Management of Venous Leg Ulcers
Publication Date: August 1, 2014
Last Updated: September 2, 2022
Diagnosis
Definition
We suggest use of a standard definition of venous ulcer as an open skin lesion of the leg or foot that occurs in an area affected by venous hypertension. (BP)
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Venous Anatomy and Pathophysiology
Venous Anatomy Nomenclature
We recommend use of the International Consensus Committee on Venous Anatomical Terminology for standardized venous anatomy nomenclature. (BP)
[Tables 1 and 2]
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Venous Leg Ulcer Pathophysiology
We recommend a basic practical knowledge of venous physiology and venous leg ulcer pathophysiology for all practitioners caring for venous leg ulcers. (BP)
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Clinical Evaluation
We recommend that for all patients with suspected leg ulcers fitting the definition of venous leg ulcer, clinical evaluation for evidence of chronic venous disease be performed. (BP)
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Nonvenous Causes of Leg Ulcers
We recommend identification of medical conditions that affect ulcer healing and other nonvenous causes of ulcers. (BP)
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Wound Documentation
We recommend serial venous leg ulcer wound measurement and documentation. (BP)
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Wound Culture
We suggest against routine culture of venous leg ulcers and only to obtain wound culture specimens when clinical evidence of infection is present. (2-C)
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Wound Biopsy
We recommend wound biopsy for leg ulcers that do not improve with standard wound and compression therapy after 4–6 weeks of treatment and for all ulcers with atypical features. (1-C)
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Laboratory Evaluation
We suggest laboratory evaluation for thrombophilia for patients with a history of recurrent venous thrombosis and chronic recurrent venous leg ulcers (2-C)
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Arterial Testing
We recommend arterial pulse examination and measurement of ankle-brachial index on all patients with venous leg ulcer. (1-B)
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Microcirculation Assessment
We suggest against routine microcirculation assessment of venous leg ulcers but suggest selective consideration as an adjunctive assessment for monitoring of advanced wound therapy. (2-C)
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Venous Duplex Ultrasound
We recommend comprehensive venous duplex ultrasound examination of the lower extremity in all patients with suspected venous leg ulcer. (1-B)
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Venous Plethysmography
We suggest selective use of venous plethysmography in the evaluation of patients with suspected venous leg ulcer if venous duplex ultrasound does not provide definitive diagnostic information. (2-B)
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Venous Imaging
We suggest selective computed tomography venography, magnetic resonance venography, contrast venography, and/or intravascular ultrasound in patients with suspected venous leg ulceration if additional advanced venous diagnosis is required for thrombotic or nonthrombotic iliac vein obstruction or for operative planning before open or endovenous interventions. (2-C)
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Venous Disease Classification
We recommend that all patients with venous leg ulcer be classified on the basis of venous disease classification assessment, including clinical CEAP, revised Venous Clinical Severity Score, and venous disease-specific quality of life assessment. (BP)
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Venous Procedural Outcome Assessment
We recommend venous procedural outcome assessment including reporting of anatomic success, venous hemodynamic success, procedure-related minor and major complications, and impact on venous leg ulcer healing. (BP)
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Treatment
Wound Care
Wound Cleansers
We suggest that venous leg ulcers be cleansed initially and at each dressing change with a neutral, nonirritating, nontoxic solution, performed with a minimum of chemical or mechanical trauma. (2-C)
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Débridement
We recommend that venous leg ulcers receive thorough débridement at their initial evaluation to remove obvious necrotic tissue, excessive bacterial burden, and cellular burden of dead and senescent cells. (1-B)
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We suggest that additional maintenance débridement be performed to maintain the appearance and readiness of the wound bed for healing. (2-B)
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We suggest that the health care provider choose from a number of débridement methods, including sharp, enzymatic, mechanical, biologic, and autolytic. More than one débridement method may be appropriate. (2-B)
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Anesthesia for Surgical Débridement
We recommend that local anesthesia (topical or local injection) be administered to minimize discomfort associated with surgical venous leg ulcer débridement. In selected cases, regional block or general anesthesia may be required. (1-B)
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Surgical Débridement
