Centella asiatica
VEINS: The Uphill Journey
by Will Block

Brandon's journey followed the  long and arduous "return" to the heights of Kilimanjaro, in the heart of Africa.
ur good friend Dr. Jack Wheeler phoned a few months ago to praise the latest "height" reached by his 16-year-old son, Brandon. During the midwinter holidays, Brandon took off by himself for Africa, where he connected with a tribal guide and climbed Kilimanjaro, the highest mountain of the "dark continent." In doing so, the young adventurer - whose photo graced this magazine when, at the age of 14, he climbed the Matterhorn with his 54-year-old father - ascended a very different kind of mountain from the other Seven Sisters, the highest peaks on the seven continents. Kilimanjaro is not "straight up," but instead rises slowly and gradually with a climb that goes . . . on . . . seemingly . . . forever.

As he climbed, young Brandon vigorously exercised his circulatory system, working his heart, arteries, capillaries, and veins. Expelled from his heart was oxygen-enriched blood replenished with nutrients. Rhythmic waves of it surged through his body, starting with the arteries, as wide as 1.5 inches in diameter, near his heart and continuously branching to ever smaller arteries and tiny arterioles, which divide into the filigree of capillaries that feed the individual cells. His well-toned circulatory system distributed blood to all the living cells of his body.

The muscular, elastic walls of Brandon's arteries served to tame the forceful heart contractions and arterial pulses, which diminished as they became more distant from his heart. His blood flowed more steadily and slowly, finally coming nearly to a stop in the capillaries so that the individual cells could absorb what they needed from it and, at the same time, release their metabolic waste products to it.

In our bodies, as in Brandon's, capillaries merge to become tiny venules, which merge to become veins. Like the arteries in reverse, the veins grow ever larger as they return toward the heart - a long, upward struggle from the feet and legs. But unlike arteries, veins have very thin walls, which can be "pumped" to some degree by contractions of the surrounding muscles. Well-toned muscles can thus play an important supplementary role in the return process that keeps blood circulating, especially when the circulatory demands are high.

By the strength of his will, every step focused on remaining in motion, always looking upward, and choosing carefully the right path to avoid having to retreat, Brandon reached the top. Similarly, the one-way valves of his veins allowed his blood - seemingly defying gravity - to return toward his heart without backflow. Although cardiovascular function is autonomic, not under the direct control of the mind, it was as if Brandon's determination governed the function of his venous system, keeping his blood flowing "uphill." Had all his veins been above his heart in his head, his blood could not have returned more securely.

When it seemed that the torture inflicted upon himself could go on no longer, Brandon finally stood atop Kilimanjaro. His uphill journey was its own reward, a tribute to the reverence the climber gains for himself* and a confirmation of the strength and beauty of a well-functioning body and a mind in charge of itself. Climbing is the challenge of returning to the heights, which is also the goal of good health - and, for that matter, of good veins.

* . . . it is some fundamental certainty which a noble soul has about itself, something which is not to be sought, is not to be found, and perhaps, also, is not to be lost. - The noble soul has reverence for itself. From Nietzsche F. Beyond Good and Evil: Prelude to a Philosophy of the Future.

When you're young and physically fit, you normally do not think much about your health. If you give your cardiovascular system any thought, it's your arteries, rarely your veins, that receive your attention. But if you're a bodybuilder, veins become more important. In fact, they must be extremely prominent on the surface of your arms, and especially your legs. Why? Because that's a sign that you're really "ripped" - highly muscularly developed, with so little body fat that your superficial veins stand out sharply against the underlying muscles. Usually, when exercise results in prominent veins, they are likely to be reflective of healthy deep veins - the ones for which muscular contractions, especially in the legs, can help the heart in its task of pushing the blood upward. By contrast, chronic venous disease is associated with diminished leg-muscle and especially calf-muscle function.1

As we know (see Mending Varicose Veins - Oct. 1999 and Get Rid of Hemorrhoids - Nov. 1999), healthy veins are harder to maintain as we age. There is a tendency to develop varicose veins, those abnormally enlarged, twisted, and unsightly veins that appear in our calves and thighs. If you're a woman, your chance of getting varicose veins is perhaps four times greater than if you were a man. This injustice is probably due to pregnancy and the stress of menopause.2

