Guideline sources The following summarized guidelines for the evaluation and management of chronic venous insufficiency 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), and the American Association of Family Physicians (AAFP 2013). 1 2 3 Guidelines 1. Classification and risk stratification Severity assessment: Use the CEAP classification for clinical audit and research in patients with chronic venous disease. B Consider using the r-VCSS and the Villalta scale for post-thrombotic syndrome for the grading of clinical severity and evaluation of treatment success in patients with chronic venous disease. C https://web.pathway.md/diseases/reci9FRt7GKe0ajcC 1/5 6/23/23, 3:26 AM Chronic venous insufficiency Pathway 2. Diagnostic investigations Ankle-brachial index: obtain ABI measurement in patients with chronic venous insufficiency and cardiovascular risk factors before initiation of compression therapy, which is contraindicated in peripheral arterial disease. B Diagnostic imaging: obtain full lower limb venous duplex ultrasound as the primary imaging modality for the diagnosis and treatment planning in patients with suspected or clinically evident chronic venous disease. B Show 2 more Plethysmography: consider obtaining air plethysmography for quantification of reflux and/or obstruction in patients with chronic venous disease, particularly when duplex ultrasound results do not reconcile with the clinical findings. C 3. Medical management Topical therapies: advise daily hydration with emollients and prescribe short courses of topical corticosteroid creams for severely inflamed skin to treat eczematous (stasis) dermatitis associated with chronic venous insufficiency. B Venoactive agents: consider offering medical treatment with venoactive drugs to reduce venous symptoms and edema in patients with symptomatic chronic venous disease not undergoing interventional treatment, awaiting intervention, or experiencing persisting symptoms and/or edema after intervention. B 4. Nonpharmacologic interventions Exercise: advise exercising in patients with symptomatic chronic venous disease, to reduce venous symptoms. B Compression stockings (medically managed): offer elastic compression stockings, exerting a pressure of at least 15 mmHg at the ankle, to reduce venous symptoms in patients with symptomatic chronic venous disease. B Show 2 more Compression stockings, after interventional treatment: As per ESVS 2022 guidelines, consider offering post-procedural compression treatment in patients with superficial venous incompetence following US-guided foam sclerotherapy or endovenous thermal ablation of a saphenous trunk. B Show 2 more As per IUP/SVM/ACP/SVS/AVF 2019 guidelines, consider offering compression therapy (with elastic stockings or wraps) after surgical or thermal procedures to eliminate varicose veins, when possible. C Show 3 more https://web.pathway.md/diseases/reci9FRt7GKe0ajcC 2/5 6/23/23, 3:26 AM Chronic venous insufficiency Pathway Compression stockings (post-thrombotic syndrome): Consider offering compression treatment, using below knee elastic compression stockings exerting a pressure of 20-40 mmHg at the ankle, to reduce severity in patients with post- thrombotic syndrome. C Consider offering adjuvant intermittent pneumatic compression to reduce its severity in patients with post-thrombotic syndrome. C 5. Therapeutic procedures Indications for interventional treatment: offer interventional treatment in patients with superficial venous incompetence presenting with symptomatic varicose veins (CEAP clinical class C2S). B Show 4 more Considerations for interventional treatment (setting): perform endovenous procedures, with or without phlebectomies, for superficial venous incompetence in the outpatient setting, where possible. B Considerations for interventional treatment (anesthesia): Administer US-guided tumescent anesthesia in patients with superficial venous incompetence undergoing endovenous thermal ablation. B Consider administering buffered solutions to reduce periprocedural pain in patients with superficial venous incompetence undergoing tumescent anesthesia. C Considerations for interventional treatment (thromboprophylaxis): Obtain risk assessment for VTE in patients with superficial venous incompetence undergoing intervention. B Consider providing individualized thromboprophylaxis strategies in patients with superficial venous incompetence undergoing intervention. C Choice of interventional treatment (thermal ablation): offer endovenous thermal ablation as first choice treatment in patients with great saphenous vein incompetence requiring treatment. A Show 5 more Choice of interventional