We recommend that surgical débridement be performed for venous leg ulcers with slough, nonviable tissue, or eschar. Serial wound assessment is important in determining the need for repeated débridement. (1-B)
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Hydrosurgical Débridement
We suggest hydrosurgical débridement as an alternative to standard surgical débridement of venous leg ulcers. (2-B)
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Ultrasonic Débridement
We suggest against ultrasonic débridement over surgical débridement in the treatment of venous leg ulcers. (2-C)
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Enzymatic Débridement
We suggest enzymatic débridement of venous leg ulcers when no clinician trained in surgical débridement is available to débride the wound. (2-C)
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We do NOT suggest enzymatic débridement over surgical débridement. (2-C)
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Biologic Débridement
We suggest that larval therapy for venous leg ulcers can be used as an alternative to surgical débridement. (2-B)
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Management of Limb Cellulitis
We recommend that cellulitis (inflammation and infection of the skin and subcutaneous tissue) surrounding the venous leg ulcer be treated with systemic gram-positive antibiotics. (1-B)
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Wound Colonization and Bacterial Biofilms
We suggest against systemic antimicrobial treatment of venous leg ulcer colonization or biofilm without clinical evidence of infection (2-C)
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Treatment of Wound Infection
We suggest that venous leg ulcers with >106 colony-forming units per gram of tissue (CFU/g) and clinical evidence of infection be treated with antimicrobial therapy. (2-C)
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We suggest antimicrobial therapy for virulent or difficult to eradicate bacteria (such as beta-hemolytic streptococci, pseudomonas, and resistant staphylococcal species) at lower levels of CFU/g. (2-C)
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We suggest a combination of mechanical disruption and antibiotic therapy as most likely to be successful in eradicating venous leg ulcer infection. (2-C)
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Systemic Antibiotics
We recommend that venous leg ulcers with clinical evidence of infection be treated with systemic antibiotics guided by sensitivities performed on wound culture. (1-C)
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Oral antibiotics are preferred initially, and the duration of antibiotic therapy should be limited to 2 weeks unless persistent evidence of wound infection is present. (1-C)
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Topical Antibiotics for Infected Wounds
We suggest against use of topical antimicrobial agents for the treatment of infected venous leg ulcers. (2-C)
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Topical Dressing Selection
We suggest applying a topical dressing that will manage venous leg ulcer exudate and maintain a moist, warm wound bed. (2-C)
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We suggest selection of a primary wound dressing that will absorb wound exudate produced by the ulcer (alginates, foams) and protect the periulcer skin. (2-B)
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Topical Dressings Containing Antimicrobials
We recommend against the routine use of topical antimicrobial-containing dressings in the treatment of noninfected venous leg ulcers. (2-A)
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Periulcer Skin Management
We suggest application of skin lubricants underneath compression to reduce dermatitis that commonly affects periulcer skin. (2-C)
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In severe cases of dermatitis associated with venous leg ulcers, we suggest topical steroids to reduce the development of secondary ulcerations and to reduce the symptoms of dermatitis. (2-C)
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Anti-inflammatory Therapies
We suggest against use of anti-inflammatory therapies for the treatment of venous leg ulcers. (2-C)
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Indications for Adjuvant Therapies
We recommend adjuvant wound therapy options for venous leg ulcers that fail to demonstrate improvement after a minimum of 4–6 weeks of standard wound therapy. (1-B)
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Split-thickness Skin Grafting
We suggest against split-thickness skin grafting as primary therapy in treatment of venous leg ulcers. (2-B)
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We suggest split-thickness skin grafting with continued compression for selected large venous leg ulcers that have failed to show signs of healing with standard care for 4–6 weeks. (2-B)
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Cellular Therapy
We suggest the use of cultured allogeneic bilayer skin replacements (with both epidermal and dermal layers) to increase the chances for healing in patients with difficult to heal venous leg ulcers in addition to compression therapy in patients who have failed to show signs of healing after standard therapy for 4–6 weeks. (2-A)
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Preparation for Cellular Therapy
We suggest a therapeutic trial of appropriate compression and wound bed moisture control before application of cellular therapy. (2-C)
