Management of venous leg ulcers: Clinical practice guidelines of the Society for Vascular Surgery® and the American Venous Forum
2014; Elsevier BV; Volume: 60; Issue: 2 Linguagem: Inglês
10.1016/j.jvs.2014.04.049
ISSN1097-6809
AutoresThomas F. O’Donnell, Marc A. Passman, William A. Marston, William J. Ennis, Michael C. Dalsing, Robert L. Kistner, Fedor Lurie, Peter K. Henke, Monika L. Gloviczki, Bo Eklöf, Julianne Stoughton, Sesadri Raju, Cynthia K. Shortell, J.D. Raffetto, H Partsch, Lori Cindrick Pounds, Mary E. Cummings, David L. Gillespie, Robert B. McLafferty, M. Hassan Murad, Thomas W. Wakefield, Péter Gloviczki,
Tópico(s)Peripheral Artery Disease Management
ResumoSVS/AVF Joint Clinical Practice Guidelines Committee—Venous Leg UlcerChair:Thomas F. O’Donnell Jr, MD (Cardiovascular Center, Tufts Medical Center, Boston, Mass)Vice Chair:Marc A. Passman, MD (Division of Vascular Surgery and Endovascular Therapy. University of Alabama at Birmingham, Birmingham, Ala; Birmingham Veterans Administration Medical Center, Birmingham, Ala)Committee Members:Mary E. Cummings, MD (University of Michigan, Ann Arbor, Mich)Michael C. Dalsing, MD (Indiana University School of Medicine, IU Health Care System, Indianapolis, Ind)Bo G. Eklöf, MD, PhD (Lund University, Sweden)William J. Ennis, DO (University of Illinois Hospital and Health Science, Chicago, Ill)David L. Gillespie, MD (Department of Vascular Surgery, Cardiovascular Care Center, Southcoast Healthcare Systems, Fall River, Mass; Uniformed Services University of the Health Sciences F. Edward Hebert School of Medicine, Bethesda, Md)Monika L.Gloviczki, MD, PhD (Gonda Vascular Center, Mayo Clinic, Rochester, Minn)Peter Gloviczki, MD (Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn)Peter K. Henke, MD (University of Michigan, Ann Arbor, Mich)Robert L. Kistner, MD (Honolulu, Hawaii)Fedor Lurie, MD, PhD (Jobst Vascular Institute, Toledo, Ohio)William A. Marston, MD (University of North Carolina, Chapel Hill, NC)Robert B. McLafferty, MD (Portland Veterans Administration Medical Center, Portland, Ore; Oregon Health Sciences University, Portland, Ore)M. Hassan Murad, MD (Division of Preventive Medicine, Mayo Clinic, Rochester, Minn)Hugo Partsch, MD (Medical University of Vienna, Austria)Lori C. Pounds, MD (University of Texas Health Science Center, San Antonio, Tex)Joseph D. Raffetto, MD (Harvard Medical School, Boston Mass; Veterans Administration Boston Healthcare System, Boston Mass; Brigham and Women’s Hospital, Boston, Mass)Sesadri Raju, MD (The Rane Center, Jackson, Miss)Cynthia K. Shortell, MD (Division of Vascular Surgery, Duke University Medical Center, Durham, NC)Julianne Stoughton, MD (Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass)Thomas W. Wakefield, MD (University of Michigan, Ann Arbor, Mich)Sub-Committee—Clinical Evaluation:Marc A. Passman, MD (chair); Peter K. Henke, MD; William A. Marston, MD; Robert B. McLafferty, MD; Lori Pounds, MDSub-Committee—Wound Care:William A. Marston, MD (co-Chair); William J. Ennis, DO (co-Chair); Emily Cummings, MD; Thomas F. O’Donnell Jr, MD; Lori C. Pounds, MDSub-Committee—Compression:Fedor Lurie, MD, PhD (co-Chair); Thomas W. Wakefield, MD (co-Chair); MD; Monika L. Gloviczki, MD, PhD; Hugo Partsch, MD; Cynthia Shortell, MDSub-Committee—Surgery:Michael C. Dalsing, MD (co-Chair); Robert Kistner, MD (co-Chair); Bo G. Eklöf, MD, PhD; David Gillespie, MD; Peter Gloviczki, MD; Julianne Stoughton, MD; Sesadri Raju, MDSub-Committee—Ancillary:Monika L. Gloviczki, MD, PhD (Chair); Cynthia K. Shortell, MD; Julianne