Guideline sources The following summarized guidelines for the evaluation and management of venous leg ulcer are prepared by our editorial team based on guidelines from the European Society for Vascular Surgery (ESVS 2022), the Society for Vascular Medicine (SVM/SVS/ACP/AVF/IUP 2019), the European Dermatology Forum (EDF 2016), and the Society for Vascular Surgery (SVS 2014). 1 2 3 4 5 5 5 6 7 8 Definition Venous leg ulcers are defined as open lesions in the skin of the lower extremities occurring due to the presence of venous hypertension. 5 Epidemiology Venous hypertension (which may be due to deep vein thrombosis, perforator insufficiency, superficial and deep vein insufficiencies, arteriovenous fistulas, or calf muscle pump insufficiencies) causes a chronic inflammatory response that, over time, can cause venous https://web.pathway.md/diseases/recadzucP6PgPISk8 1/10 6/29/23, 3:25 AM Venous leg ulcer Pathway ulceration. The inciting inflammatory injury is chronic extravasation of macromolecules and RBC degradation products with resultant iron overload. 7 Pathophysiology The incidence of venous leg ulcers in the United States is estimated at 50-2200 cases per 100,000 person-years. 6 Disease course Ulcers are typically shallow, with an irregular edge and well-defined margins, and are characteristically located anterior to the medial malleolus, pretibial area, or lower third of leg. Capillary leaking causes edema leading to maceration, pruritus and scaling. Pain may be absent, mild or extreme, is usually worse at the end of the day and relieved by elevation of the leg. 5 Prognosis and risk of recurrence Chronic venous leg ulcers result in reduced mobility, significant financial implications, and poor quality of life. Compression therapy results in healing rates of approximately 55-60% at 2 months. 5 8 Guidelines 1. Screening and diagnosis Definition of venous ulcer: define venous ulcers as an open skin lesion of the leg or foot that occurs in an area affected by venous hypertension. B 2. Classification and risk stratification Anatomic classification of disease: use the International Consensus Committee on Venous Anatomical Terminology for standardized venous anatomy nomenclature. B Assessment of disease severity: As per EDF 2016 guidelines, determine the full CEAP classification in all patients using a combination of physical examination and technical aid (especially duplex). Record the size, the site and the characteristics of the ulcer in addition. Determine an ankle/arm index. E As per SVS 2014 guidelines, classify all patients with venous leg ulcers based on venous disease classification assessment, including clinical CEAP (provided below), revised VCSS, and venous disease-specific quality of life assessment: Situation Guidance No visible or palpable signs of venous disease C0 Telangiectasies or reticular veins C1 https://web.pathway.md/diseases/recadzucP6PgPISk8 2/10 6/29/23, 3:25 AM Venous leg ulcer Pathway C2 Varicose veins Edema C3 Pigmentation or eczema C4a Lipodermatosclerosis or athrophie blanche C4b Healed venous ulcer C5 Active venous ulcer. B C6 3. Diagnostic investigations Clinical history: Evaluate for evidence of chronic venous disease for all patients with suspected leg ulcers fitting the definition of venous leg ulcer. B Elicit a history of medical conditions that affect ulcer healing and other nonvenous causes of ulcers. B Physical examination: As per ESVS 2022 guidelines, obtain objective arterial assessment in patients with active leg ulceration. B As per EDF 2016 guidelines: Determine the ankle-brachial-pressure index before pressure therapy. E Measure systolic ankle-brachial-pressure index in patients with leg ulcer to rule out concomitant arterial occlusive disease. Consider obtaining further arterial investigations, if indicated. E As per SVS 2014 guidelines: Examine arterial pulses, and obtain an ABI measurement in all patients with venous leg ulcers. B Measure venous leg ulcer wounds and document their size over time. B Diagnostic imaging: As per EDF 2016 guidelines, do not obtain Doppler ultrasound for routine investigation of the deep venous system and the venae perforantes in the diagnostic evaluation of venous leg ulcer. D Show 2 more As per SVS 2014 guidelines: Obtain comprehensive venous duplex ultrasound examination of the lower extremity in all patients with suspected venous leg ulcers. B Consider obtaining CTV, MRV, contrast venography, and/or intravascular ultrasound selectively in patients with suspected venous leg ulceration in whom: additional advanced venous diagnosis is required for thrombotic or nonthrombotic iliac vein obstruction operative planning is required before open or endovenous interventions. C https://web.pathway.md/diseases/recadzucP6PgPISk8 3/10 6/29/23, 3:25 AM Venous leg ulcer Pathway Plethysmography: As per EDF 2016 guidelines, do not obtain routine photoplethysmography because of its low sensitivity and specificity, nor the remaining plethysmography methods because of the lack of