Case Series to evaluate the efficacy of Tab. Arjuna (Terminalia arjuna (Roxb.) Wight & Arn.) in combination with Siravyadha (Therapeutic Phlebotomy) in improving clinical outcomes and quality of life in primary chronic venous disease

Chronic venous disease or CVD is one of the most common vascular disorders observed across the globe and can severely impact quality of life, reduce the individual’s working hours, and impose a socioeconomic burden. CVD typically refers to telangiectases or spider veins, reticular veins, varicose veins, lower extremity edema, skin trophic changes, and ulceration secondary to ambulatory venous hypertension, which is caused by venous valve reflux, venous flow obstruction, or both. Several epidemiological studies have reported that CVD is a progressive condition. If CVD is left untreated, it results in a gradual loss of cosmesis and a variety of complications, the major ones being persistent pain and discomfort, hemorrhage, superficial thrombophlebitis, and progressive skin changes that may ultimately lead to ulceration.The goal of CVD treatment focuses on decompressing the sources of increased venous pressure. If the superficial saphenous vein is involved, then there are several types of surgical procedures to manage CVD. If the deep venous system is involved, compression stockings are used. Compression therapy is the standard of care for patients with advanced CVD and venous ulcers. Still, compliance rates are poor due to multiple reasons, including physical discomfort, difficulty in application, cost, and psychological factors. Advanced treatments include surgery like vein stripping, ultrasound-guided foam sclerotherapy, radiofrequency, and laser ablation. Risks and complications of all these procedures include perforation, DVT, pulmonary embolism, phlebitis, hematoma, infection, skin burns, and nerve injury.

The pathological stages of CVD have been evaluated with a range of pathological conditions in Ayurveda, such as Siragranthi, Raktavaritavata, Apana Vaigunya, Arsha, Vatarakta, Kushtha, and Dushta Vrana, depending upon the presentations of the patient.Siravyadha or Therapeutic phlebotomy, one of the Panchasodhana or five purificatory therapies, is a specialized procedure aimed at eliminating dushtarakta vitiated blood or accumulated by venous stasis. The procedure is specifically indicated for the various pathological stages of CVD. Further, the procedure reduces venous congestion and stasis, and thereby reduces venous hypertension. An RCT and a pre post trial conducted to study the efficacy of Siravyadha in CVD have reported a reduction in the severity of CVD assessed through Venous Clinical Severity Score and improved the quality of life of CVD patients.Arjuna  or Terminalia arjuna is a potential drug that has pharmacological actions on the circulatory system. According to Bhava Prakasha, Arjuna is considered Hridyam or beneficial for the heart and circulatory system, supporting circulatory activities and aiding in wound healing. Contemporary researchers have explored it as a potential drug having pharmacological action on reducing venous edema, venous hypertension, and venous hypoxia. The drug also has the potential to reverse vascular remodelling, and the vasoactive constituents considerably influence endothelial well-being and remarkably improve overall venous health. A prospective observational study conducted by the investigator on 25 patients or 31 limbs of CVD treated with Tab Arjuna 500mg BD found that there was a six point difference in the median VCSS score on the 90th day of both limbs compared to baseline. Hence, it is proposed that the combination of the interventions will enhance the venous sufficiency by decreasing the venous hypertension and venous stasis and thereby eventually reduce the disease severity of advanced stages of CVD.