It has become recognized that varicose veins are the earliest sign of a form of cardiovascular disease - venous insufficiency - that can end in venous thromboembolism, which is nearly as insidious as coronary artery disease. Sadly, not much attention has been focused on this very serious and pervasive problem. What starts out as venous insufficiency can lead to venous thrombosis (blood clots) and even death. Recent studies using duplex scanners indicate that the frequency of venous thrombosis appears to be increased in patients with varicose disease.3

Venous thromboembolism (vein blockage by a clot) is the third most common cardiovascular disease in the United States, after heart attack and stroke. It has been estimated to affect up to half a million Americans annually, resulting in 300,000 to 600,000 hospitalizations and up to 100,000 deaths.4 When venous insufficiency becomes chronic, varicose veins may ulcerate (erupt) on the skin, a clinical manifestation of venous thromboembolism.

Most venous insufficiency, however, manifests itself in less dramatic ways, namely, as nonulcerating varicose veins of the lower extremities and the anus. The latter are hemorrhoids, a particularly unpleasant form of varicosity.5 It is estimated that by the age of 50, nearly half of all adults are affected by varicosity of some kind.6 In Western societies, venous insufficiency is a dominant factor in age-related disablement. The cost of care for this disease dwarfs those for other common disorders seen by general surgeons,7 and the nursing profession is inundated by demands for outpatient care for venous ulcers, which absorbs up to 30% of all outpatient monies expended. Furthermore, the disability attributable to varicose veins or leg ulcers is a liability that can extend over long periods of time.

Good veins are not guaranteed. Furthermore, varicosities tend to precipitate even worse problems. As a varicose vein enlarges, it will contain larger volumes of blood, thus increasing the back-pressure on the valve below it. If this pressure becomes great enough to compromise the valve, the varicosity will enlarge even more, thus further damaging the valve and increasing the back-pressure on the next valve down - and so the condition continues to worsen. The effects of gravity and body weight are the primary reasons why varicose veins occur almost exclusively in the legs. They may be present in either one or both legs.

Without treatment, the veins will enlarge and worsen with time. Incompetent veins will further impact the circulatory system, accelerating damage to arteries by increasing atherosclerotic hardening, with the increased likelihood of heart attack or stroke. While the damage may accrue gradually or rapidly, untreated cardiovascular damage inevitably becomes worse, precipitating life-threatening crises. Symptoms preceding overt venous insufficiency and varicose veins are heavy, achy, drawing pains, swelling (edema), tenderness, and a tired feeling in the legs. In women these symptoms often become worse shortly before menstruation. Most often, as the veins themselves worsen, so do the symptoms.

As untreated varicose veins enlarge, venous insufficiency becomes worse. It entails blood congestion characterized by the blood's inability to return from the legs to the heart. Other ailments, including thrombosis, phlebitis (inflammation of the veins), ulcers, and bleeding infection, can follow.

Stockings, injections (sclerotherapy), laser treatments, and surgery - from ambulatory phlebectomy (removing veins with a kind of fishhook) to "stripping and ligation" (tying veins shut and removing them from the leg) - have their advocates in conventional medicine. These procedures, however, do not deal fundamentally with the underlying problems, which are the structure, function, and biochemistry of the venous system. Fortunately, science has discovered a number of nutritional approaches that appear, from the results of double-blind, placebo-controlled studies, to be viable alternatives to conventional therapies. They have inspired a number of theories about the nature of venous insufficiency - but the proof is in the pudding.

As far as we know, until last October no commercial source in the United States had compiled the evidence for the effects on veins of certain rare flavonoids - specifically, troxerutin, diosmin, and hesperidin. Yet, as remarkable as the evidence is that these flavonoids can relieve the unsightliness and aggravation of varicose veins and hemorrhoids, it is even more remarkable that they had never appeared before in a single dietary supplement available in this country, or, for that matter, anywhere else in the world!  Furthermore, Europeans have known about the phytonutrient horse chestnut - another remarkable product for varicose veins - for some time, yet it is only recently that word of its powerful support for proper vein function began to break on American shores.

When horse chestnut is combined with troxerutin, diosmin, and hesperidin, the results are outstanding. And now you can obtain these four ingredients in the same amounts that are used in scientific studies to produce significant improvement of varicose veins and hemorrhoids.