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We recommend that adequate wound bed preparation, including complete removal of slough, debris, and any necrotic tissue, be completed before the application of a bilayered cellular graft. (1-C)
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We recommend additional evaluation and management of increased bioburden levels before the application of cellular therapy. (1-C)
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Frequency of Cellular Therapy Application
We suggest reapplication of cellular therapy as long as the venous leg ulcer continues to respond on the basis of wound documentation. (2-C)
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Tissue Matrices, Human Tissues, or Other Skin Substitutes
We suggest the use of a porcine small intestinal submucosal tissue construct in addition to compression therapy for the treatment of venous leg ulcers that have failed to show signs of healing after standard therapy for 4–6 weeks. (2-B)
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Negative Pressure Therapy
We suggest against routine primary use of negative pressure wound therapy for venous leg ulcers. (2-C)
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Electrical Stimulation
We suggest against electrical stimulation therapy for venous leg ulcers. (2-C)
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Ultrasound Therapy
We suggest against routine ultrasound therapy for venous leg ulcers. (2-B)
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Compression
Compression–Ulcer Healing
In a patient with a venous leg ulcer, we recommend compression therapy over no compression therapy to increase venous leg ulcer healing rate. (1-A)
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Compression–Ulcer Recurrence
In a patient with a healed venous leg ulcer, we suggest compression therapy to decrease the risk of ulcer recurrence. (2-B)
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Multicomponent Compression Bandage
We suggest the use of multicomponent compression bandage over single-component bandages for the treatment of venous leg ulcers. (2-B)
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Compression–Arterial Insufficiency
In a patient with a venous leg ulcer and underlying arterial disease, we do NOT suggest compression bandages or stockings if the ankle-brachial index is 0.5 or less or if absolute ankle pressure is <60 mm Hg. (2-C)
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Intermittent Pneumatic Compression
We suggest use of intermittent pneumatic compression when other compression options are not available, cannot be used, or have failed to aid in venous leg ulcer healing after prolonged compression therapy. (2-C)
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Operative/Endovascular Management
Superficial Venous Reflux and Active Venous Leg Ulcer–Ulcer Healing
In a patient with a venous leg ulcer (C6) and incompetent superficial veins that have axial reflux directed to the bed of the ulcer, we suggest ablation of the incompetent veins in addition to standard compressive therapy to improve ulcer healing. (2-C)
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Superficial Venous Reflux and Active Venous Leg Ulcer–Prevent Recurrence
In a patient with a venous leg ulcer (C6) and incompetent superficial veins that have axial reflux directed to the bed of the ulcer, we recommend ablation of the incompetent veins in addition to standard compressive therapy to prevent recurrence. (1-B)
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Superficial Venous Reflux and Healed Venous Leg Ulcer
In a patient with a healed venous leg ulcer (C5) and incompetent superficial veins that have axial reflux directed to the bed of the ulcer, we recommend ablation of the incompetent veins in addition to standard compressive therapy to prevent recurrence. (1-C)
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Superficial Venous Reflux With Skin Changes at Risk for Venous Leg Ulcer (C4b)
In a patient with skin changes at risk for venous leg ulcer (C4b) and incompetent superficial veins that have axial reflux directed to the bed of the affected skin, we suggest ablation of the incompetent superficial veins in addition to standard compressive therapy to prevent ulceration. (2-C)
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Combined Superficial and Perforator Venous Reflux With or Without Deep Venous Reflux and Active Venous Leg Ulcer
In a patient with a venous leg ulcer (C6) and incompetent superficial veins that have reflux to the ulcer bed in addition to pathologic perforating veins (outward flow of 500 ms duration, with a diameter of 3.5 mm) located beneath or associated with the ulcer bed, we suggest ablation of both the incompetent superficial veins and perforator veins in addition to standard compressive therapy to aid in ulcer healing and to prevent recurrence. (2-C)
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Combined Superficial and Perforator Venous Reflux With or Without Deep Venous Disease and Skin Changes at Risk for Venous Leg Ulcer (C4b) or Healed Venous Ulcer (C5)
In a patient with skin changes at risk for venous leg ulcer (C4b) or healed venous ulcer (C5) and incompetent superficial veins that have reflux to the ulcer bed in addition to pathologic perforating veins (outward flow of 500 ms duration, with a diameter of 3.5 mm) located beneath or associated with the healed ulcer bed, we suggest ablation of the incompetent superficial veins to prevent the development or recurrence of a venous leg ulcer. (2-C)