Stoughton, MD; William J. Ennis, DOSub-Committee—Primary Prevention:Peter K. Henke, MD (Chair); Emily Cummings, MD; Michael C. Dalsing, MD; Fedor Lurie, MD, PhDSection ContributorsEditors: Thomas F. O’Donnell Jr, MD; Marc A. Passman, MDSummary of Guidelines: SVS/AVF CommitteeNeed for Intersociety Consensus Guidelines: Thomas F. O’Donnell Jr, MDMethodology of Guidelines: Thomas F. O’Donnell Jr, MD; Mohammad Hassan Murad, MDDefinition—Venous Leg Ulcer: Thomas F. O’Donnell Jr, MD; Robert Kistner, MDVenous Anatomy and Pathophysiology: Marc A. Passman, MD (Anatomy); Joseph D. Raffetto, MD (Pathophysiology)Clinical Evaluation: Marc A. Passman, MD; William A. Marston, MD; Peter Henke, MD; Robert B. McLafferty, MD; Lori C. Pounds, MD; William J. Ennis, MDWound Care: William A. Marston, MD; William J. Ennis, DO; Emily Cummings, MD; Lori Pounds, MD; Thomas F. O’Donnell Jr, MDCompression: Fedor Lurie, MD, PhD; Thomas W. Wakefield, MD; Monika L. Gloviczki, MD, PhD; Hugo Partsch, MD; Cynthia Shortell, MD; Andrea Obi, MD (University of Michigan, Ann Arbor, Mich)Surgery: Michael C. Dalsing, MD; Robert Kistner, MD; Bo G. Eklöf, MD, PhD; Peter Gloviczki, MD; Sesadri Raju, MD; Julianne Stoughton, MD; David Gillespie, MDAncillary: Monika L. Gloviczki, MD, PhD; Cynthia K. Shortell, MD; Julianne Stoughton, MD; William J. Ennis, MD; William A. Marston, MDPrimary Prevention: Peter Henke, MD; Fedor Lurie, MD, PhD; Emily Cummings, MD; Michael C. Dalsing, MD DEFINITION VENOUS LEG ULCERGuideline 1.1: Venous Leg Ulcer DefinitionWe 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. [BEST PRACTICE]VENOUS ANATOMY AND PATHOPHYSIOLOGYGuideline 2.1: Venous Anatomy NomenclatureWe recommend use of the International Consensus Committee on Venous Anatomical Terminology for standardized venous anatomy nomenclature. [BEST PRACTICE]Guideline 2.2: Venous Leg Ulcer PathophysiologyWe recommend a basic practical knowledge of venous physiology and venous leg ulcer pathophysiology for all practitioners caring for venous leg ulcers. [BEST PRACTICE]CLINICAL EVALUATIONGuideline 3.1: Clinical EvaluationWe 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. [BEST PRACTICE]Guideline 3.2: Nonvenous Causes of Leg UlcersWe recommend identification of medical conditions that affect ulcer healing and other nonvenous causes of ulcers. [BEST PRACTICE]Guideline 3.3: Wound DocumentationWe recommend serial venous leg ulcer wound measurement and documentation. [BEST PRACTICE]Guideline 3.4: Wound CultureWe suggest against routine culture of venous leg ulcers and only to obtain wound culture specimens when clinical evidence of infection is present. [GRADE - 2; LEVEL OF EVIDENCE - C]Guideline 3.5: Wound BiopsyWe recommend wound biopsy for leg ulcers that do not improve with standard wound and compression therapy after 4 to 6 weeks of treatment and for all ulcers with atypical features. [GRADE - 1; LEVEL OF EVIDENCE - C]Guideline 3.6: Laboratory EvaluationWe suggest laboratory evaluation for thrombophilia for patients with a history of recurrent venous thrombosis and chronic recurrent venous leg ulcers. [GRADE - 2; LEVEL OF EVIDENCE - C]Guideline 3.7: Arterial TestingWe recommend arterial pulse examination and measurement of ankle-brachial index on all patients with venous leg ulcer. [GRADE - 1; LEVEL OF EVIDENCE - B]Guideline 3.8: Microcirculation AssessmentWe suggest against routine microcirculation assessment of venous leg ulcers but suggest selective consideration as an adjunctive assessment for monitoring of advanced wound therapy. [GRADE - 2; LEVEL OF EVIDENCE - C]Guideline 3.9: Venous Duplex UltrasoundWe recommend comprehensive venous duplex ultrasound examination of the lower extremity in all patients with suspected venous leg ulcer. [GRADE - 1; LEVEL OF EVIDENCE - B]Guideline 3.10: Venous PlethysmographyWe 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. [GRADE - 2; LEVEL OF EVIDENCE - B]Guideline 3.11: Venous ImagingWe 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. [GRADE - 2; LEVEL OF EVIDENCE - C]Guideline 3.12: Venous Disease ClassificationWe 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. [BEST PRACTICE]Guideline 3.13: Venous Procedural Outcome AssessmentWe 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. [BEST PRACTICE]WOUND CAREGuideline 4.1: Wound CleansersWe 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. [GRADE - 2; LEVEL OF EVIDENCE - C]Guideline 4.2: DébridementWe 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. [GRADE - 1; LEVEL OF EVIDENCE - B] We suggest that additional maintenance débridement be performed to maintain the appearance and readiness of the wound bed for healing. [GRADE - 2; LEVEL OF EVIDENCE - B] 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. [GRADE - 2; LEVEL OF EVIDENCE - B]Guideline 4.3: Anesthesia for Surgical DébridementWe 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. [GRADE - 1; LEVEL OF EVIDENCE - B]Guideline 4.4: Surgical DébridementWe 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. [GRADE - 1; LEVEL OF EVIDENCE - B]Guideline 4.5 Hydrosurgical DébridementWe suggest hydrosurgical débridement as an alternative to standard surgical débridement of venous leg ulcers. [GRADE - 2; LEVEL OF EVIDENCE - B]Guideline 4.6: Ultrasonic DébridementWe suggest against ultrasonic débridement over surgical débridement in the treatment of venous leg ulcers. [GRADE - 2; LEVEL OF EVIDENCE - C]Guideline 4.7: Enzymatic DébridementWe suggest enzymatic débridement of venous leg ulcers when no clinician trained in surgical débridement is available to débride the wound. [GRADE - 2; LEVEL OF EVIDENCE - C] We do not suggest enzymatic débridement over surgical débridement. [GRADE - 2; LEVEL OF EVIDENCE - C]Guideline 4.8: Biologic DébridementWe suggest that larval therapy for venous leg ulcers can be used as an alternative to surgical débridement. [GRADE - 2; LEVEL OF EVIDENCE - B]Guideline 4.9: Management of Limb CellulitisWe recommend that cellulitis (inflammation and infection of the skin and subcutaneous tissue) surrounding the venous leg ulcer be treated with systemic gram-positive antibiotics. [GRADE - 1; LEVEL OF EVIDENCE - B]Guideline 4.10: Wound Colonization and Bacterial BiofilmsWe suggest against systemic antimicrobial treatment of venous leg ulcer colonization or biofilm without clinical evidence of infection. [GRADE - 2; LEVEL OF EVIDENCE - C]Guideline 4.11: Treatment of Wound InfectionWe suggest that venous leg ulcers with >1 × 106 CFU/g of tissue and clinical evidence of infection be treated with antimicrobial therapy. [GRADE - 2; LEVEL OF EVIDENCE - C] 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 colony-forming units per gram of tissue. [GRADE - 2; LEVEL OF EVIDENCE - C] We suggest a combination of mechanical disruption and antibiotic therapy as most likely to be successful in eradicating venous leg ulcer infection. [GRADE - 2; LEVEL OF EVIDENCE - C]Guideline 4.12: Systemic AntibioticsWe recommend that venous leg ulcers with clinical evidence of infection be treated with systemic antibiotics guided by sensitivities performed on wound culture. [GRADE - 1; LEVEL OF EVIDENCE - C] 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. [GRADE - 1; LEVEL OF EVIDENCE - C]Guideline 4.13: Topical Antibiotics for Infected WoundsWe suggest against use of topical antimicrobial agents for the treatment of infected venous leg ulcers. [GRADE - 2; LEVEL OF EVIDENCE - C]Guideline 4.14: Topical Dressing SelectionWe suggest applying a topical dressing that will manage venous leg ulcer exudate and maintain a moist, warm wound bed. [GRADE - 2; LEVEL OF EVIDENCE - C] We suggest selection of a primary wound dressing that will absorb wound exudate produced by the ulcer (alginates, foams) and protect the periulcer skin. [GRADE - 2; LEVEL OF EVIDENCE - B]Guideline 4.15: Topical Dressings Containing AntimicrobialsWe recommend against the routine use of topical antimicrobial-containing dressings in the treatment of noninfected venous leg ulcers. [GRADE - 2; LEVEL OF EVIDENCE - A]Guideline 4.16: Periulcer Skin ManagementWe suggest application of skin lubricants underneath compression to reduce dermatitis that commonly affects periulcer skin. [GRADE - 2; LEVEL OF EVIDENCE -C] 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. [GRADE - 2; LEVEL OF EVIDENCE - C]Guideline 4.17: Anti-inflammatory TherapiesWe suggest against use of anti-inflammatory therapies for the treatment of venous leg ulcers. [GRADE - 2; LEVEL OF EVIDENCE - C]Guideline 4.18: Indications for Adjuvant TherapiesWe recommend adjuvant wound therapy options for venous leg ulcers that fail to demonstrate improvement after a minimum of 4 to 6 weeks of standard wound therapy. [GRADE - 1; LEVEL OF EVIDENCE - B]Guideline 4.19: Split-thickness Skin GraftingWe suggest against split-thickness skin grafting as primary therapy in treatment of venous leg ulcers. [GRADE - 2; LEVEL OF EVIDENCE - B] 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 to 6 weeks. [GRADE - 2; LEVEL OF EVIDENCE - B]Guideline 4.20: Cellular TherapyWe 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 to 6 weeks. [GRADE - 2; LEVEL OF EVIDENCE - A]Guideline 4.21: Preparation for Cellular TherapyWe suggest a therapeutic trial of appropriate compression and wound bed moisture control before application of cellular therapy. [GRADE - 2; LEVEL OF EVIDENCE - C] 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. [GRADE - 1; LEVEL OF EVIDENCE - C] We recommend additional evaluation and management of increased bioburden levels before the application of cellular therapy. [GRADE - 1; LEVEL OF EVIDENCE - C]Guideline 4.22: Frequency of Cellular Therapy ApplicationWe suggest reapplication of cellular therapy as long as the venous leg ulcer continues to respond on the basis of wound documentation. [GRADE - 2; LEVEL OF EVIDENCE - C]Guideline 4.23: Tissue Matrices, Human Tissues, or Other Skin SubstitutesWe 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 to 6 weeks. [GRADE - 2; LEVEL OF EVIDENCE - B]Guideline 4.24: Negative Pressure TherapyWe suggest against routine primary use of negative pressure wound therapy for venous leg ulcers. [GRADE - 2; LEVEL OF EVIDENCE - C]Guideline 4.25: Electrical StimulationWe suggest against electrical stimulation therapy for venous leg ulcers. [GRADE - 2; LEVEL OF EVIDENCE - C]Guideline 4.26: Ultrasound TherapyWe suggest against routine ultrasound therapy for venous leg ulcers. [GRADE - 2; LEVEL OF EVIDENCE - B]COMPRESSIONGuideline 5.1: Compression—Ulcer HealingIn a patient with a venous leg ulcer, we recommend compression therapy over no compression therapy to increase venous leg ulcer healing rate. [GRADE - 1; LEVEL OF EVIDENCE - A]Guideline 5.2: Compression—Ulcer RecurrenceIn a patient with a healed venous leg ulcer, we suggest compression therapy to decrease the risk of ulcer recurrence. [GRADE - 2; LEVEL OF EVIDENCE - B]Guideline 5.3: Multicomponent Compression BandageWe suggest the use of multicomponent compression bandage over single-component bandages for the treatment of venous leg ulcers. [GRADE - 2; LEVEL OF EVIDENCE - B]Guideline 5.4: Compression—Arterial InsufficiencyIn 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 less than 60 mm Hg. [GRADE - 2; LEVEL OF EVIDENCE - C]Guideline 5.5: Intermittent Pneumatic CompressionWe 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. [GRADE - 2; LEVEL OF EVIDENCE - C]OPERATIVE/ENDOVASCULAR MANAGEMENTGuideline 6.1: Superficial Venous Reflux and Active Venous Leg Ulcer—Ulcer HealingIn 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. [GRADE - 2; LEVEL OF EVIDENCE - C]Guideline 6.2: Superficial Venous Reflux and Active Venous Leg Ulcer—Prevent RecurrenceIn 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. [GRADE - 1; LEVEL OF EVIDENCE - B]Guideline 6.3: Superficial Venous Reflux and Healed Venous Leg UlcerIn 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. [GRADE - 1; LEVEL OF EVIDENCE - C]Guideline 6.4: 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. [GRADE - 2; LEVEL OF EVIDENCE - C]Guideline 6.5: Combined Superficial and Perforator Venous Reflux With or Without Deep Venous Reflux and Active Venous Leg UlcerIn 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. [GRADE - 2; LEVEL OF EVIDENCE - C]Guideline 6.6: 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. [GRADE - 2; LEVEL OF EVIDENCE - C] 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. [GRADE - 2; LEVEL OF EVIDENCE - C]Guideline 6.7: Pathologic Perforator Venous Reflux in the Absence of Superficial Venous Disease, With or Without Deep Venous Reflux, and a Healed or Active Venous UlcerIn 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. [GRADE - 2; LEVEL OF EVIDENCE - C]Guideline 6.8: Treatment Alternatives for Pathologic Perforator VeinsFor 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. [GRADE - 1; LEVEL OF EVIDENCE - C]Guideline 6.9: Infrainguinal Deep Venous Obstruction and Skin Changes at Risk for Venous Leg Ulcer (C4b), Healed (C5) or Active (C6) Venous Leg UlcerIn 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. [GRADE - 2; LEVEL OF EVIDENCE - C]Guideline 6.10: Deep Venous Reflux With Skin Changes at Risk for Venous Leg Ulcer (C4b), Healed (C5) or Active (C6) Venous Leg Ulcer—LigationIn 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. [GRADE - 2; LEVEL OF EVIDENCE - C]Guideline 6.11: Deep Venous Reflux With Skin Changes at Risk for Venous Leg Ulcer (C4b), Healed (C5) or Active (C6) Venous Leg Ulcer—Primary Valve RepairIn 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. [GRADE - 2; LEVEL OF EVIDENCE - C]Guideline 6.12: Deep Venous Reflux With Skin Changes at Risk for Venous Leg Ulcer (C4b), Healed (C5) or Active (C6) Venous Leg Ulcer—Valve Transposition or TransplantationIn 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. [GRADE - 2; LEVEL OF EVIDENCE - C]Guideline 6.13: Deep Venous Reflux With Skin Changes at Risk for Venous Leg Ulcer (C4b), Healed (C5) or Active (C6) Venous Leg Ulcer—Autogenous Valve SubstituteIn 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. [GRADE - 2; LEVEL OF EVIDENCE - C]Guideline 6.14: 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 RepairIn 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. [GRADE - 1; LEVEL OF EVIDENCE - C]Guideline 6.15: Proximal Chronic Venous Occlusion/Severe Stenosis (Bilateral) With Recalcitrant Venous Ulcer—Open RepairIn 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. [GRADE - 2; LEVEL OF EVIDENCE - C]Guideline 6.16: Unilateral Iliofemoral Venous Occlusion/Severe Stenosis With Recalcitrant Venous Ulcer—Open RepairIn 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. [GRADE - 2; LEVEL OF EVIDENCE - C]Guideline 6.17: Proximal Chronic Total Venous Occlusion/Severe Stenosis (Bilateral or Unilateral) With Recalcitrant Venous Ulcer—Adjunctive Arteriovenous FistulaFor 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. [GRADE - 2; LEVEL OF EVIDENCE - C]ANCILLARY MEASURESGuideline 7.1: Nutrition Assessment and ManagementWe 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. [BEST PRACTICE]Guideline 7.2: Systemic Drug TherapyFor long-standing or large venous leg ulcer, we recommend treatment with either pentoxifylline or micronized purified flavonoid fraction used in combination with compression therapy. [GRADE - 1; LEVEL OF EVIDENCE - B]Guideline 7.3: PhysiotherapyWe suggest supervised active exercise to improve muscle pump function and to reduce pain and edema in patients with venous leg ulcers. [GRADE - 2; LEVEL OF EVIDENCE - B]Guideline 7.4: Manual Lymphatic DrainageWe suggest against adjunctive lymphatic drainage for healing of the chronic venous leg ulcers. [GRADE - 2; LEVEL OF EVIDENCE - C]Guideline 7.5: BalneotherapyWe suggest balneotherapy to improve skin trophic changes and quality of life in patients with advanced venous disease. [GRADE - 2; LEVEL OF EVIDENCE - B]Guideline 7.6: Ultraviolet lightWe suggest against use of ultraviolet light for the treatment of venous leg ulcers. [GRADE - 2; LEVEL OF EVIDENCE - C]PRIMARY PREVENTIONGuideline 8.1: Primary Prevention—Clinical CEAP C3-4 Primary Venous DiseaseIn patients with clinical CEAP C3-4 disease due to primary valvular reflux, we recommend compression, 20 to 30 mm Hg, knee or thigh high. [GRADE - 2; LEVEL OF EVIDENCE - C]Guideline 8.2: Primary Prevention—Clinical CEAP C1-4 Post-thrombotic Venous DiseaseIn patients with clinical CEAP C1-4 disease related to prior deep venous thrombosis (DVT), we recommend compression, 30 to 40 mm Hg, knee or thigh high. [GRADE - 1; LEVEL OF EVIDENCE - B]Guideline 8.3. Primary Prevention—Acute DVT TreatmentAs post-thrombotic syndrome is a common preceding event for venous leg ulcers, we recommend current evidence-based therapies for acute DVT treatment. [GRADE - 1; LEVEL OF EVIDENCE - B] We suggest use of low-molecular-weight heparin over vitamin K antagonist therapy of 3-month duration to decrease post-thrombotic syndrome. [GRADE - 2; LEVEL OF EVIDENCE - B] We suggest catheter-directed thrombolysis in patients with low bleeding risk with iliofemoral DVT of duration <14 days. [GRADE - 2; LEVEL OF EVIDENCE - B]Guideline 8.4: Primary Prevention—Education MeasuresIn 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. [BEST PRACTICE]Guideline 8.5: Primary Prevention—Operative TherapyIn patients with asymptomatic C1-2 disease from either primary or secondary causes, we suggest against prophylactic interventional therapies to prevent venous leg ulcer. [GRADE - 2; LEVEL OF EVIDENCE - C] DEFINITION VENOUS LEG ULCER Guideline 1.1: Venous Leg Ulcer 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. [BEST PRACTICE] VENOUS ANATOMY AND PATHOPHYSIOLOGY Guideline 2.1: Venous Anatomy Nomenclature We recommend use of the International Consensus Committee
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