These four ingredients offer to help restore vital vein function and have been found to help:

  • Improve the unsightliness of varicose veins
  • Alleviate the aggravation of hemorrhoids
  • Prevent edema (swelling)
  • Strengthen vein walls
  • Improve blood-flow characteristics that can result in abnormal function

Originally found in India and tropical islands of the Indian Ocean but now widely distributed throughout the world, Centella asiatica, commonly known as gotu kola (also Indian pennywort and various other names), has recently become popular because of its pharmaceutical and cosmetic properties. Known 3000 years ago to Ayurvedic medicine (and known, incidentally, to be a favorite food of elephants), Centella was described in the ancient Vedas as being useful either in poultices applied directly to the skin or by the oral route, to help heal wounds and ugly skin lesions of various origins.

After a long period of empirical use (that is, based on anecdotal evidence), the first scientific investigations of Centella were undertaken in Madagascar in the mid-19th century, some of the results of which were described in the French Codex in 1884. Extracts have been prepared since 1941, and since then a growing body of research has been carried out by chemists and pharmacologists. The most active agents found in Centella are compounds called triterpenes.

In 1994 a double-blind, placebo-controlled study was carried out on 87 patients with chronic venous hypertensive microangiopathy, an advanced form of deep venous disease characterized by blood flowing into the skin via seepage through the walls of the veins. The patients were given Centella asiatica for 60 days in doses of either 30 mg or 60 mg twice daily.8 Microcirculatory parameters measuring seepage were improved significantly. Centella was well tolerated, and no unwanted effects were observed. The positive effects appeared to be dose-related.

The effects of Centella on metabolism in the connective tissue of the vascular wall and on the microcirculation were found to reduce edema in the ankles and feet. Microcapillary filtration, a measure of venous-wall decline, was decreased, as were several other parameters reflecting blood seepage.9 Centella was found to be helpful for venous insufficiency, and its effects were dose-dependent.

In the later stages of venous thrombosis, a condition known as postphlebitic syndrome can occur. It is characterized by destruction of the valves of deep veins. Also, rather than the body's recanalizing the thrombosed veins (working around them with new growth), it simply obliterates them, resulting in chronic venous insufficiency, marked by edema, ongoing skin inflammation, and ulceration of the leg. In a study with both normal subjects and patients with postphlebitic syndrome, Centella was given to determine its impact on circulating endothelial cells, a measure of the damage caused by the disease.10  The diseased subjects naturally had more circulating endothelial cells than the normal subjects, but after treatment for three weeks with an extract of Centella asiatica, a statistically significant reduction was found in their levels.

At the Microcirculation Laboratory at D'Annunzio University in Chieti, Italy, a new system to evaluate capillary permeability was used to study variations of permeability and microcirculation in 10 normal subjects, 22 patients with moderate, superficial venous hypertension, and 12 patients with postphlebitic limbs and severe venous hypertension.11 All 34 of the patients had ankle and foot edema, for which they were treated with 60 mg of Centella three times daily.

After two weeks of treatment, wheals (raised marks) that were induced by a capillary measurement device on the skin of the limbs with venous incompetence disappeared much faster than before, in both groups of patients. As well, capillary permeability decreased (improved), indicating a significant improvement of the microcirculation and symptoms of deep venous incompetence.

Also at D'Annunzio University, but in its Cardiovascular Clinic, researchers evaluated three groups of patients, all of whom had venous hypertension, and compared them with normal subjects in an open study. The physical parameters measured were capillary filtration rate and ankle circumference.12 In addition, four symptoms were evaluated: swelling sensation, restless lower extremity, pain and cramps, and tiredness. After four weeks of treatment with Centella, the patients' symptoms were found to improve in proportion to the dose, which ranged from 90 to 180 mg/day.

Increased turnover of mucopolysaccharides (sugar-protein complexes such as acetylglucosamine), which are involved in repairing tissue, is suggestive of damage believed to be responsible for loss of connective-tissue integrity in the walls of veins.  Indeed, higher levels of mucopolysaccharides have been measured in subjects with varicose veins.13 When Centella was given at just 60 mg/day for three months, these levels fell progressively.