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Treatment of the incompetent perforating veins can be performed simultaneously with correction of axial reflux or can be staged with re-evaluation of perforator veins for persistent incompetence after correction of axial reflux. (2-C)
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Pathologic Perforator Venous Reflux in the Absence of Superficial Venous Disease, With or Without Deep Venous Reflux, and a Healed or Active Venous Ulcer
In a patient with isolated pathologic perforator veins (outward flow of 500 ms duration, with a diameter of 3.5 mm) located beneath or associated with the healed (C5) or active ulcer (C6) bed regardless of the status of the deep veins, we suggest ablation of the “pathologic” perforating veins in addition to standard compression therapy to aid in venous ulcer healing and to prevent recurrence. (2-C)
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Treatment Alternatives for Pathologic Perforator Veins
For those patients who would benefit from pathologic perforator vein ablation, we recommend treatment by percutaneous techniques that include ultrasound-guided sclerotherapy or endovenous thermal ablation (radiofrequency or laser) over open venous perforator surgery to eliminate the need for incisions in areas of compromised skin. (1-C)
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Infrainguinal Deep Venous Obstruction and Skin Changes at Risk for Venous Leg Ulcer (C4b), Healed (C5) or Active (C6) Venous Leg Ulcer
In a patient with infrainguinal deep venous obstruction and skin changes at risk for venous leg ulcer (C4b), healed venous leg ulcer (C5), or active venous leg ulcer (C6), we suggest autogenous venous bypass or endophlebectomy in addition to standard compression therapy to aid in venous ulcer healing and to prevent recurrence. (2-C)
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Deep Venous Reflux With Skin Changes at Risk for Venous Leg Ulcer (C4b), Healed (C5) or Active (C6) Venous Leg Ulcer–Ligation
In a patient with infrainguinal deep venous reflux and skin changes at risk for venous leg ulcer (C4b), healed venous leg ulcer (C5), or active venous leg ulcer (C6), we suggest against deep vein ligation of the femoral or popliteal veins as a routine treatment. (2-C)
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Deep Venous Reflux With Skin Changes at Risk for Venous Leg Ulcer (C4b), Healed (C5) or Active (C6) Venous Leg Ulcer–Primary Valve Repair
In a patient with infrainguinal deep venous reflux and skin changes at risk for venous leg ulcer (C4b), healed venous leg ulcer (C5), or active venous leg ulcer (C6), we suggest individual valve repair for those who have axial reflux with structurally preserved deep venous valves in addition to standard compression therapy to aid in venous ulcer healing and to prevent recurrence. (2-C)
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Deep Venous Reflux With Skin Changes at Risk for Venous Leg Ulcer (C4b), Healed (C5) or Active (C6) Venous Leg Ulcer–Valve Transposition or Transplantation
In a patient with infrainguinal deep venous reflux and skin changes at risk for venous leg ulcer (C4b), healed venous leg ulcer (C5), or active venous leg ulcer (C6), we suggest valve transposition or transplantation for those with absence of structurally preserved axial deep venous valves when competent outflow venous pathways are anatomically appropriate for surgical anastomosis in addition to standard compression therapy to aid in venous leg ulcer healing and to prevent recurrence. (2-C)
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Deep Venous Reflux With Skin Changes at Risk for Venous Leg Ulcer (C4b), Healed (C5) or Active (C6) Venous Leg Ulcer–Autogenous Valve Substitute
In a patient with infrainguinal deep venous reflux and skin changes at risk for venous leg ulcer (C4b), healed venous leg ulcer (C5), or active venous leg ulcer (C6), we suggest consideration of autogenous valve substitutes by surgeons experienced in these techniques to facilitate ulcer healing and to prevent recurrence in those with no other option available in addition to standard compression therapy to aid in venous ulcer healing and to prevent recurrence. (2-C)
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Proximal Chronic Total Venous Occlusion/Severe Stenosis With Skin Changes at Risk for Venous Leg Ulcer (C4b), Healed (C5) or Active (C6) Venous Leg Ulcer–Endovascular Repair
In a patient with inferior vena cava or iliac vein chronic total occlusion or severe stenosis, with or without lower extremity deep venous reflux disease, that is associated with skin changes at risk for venous leg ulcer (C4b), healed venous leg ulcer (C5), or active venous leg ulcer (C6), we recommend venous angioplasty and stent recanalization in addition to standard compression therapy to aid in venous ulcer healing and to prevent recurrence. (1-C)
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Proximal Chronic Venous Occlusion/Severe Stenosis (Bilateral) With Recalcitrant Venous Ulcer–Open Repair
In a patient with inferior vena cava or iliac vein chronic occlusion or severe stenosis, with or without lower extremity deep venous reflux disease, that is associated with a recalcitrant venous leg ulcer and failed endovascular treatment, we suggest open surgical bypass with use of an externally supported expanded polytetrafluoroethylene graft in addition to standard compression therapy to aid in venous leg ulcer healing and to prevent recurrence. (2-C)
