 weeks, the time collagen, and preventing the synthesis and release of inflammatory
required to reabsorb the leaked fluid improved significantly.36 In mediators.
another small study with patients taking either 90 or 180 mg of In an open, controlled comparative study, horse chestnut seed
gotu kola per day for 4 weeks, vein function according to various extract at 600 mg per day was compared with Pycnogenol at 360
measurements improved in a dose related fashion. Another study mg per day in 40 patients with CVI over a treatment period of 4
compared 60 and 120 mg, again finding a dose-related reduction in weeks. The study monitored circumference of the lower legs and
discomfort, edema, and sense of leg heaviness.37 The plant’s triter- subjective rating of symptoms of pain, cramps, night-time swelling,
penic fraction prevented microcirculatory changes in adults with the sensation of “heaviness” in the lower legs, and reddening of
mild to moderate superficial venous disease during flights lasting the skin of the legs. Pycnogenol significantly reduced the circum-
over 3 hours.38 ference of the lower legs and significantly improved subjective
Gotu kola is well known for its wound-healing abilities. The herb symptoms. It also significantly decreased blood cholesterol and
and its constituents are beneficial in promoting wound healing and low-density lipoprotein (LDL) levels, while levels of high-density
have been used to treat people with keloids,39 phlebitis and venous lipoprotein (HDL) remained unaffected. Horse chestnut did not
hypertension,40,41 leprosy,42 stretch marks in pregnancy,43 and a significantly reduce the circumference of the lower limbs and mar-
variety of other ailments. In wound studies, gotu kola increased ginally reduced symptoms. Horse chestnut seed and Pycnogenol
antioxidants in newly formed tissue while greatly reducing toxic were equally well tolerated.
lipid peroxide levels.44 Gotu kola and its flavonoids increased ten- Unlike butcher’s broom and horse chestnut, Pycnogenol has
sile strength, collagen content, and epithelialization in many types been shown to provide a benefit in advanced stages of CVI. A
of wounds when used internally or topically.45–47 Gotu kola had study of 39 patients with severe CVI found that Pycnogenol in a
different actions at different stages of wound healing, and consis- dose of 50 mg taken 3 times daily improved capillary filtration and
tently increased collagen synthesis at wound sites.48,49 Most symptomatic score, and reduced edema.51
herbalists think that gotu kola should be used or prepared fresh In another study, 86 patients with severe CVI were given either
for optimal effectiveness. It has no known adverse effects. 150 mg or 300 mg of Pycnogenol or 1000 mg of Daflon—a mi-
Gotu kola grows in tropical areas and is readily cultivated. cronized, purified flavonoid mixture. Ankle swelling was meas-
Though the entire plant is often harvested to make medicine, it is ured early in the morning, before becoming affected by standing,
sufficiently easy to grow that it is for the most part very sustain- and again after 30 minutes of resting with the feet elevated. Meas-
able. The dosing is as follows: dried herb, 90–180 mg per day; tinc- urements were made at the beginning of the study and again after
ture 2–4 mL t.i.d. 4 and 8 weeks of treatment. Each patient recorded a composite,
analogue score based on signs and symptoms (edema, pain, rest-
less limbs, subjective swelling, and skin alterations/redness), and
Oligomeric Proanthocyanidins
an independent physician made a separate evaluation of edema.
Oligomeric proanthocyanidins (OPCs) are found in the heart- After 8 weeks of treatment, Pycnogenol decreased ankle swelling
wood and bark of some trees as well as in some seeds and most by 35%, while Daflon decreased it by 19%. Pycnogenol also de-
berries, ranging from Crataegus spp. (hawthorn) berries to Vac- creased the composite score for edema and other symptoms in
cinium spp. (blueberries), in which the OPC composition varies the lower legs by 64%, whereas Daflon was only half as effective,
among plants. The most common sources of OPCs on the market reducing the score by 32%. Additionally, Pycnogenol was found
are extracts of grape seeds or of Pinus maritimus (maritime pine to have significantly increased tissue oxygen and to have reduced
bark). Pycnogenol® (Horphag Research, Geneva, Switzerland), ex- CO2, which were measured transdermally with small sensors at-
tracted from French maritime pine bark, has been relatively well re- tached to the skin, suggesting a considerable improvement in
searched in CVI. blood circulation to the legs. Daflon, in contrast, did not yield any
OPCs are primarily known for their antioxidant activity. How- significant effect on tissue oxygenation, indicating that it appar-
ever, they also appear to have anti-inflammatory, antiallergic, and ently does not improve blood circulation to the legs. In this study,
vasodilatory actions. In addition, these substances have been found only the composite edema score reflected a benefit of the higher
to inhibit lipid peroxidation, platelet aggregation, and capillary dose of Pycnogenol.52
310 ALTERNATIVE & COMPLEMENTARY THERAPIES—DECEMBER 2007

Grapes, as well as their seeds and leaves, are widely available

and highly sustainable. Dosing of the dried botanical product is
370–720 mg per day.

Conclusion
The herbs discussed in this paper are useful both for treating
CVI and preventing its worsening. Because many different
flavonoids appear to have a beneficial effect on CVI, patients tak-
ing the flavonoid-containing products described in this article
should be advised to also increase their dietary intake of berries,
as well as of other fruits and vegetables. Where patients are will-
ing, better progress can be made if these treatments are combined
with the use of compression therapy, frequent elevation of the
legs, appropriate exercise, and when needed, weight loss. I
Vitis vinifera (grapes).

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