Ninety-four patients suffering from venous insufficiency of the lower limbs participated in a multicenter, randomized, double-blind, placebo-controlled study.14 They were given Centella at either 60 or 120 mg/day, or placebo, and the former produced a significant difference in symptoms. Relief from heaviness in the lower limbs caused by edema, and lower energy levels, as well as overall self-evaluation by the patient, indicated that Centella was beneficial.

When considering a course of action to help maintain proper venous function - whether for varicose veins or hemorrhoids, or venous insufficiency in general - it is useful to know that another option has now been added to the proven stock of troxerutin, diosmin, hesperidin, and horse chestnut. Welcome, Centella! Together, these five items demonstrate a variety of venotonic effects, including:

  •  Reduced swelling (antiedemic)
  •  Soothed inflammation (anti-inflammatory)
  •  Protection against oxidation (antioxidant)
  •  Strengthened wall structure (venoprotective)

The protective benefits of these phytonutrients are highlighted by relief from the symptoms of venous insufficiency, such as tension or heaviness in the legs, pain, and a sense of tiredness. You may not be off soon to conquer the highest mountains in the world, but the chances are good, given the first-rate science behind these supplements, that such simple pleasures as walking up the stairs without grimacing will be yours again. Climbing is the goal of good veins.


  1. Yang D, Vandongen YK, Stacey MC. Changes in calf muscle function in chronic venous disease. Cardiovasc Surg 1999 Jun;7(4):451-6.
  2. Canonico S, Gallo C, Paolisso G, Pacifico F, Signoriello G, Sciaudone G, Ferrara N, Piegari V, Varricchio M, Rengo F. Prevalence of varicose veins in an Italian elderly population. Angiology 1998 Feb;49(2):129-35.
  3. Guex JJ. Thrombotic complications of varicose veins. A literature review of the role of superficial venous thrombosis. Dermatol Surg 1996 Apr;22(4):378-82.
  4. Hooper WC, Evatt BL. The role of activated protein c resistance in the pathogenesis of venous thrombosis. Am J Med Sci 1998 Aug;316(2):120-8.
  5. CDC. Vital and Health Statistics, Series 10, No. 199 (10/98), p. 83.
  6. Van den Oever R, Hepp B, Debbaut B, Simon I. Socio-economic impact of chronic venous insufficiency. An underestimated public health problem. Int Angiol 1998 Sep;17(3):161-7.
  7. Evans CJ, Fowkes FG, Hajivassiliou CA, Harper DR, Ruckley CV. Epidemiology of varicose veins. A review. Int Angiol 1994 Sep;13(3):263-70.
  8. Cesarone MR, Laurora G, De Sanctis MT, Incandela L, Grimaldi R, Marelli C, Belcaro G. The microcirculatory activity of Centella asiatica in venous insufficiency. A double-blind study. Minerva Cardioangiol 1994 Jun;42(6):299-304.
  9. Cesarone MR, Laurora G, De Sanctis MT, Belcaro G. Activity of Centella asiatica in venous insufficiency. Minerva Cardioangiol 1992 Apr;40(4):137-43.
  10. Montecchio GP, Samaden A, Carbone S, Vigotti M, Siragusa S, Piovella F. Centella asiatica triterpenic fraction (CATTF) reduces the number of circulating endothelial cells in subjects with postphlebitic syndrome. Haematologica 1991 May-Jun;76(3):256-9.
  11. Belcaro GV, Grimaldi R, Guidi G. Improvement of capillary permeability in patients with venous hypertension after treatment with TTFCA. Angiology 1990 Jul;41(7):533-40.
  12. Belcaro GV, Rulo A, Grimaldi R. Capillary filtration and ankle edema in patients with venous hypertension treated with TTFCA. Angiology 1990 Jan;41(1):12-8.
  13. Arpaia MR, Ferrone R, Amitrano M, Nappo C, Leonardo G, del Guercio R. Effects of Centella asiatica extract on mucopolysaccharide metabolism in subjects with varicose veins. Int J Clin Pharmacol Res 1990;10(4):229-33.
  14. Pointel JP, Boccalon H, Cloarec M, Ledevehat C, Joubert M. Titrated extract of Centella asiatica (TECA) in the treatment of venous insufficiency of the lower limbs. Angiology 1987 Jan;38(1 Pt 1):46-50.

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