additional value in daily practice. D As per SVS 2014 guidelines, consider obtaining venous plethysmography selectively in the evaluation of patients with suspected venous leg ulcer, if venous duplex ultrasound does not provide definitive diagnostic information. C Wound cultures: As per EDF 2016 guidelines, obtain a swab from a venous leg ulcer for culture only if there are signs of an infection, before surgery on leg ulcers and for MRSA detection. Consider initiating oral or IV antibiotics afterwards. E As per SVS 2014 guidelines: Consider obtaining wound culture specimens when clinical evidence of infection is present. C Consider avoiding routine wound culture specimens in the absence of clinical evidence of infection. D Direct venous pressure assessment: do not obtain routine direct venous pressure measurement in patients with chronic venous insufficiency and with venous leg ulcer since the 'C' in CEAP correlates well with the venous. D Microcirculation assessment: Consider obtaining microcirculation assessment of venous leg ulcers selectively, as an adjunct to the monitoring of advanced wound therapy. C Consider avoiding routine microcirculation assessment of venous leg ulcers. D Evaluation for thrombophilia: consider obtaining laboratory evaluation for thrombophilia for patients with a history of recurrent venous thrombosis and chronic recurrent venous leg ulcers. C Evaluation for contact dermatitis: obtain a test with a series of allergens presenting in products for treating wounds and wound dressings in addition to the European standard series in all cases of leg eczema in chronic venous insufficiency when contact allergy is suspected. E 4. Diagnostic procedures Wound biopsy: As per EDF 2016 guidelines, consider taking multiple biopsies if an ulcer does not respond or responds inadequately to therapy and has an atypical appearance. E As per SVS 2014 guidelines, perform 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. B 5. Medical management https://web.pathway.md/diseases/recadzucP6PgPISk8 4/10 6/29/23, 3:25 AM Venous leg ulcer Pathway Venoactive agents: As per ESVS 2022 guidelines, consider offering micronized purified flavonoid fraction, hydroxyethylrutosides, pentoxifylline, or sulodexide as an adjunct to compression and local wound care to improve ulcer healing in patients with active venous leg ulceration. B As per SVS 2014 guidelines, treat long-standing or large venous leg ulcers with either pentoxifylline or micronized purified flavonoid fraction used in combination with compression therapy. B Antibiotics: As per ESVS 2022 guidelines, do not use local or systemic antibiotics to improve ulcer healing in patients with active venous leg ulceration without infection. D As per SVS 2014 guidelines, treat cellulitis surrounding the venous leg ulcer with systemic gram-positive antibiotics. B Show 2 more Topical corticosteroids: consider applying topical steroids in patients with severe dermatitis associated with venous leg ulcers, to alleviate symptoms and reduce the development of secondary ulcerations. C Other medical therapies: As per EDF 2016 guidelines: Do not use ergotamine because of the serious side effects. D Ensure adequate alleviation of pain. E As per SVS 2014 guidelines, avoid using anti-inflammatory therapies for the treatment of venous leg ulcers. D 6. Nonpharmacologic interventions Lifestyle modifications: advise patients avoiding overweight and discourage smoking. E Nutritional assessment: As per EDF 2016 guidelines, optimize nutritional status and encourage adequate nutrition in patients with venous leg ulcer. E As per SVS 2014 guidelines, perform a nutritional assessment in any patient with a venous leg ulcer who has evidence of malnutrition, and provide nutritional supplementation if malnutrition is identified. B Physical therapy: As per EDF 2016 guidelines, advise avoiding immobility and encourage calf muscle pumping (walking, adequate footwear) in patients with venous leg ulcer. E As per SVS 2014 guidelines, consider offering supervised active exercise to improve muscle pump function and to reduce pain and edema in patients with venous leg ulcers. C Manual lymphatic drainage: consider avoiding adjunctive lymphatic drainage for healing of the chronic venous leg ulcers. D Compression therapy: https://web.pathway.md/diseases/recadzucP6PgPISk8 5/10 6/29/23, 3:25 AM Venous leg ulcer Pathway As per ESVS 2022 guidelines, offer compression therapy to improve ulcer healing in patients with active venous leg ulceration. A Show 6 more As per SVM 2019 guidelines: Offer compression therapy to increase venous leg ulcer healing rate and to decrease the risk of ulcer recurrence in patients with a venous leg ulcer. B Consider limiting the use of compression in patients with a venous leg ulcer and underlying arterial disease to patients with ABI > 0.5 or if absolute ankle pressure is > 60 mmHg. C As per EDF 2016 guidelines, offer compression therapy as the first choice treatment in patients with uncomplicated venous leg