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Unilateral Iliofemoral Venous Occlusion/Severe Stenosis With Recalcitrant Venous Ulcer–Open Repair
In a patient with unilateral iliofemoral venous occlusion/severe stenosis with recalcitrant venous leg ulcer for whom attempts at endovascular reconstruction have failed, we suggest open surgical bypass with use of saphenous vein as a cross-pubic bypass (Palma procedure) to aid in venous ulcer healing and to prevent recurrence. A synthetic graft is an alternative in the absence of autogenous tissue. (2-C)
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Proximal Chronic Total Venous Occlusion/Severe Stenosis (Bilateral or Unilateral) With Recalcitrant Venous Ulcer–Adjunctive Arteriovenous Fistula
For those patients who would benefit from an open venous bypass, we suggest the addition of an adjunctive arteriovenous fistula (4–6 mm in size) as an adjunct to improve inflow into autologous or prosthetic crossover bypasses when the inflow is judged to be poor to aid in venous leg ulcer healing and to prevent recurrence. (2-C)
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Ancillary Measures
Nutrition Assessment and Management
We recommend that nutrition assessment be performed in any patient with a venous leg ulcer who has evidence of malnutrition and that nutritional supplementation be provided if malnutrition is identified. (BP)
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Systemic Drug Therapy
For long-standing or large venous leg ulcer, we recommend treatment with either pentoxifylline or micronized purified flavonoid fraction used in combination with compression therapy. (1-B)
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Physiotherapy
We suggest supervised active exercise to improve muscle pump function and to reduce pain and edema in patients with venous leg ulcers. (2-B)
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Manual Lymphatic Drainage
We suggest against adjunctive lymphatic drainage for healing of the chronic venous leg ulcers. (2-C)
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Balneotherapy
We suggest balneotherapy to improve skin trophic changes and quality of life in patients with advanced venous disease. (2-B)
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Ultraviolet light
We suggest against use of ultraviolet light for the treatment of venous leg ulcers. (2-C)
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Primary Prevention
Primary Prevention–Clinical CEAP C3-4 Primary Venous Disease
In patients with clinical CEAP C3-4 disease due to primary valvular reflux, we recommend compression, 20–30 mm Hg, knee or thigh high. (2-C)
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Primary Prevention–Clinical CEAP C1-4 Post-thrombotic Venous Disease
In patients with clinical CEAP C1-4 disease related to prior deep venous thrombosis (DVT), we recommend compression, 30–40 mm Hg, knee or thigh high. (1-B)
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Guideline 8.3. Primary Prevention–Acute DVT Treatment
As post-thrombotic syndrome is a common preceding event for venous leg ulcers, we recommend current evidence-based therapies for acute DVT treatment. (1-B)
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We suggest use of low-molecular-weight heparin over vitamin K antagonist therapy of 3-month duration to decrease postthrombotic syndrome. (2-B)
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We suggest catheter-directed thrombolysis in patients with low bleeding risk with iliofemoral DVT of duration <14 days. (2-B)
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Primary Prevention–Education Measures
In patients with C1-4 disease, we suggest patient and family education, regular exercise, leg elevation when at rest, careful skin care, weight control, and appropriately fitting foot wear. (BP)
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Primary Prevention–Operative Therapy
In patients with asymptomatic C1-2 disease from either primary or secondary causes, we suggest against prophylactic interventional therapies to prevent venous leg ulcer. (2-C)
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Recommendation Grading
Overview
Title
Management of Venous Leg Ulcers
Authoring Organizations
American Venous Forum
Society for Vascular Surgery
Publication Month/Year
August 1, 2014
Last Updated Month/Year
October 17, 2024
Supplemental Implementation Tools
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Document Objectives
The objective of the current SVS and AVF clinical practice guidelines is to focus on complete management of VLUs at all levels of care based on strength and quality of supporting evidence to guide specific recommendations. Combined with these other SVS and AVF clinical practice guidelines, a more complete evidence-based strategy is available for management of patients with chronic venous disease.
Target Patient Population
Patients with venous ulcers
Target Provider Population
Specialists who treat vascular diseases and wounds
PICO Questions
What is the best treatment for active venous ulcer?
What is the best treatment for healed venous ulcer?
What is the best method for preventing recurrence of venous ulcers?
Can progression from Primary Venous Disease to active venous ulcer be prevented?
Inclusion Criteria
Male, Female, Adult, Older adult
Health Care Settings
Ambulatory, Outpatient
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Diagnosis, Assessment and screening, Treatment, Management, Prevention
Diseases/Conditions (MeSH)
D007871 - Leg Ulcer, D014647 - Varicose Ulcer
Keywords
Venous leg ulcers, Venous ulcer, VLU