treatment (non-thermal ablation): consider offering cyanoacrylate adhesive closure when a non-thermal non-tumescent technique is preferred in patients with great saphenous vein incompetence requiring treatment. B Show 6 more Interventions for varicose tributaries: Offer ambulatory phlebectomy, US-guided foam sclerotherapy or a combination of both in patients with chronic venous disease requiring treatment of varicose tributaries. B Consider offering concomitant tributary treatment, as part of a shared decision process, in patients with an incompetent saphenous trunk undergoing endovenous thermal or non-thermal ablation. C https://web.pathway.md/diseases/reci9FRt7GKe0ajcC 3/5 6/23/23, 3:26 AM Chronic venous insufficiency Pathway Interventions for incompetent perforating veins: consider offering endovenous ablation, division or ligation in patients with chronic venous disease requiring treatment of incompetent perforating veins. C Interventions for reticular veins and telangiectasias: obtain duplex ultrasound of lower extremity veins before treatment initiation in patients presenting with reticular veins and/or telangiectasias, to look for associated incompetent veins. B Show 4 more Interventions for foot and ankle veins: consider offering phlebectomy, sclerotherapy, or foot perforating vein ligation during or after ablation of proximal reflux in patients presenting with foot and ankle varicose veins. C 6. Surgical interventions High ligation and stripping: Consider performing high ligation and stripping in patients with great saphenous vein incompetence requiring treatment, if endovenous thermal ablation options are not available. B Consider administering US-guided tumescent anesthesia as an alternative to general or regional anesthesia in patients with superficial venous incompetence undergoing high ligation/stripping. C Ambulatory conservative hemodynamic treatment: consider offering ambulatory conservative hemodynamic treatment of venous incompetence, performed by physicians experienced in this treatment strategy, in patients with superficial venous incompetence requiring treatment. C Ambulatory selective variceal ablation: consider offering phlebectomy with preservation of the saphenous trunk in patients with uncomplicated varicose veins (CEAP clinical class C2) requiring treatment. C 7. Specific circumstances Pregnant patients: offer elastic compression hosiery in pregnant patients presenting with symptoms and/or signs of chronic venous disease. B Patients on anticoagulants: do not interrup anticoagulation in patients with chronic venous disease receiving anticoagulants and scheduled to undergo endovenous thermal ablation. D Patients with obesity: Consider advising weight loss for improving venous outcomes in obese patients with chronic venous disease. C Consider offering endovenous ablation in obese patients with saphenous trunk incompetence requiring treatment. C Patients with iliac vein outflow obstruction: ensure management by a multidisciplinary team in patients with iliac vein outflow obstruction. B https://web.pathway.md/diseases/reci9FRt7GKe0ajcC 4/5 6/23/23, 3:26 AM Chronic venous insufficiency Pathway Show 5 more Patients with deep venous incompetence: Consider offering surgical repair of valvular incompetence, performed in specialized centers, in patients with extensive axial deep venous incompetence and severe persistent symptoms and signs, if previous management has failed. C Consider offering treatment of incompetent superficial veins in patients with chronic venous disease caused by combined superficial and deep venous incompetence. C Patients with popliteal vein aneurysm: consider performing surgical repair in patients with a popliteal vein aneurysm with thromboembolic complications or those that are saccular, fusiform exceeding 20 mm, or containing thrombus. C 8. Follow-up and surveillance Post-procedural monitoring: consider obtaining duplex ultrasound surveillance 1-4 weeks after treatment of a saphenous trunk. C Management of recurrent varicose veins: consider offering endovenous thermal ablation or US- guided foam sclerotherapy, with or without phlebectomy, in patients with symptomatic recurrent varicose veins due to saphenous trunk incompetence. C Show 2 more References 1. 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 2. Kathryn P Trayes, James S Studdiford, Sarah Pickle et al. Edema: Diagnosis and Management. Am Fam Physician. 2013 Jul 15;88 2 102 10. Open 3. 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 4. 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 5. 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/reci9FRt7GKe0ajcC 5/5