ulcer. E Show 3 more As per SVS 2014 guidelines, initiate compression therapy to accelerate venous leg ulcer healing in patients with venous leg ulcers. A Show 2 more Balneotherapy: consider implementing balneotherapy to improve trophic skin changes and quality of life in patients with advanced venous disease. C 7. Therapeutic procedures Indications for intervention: offer treatment of the incompetent veins to reduce the risk of ulcer recurrence in patients with superficial venous incompetence and healed venous leg ulceration. A Show 2 more Sclerotherapy: As per ESVS 2022 guidelines, consider offering ablation of the sub-ulcer venous plexus using US-guided foam sclerotherapy as part of the treatment strategy in patients with active venous leg ulceration. C As per EDF 2016 guidelines: Consider offering endovenous thermal ablation of superficial venous refluxes in all patients with venous leg ulcer. E Consider offering foam sclerotherapy in patients with isolated perforator insufficiency. E As per SVS 2014 guidelines, offer US-guided sclerotherapy, if ablation of pathologic perforator veins is indicated, to eliminate the need for open incisions in areas of compromised skin. B Sclero-compression therapy: consider offering sclero-compression therapy in patients with locally draining varices on the ulcer to speed wound healing. E Endovenous thermal ablation: As per ESVS 2022 guidelines, offer early endovenous ablation to accelerate ulcer healing in patients with active venous leg ulceration and superficial venous incompetence. B As per EDF 2016 guidelines, consider offering (foam) sclerotherapy of superficial venous refluxes in all patients with venous leg ulcer. E https://web.pathway.md/diseases/recadzucP6PgPISk8 6/10 6/29/23, 3:25 AM Venous leg ulcer Pathway As per SVS 2014 guidelines, offer endovenous thermal ablation, if ablation of pathologic perforator veins is indicated, to eliminate the need for open incisions in areas of compromised skin. B Venous angioplasty and stenting: As per ESVS 2022 guidelines, consider offering venous stenting in patients with active or healed venous leg ulceration and iliac vein outflow obstruction. C As per SVS 2014 guidelines, perform venous angioplasty and stent recanalization in addition to standard compression therapy to aid in venous ulcer healing and to prevent recurrence in patients with IVC 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, healed venous leg ulcer, or active venous leg ulcer. B Ultraviolet phototherapy: consider avoiding the use of UV light to treat venous leg ulcers. D 8. Surgical interventions Surgical ablation of incompetent veins: As per EDF 2016 guidelines, consider offering surgical ablation of superficial venous refluxes in all patients with venous leg ulcer. E As per SVS 2014 guidelines, consider performing surgical ablation incompetent veins to improve ulcer healing in a patients with venous leg ulcers (C6) and incompetent superficial veins that have axial reflux directed to the bed of the ulcer. C Show 2 more Subfascial endoscopic perforating vein surgery: Perform perforantectomy with subfascial endoscopic perforating vein surgery if surgical intervention is considered for treating venae perforates insufficiency in patients with medial and/or recurrent venous leg ulcer. E Perform crossectomy and short stripping of the great saphenous vein or perforantectomy according to the subfascial endoscopic perforating vein surgery as first-line treatment in patients with venous leg ulcer with combined insufficiency of superficial and perforatory systems. E Venous valve repair: consider performing individual valve repair in patients with infrainguinal deep venous reflux and skin changes at risk for venous leg ulcer (C4b), a healed venous leg ulcer (C5), or an active venous leg ulcer (C6), in whom there is axial reflux with structurally preserved deep venous valves, to aid in venous ulcer healing and to prevent recurrence. C Venous bypass or fistulas: consider autogenous venous bypass or endophlebectomy in patients 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). Consider Palma procedure to aid in venous ulcer healing and to prevent recurrence in patients with unilateral iliofemoral venous occlusion/severe stenosis with recalcitrant venous leg ulcers for whom attempts at endovascular reconstruction have failed. Perform a synthetic graft as an alternative in the absence of autogenous tissue. [GRADE - 2; LEVEL OF EVIDENCE - C]. C Deep vein ligation: consider avoiding deep vein ligation of the femoral or popliteal veins as a routine treatment in patient with infrainguinal deep venous reflux and skin changes at risk for https://web.pathway.md/diseases/recadzucP6PgPISk8 7/10 6/29/23, 3:25 AM Venous leg ulcer Pathway venous leg ulcer (C4b), a healed venous leg ulcer (C5), or an active venous leg ulcer (C6). D Wound care, non-surgical debridement: As per EDF 2016 guidelines, apply collagenase as the only agent for enzymatic treatment. E As per SVS 2014 guidelines, consider performing hydrosurgical debridement as an alternative to standard surgical debridement of venous leg ulcers. C Show 3 more Wound care, surgical debridement: As per EDF 2016 guidelines, begin ulcer cleansing with surgical necrotomy, if possible. Cleanse wounds with tap water. Do not use topical antiseptics. E As per SVS 2014 guidelines, perform thorough debridement of venous leg ulcers at their initial evaluation, in order to remove obvious necrotic tissue, excessive bacterial burden, and cellular burden of dead and senescent cells. B Show 2 more Wound care, dressing: As per EDF 2016 guidelines, apply modern wound dressings for achieving a moist wound environment also because the dressings do not need frequent changing. Choose a particular product depending mainly on the level of exudation. E As per SVS 2014 guidelines, consider cleansing venous leg ulcers initially and at each dressing change with a neutral, nonirritating, nontoxic solution, performed with a minimum of chemical or mechanical trauma. C Show 2 more Wound care, skin grafting: As per EDF 2016 guidelines: Consider performing skin grafting on venous leg ulcer with sufficient granulation tissue. E Recognize that tissue-engineered skin grafts have a possible place in the future for treating venous ulcers. E As per SVS 2014 guidelines, consider avoiding split-thickness skin grafting as primary therapy to treat venous leg ulcers. D Wound care (cellular therapy): consider the use of cultured allogeneic bilayer skin replacements in patients with venous leg ulcers that have failed to show signs of healing after standard therapy for 4-6 weeks. B Wound care (porcine small intestinal submucosal tissue): consider the use of a porcine small intestinal submucosal tissue construct in patients with venous leg ulcers that have failed to show signs of healing after standard therapy for 4-6 weeks. C Wound care (other adjuvant therapies): offer adjuvant wound therapy options for venous leg ulcers that fail to demonstrate improvement after a minimum of 4-6 weeks of standard wound therapy. B Show 3 more 9. Preventative measures https://web.pathway.md/diseases/recadzucP6PgPISk8 8/10 6/29/23, 3:25 AM Venous leg ulcer Pathway Primary prevention: consider providing patient and family counseling regarding regular exercise, leg elevation when at rest, careful skin care, weight control, and appropriately fitting footwear in patients with class C1-4 disease. C Show 2 more 10. Follow-up and surveillance Procedural outcome assessment: assess outcomes following the use of procedures, including reporting of anatomic success, venous hemodynamic success, procedure-related minor and major complications, and impact on venous leg ulcer healing. B Clinical findings Symptoms Past medical history Leg itching DVT Leg pain Obesity Leg swelling Operation on the leg Traumatic injury Vascular exam Leg edema References 1. H.A.M. Neumann, A. Cornu-Th nard, M. J nger et al. Evidence-based S3 guidelines for diagnostics and treatment of venous leg ulcers. J Eur Acad Dermatol Venereol. 2016 Nov;30 11 1843 1875. Open 2. Fedor Lurie, Brajesh K Lal, Pier Luigi Antignani et al. Compression therapy after invasive treatment of superficial veins of the lower extremities: Clinical practice guidelines of the American Venous Forum, Society for Vascular Surgery, American College of Phlebology, Society for Vascular Medicine, and International Union of Phlebology. J Vasc Surg Venous Lymphat Disord. 2019 Jan;7 1 17 28. Open 3. Marianne G De Maeseneer, Stavros K Kakkos, Thomas Aherne et al. Editor's Choice European Society for Vascular Surgery ESVS 2022 Clinical Practice Guidelines on the Management of Chronic Venous Disease of the Lower Limbs. Eur J Vasc Endovasc Surg. 2022 Feb;63 2 184 267. Open 4. O'Donnell TF Jr, Passman MA, Marston WA et al. Management of venous leg ulcers: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg. 2014 Aug;60 2 Suppl):3S 59S. Open 5. Vasudevan B. Venous leg ulcers: Pathophysiology and Classification. Indian Dermatol Online J. 2014 Jul;5 3 366 70. Open 6. Rice JB, Desai U, Cummings AK et al. Burden of venous leg ulcers in the United States. J Med Econ. 2014 May;17 5 347 56. Open 7. Crawford JM, Lal BK, Duran WN et al. Pathophysiology of venous ulceration. J Vasc Surg Venous Lymphat Disord. 2017 Jul;5 4 596 605. Open https://web.pathway.md/diseases/recadzucP6PgPISk8 9/10 6/29/23, 3:25 AM Venous leg ulcer Pathway 8. Vivas A, Lev-Tov H, Kirsner RS. Venous Leg Ulcers. Ann Intern Med. 2016 Aug 2;165 3 ITC17 ITC32. Open 9. Bo Ekl f, Robert B Rutherford, John J Bergan et al. Revision of the CEAP classification for chronic venous disorders: consensus statement. J Vasc Surg. 2004 Dec;40 6 1248 52. Open 10. Michael A Vasquez, Eberhard Rabe, Robert B McLafferty et al. Revision of the venous clinical severity score: venous outcomes consensus statement: special communication of the American Venous Forum Ad Hoc Outcomes Working Group. J Vasc Surg. 2010 Nov;52 5 1387 96. Open https://web.pathway.md/diseases/recadzucP6PgPISk8 10/10