ABSTRACT
No. Guideline Grade of recommendation (1: strong; 2: weak) Grade of evidence (A: high quality; B: moderate quality; C: low or very low quality) Part 1. Basic Considerations of Venous Disorders Guidelines 1.1.0 of the American Venous Forum on the development and anatomy of the venous system 1.1.1 The main deep vein of the thigh between the popliteal and the common femoral vein is the femoral vein. The old term “superficial femoral vein” should be abandoned. 1 1.1.2 The main superficial veins of the lower limb are the great saphenous vein and the small saphenous vein. 1 1.1.3 The old terms “Cockett” and “Giacomini” veins should be replaced by the new terms “posterior tibial perforating vein” and “intersaphenous vein,” respectively. The use of eponyms is discouraged. 1 Guidelines 1.2.0 of the American Venous Forum on the physiology and hemodynamics of the normal venous circulation 1.2.1 Venous return follows a continued dynamic pressure gradient. The majority of the energy imparted by the pumping action of the heart is dissipated in distribution to the arterial circulation. A 1.2.2 The hydrostatic pressure in the venous system is directly related to the height of the column of blood in relation to the zero point of the right atrium. A 1.2.3 Venous return against gravity is accomplished by the combined action of an active extremity muscle pump and one-way venous valves. A 1.2.4 The plantar venous pump acts to prime the calf muscle pump. C 7841.2.5 The thigh muscle pump contributes little to venous return. B 1.2.6 The anatomic structure of a vein allows for great variation in its diameter. This facilitates the capacitance function of the venous system for adjustment to volume and temperature changes. A 1.2.7 External pressure on collapsible proximal veins increases distal venous pressure. B Guidelines 1.3.0 of the American Venous Forum on the classification and etiology of chronic venous disease 1.3.1 We recommend using the CEAP (clinical class, etiology, anatomy, pathophysiology) classification to describe chronic venous disorders. The system has been validated. 1 B 1.3.2 We recommend using the basic CEAP classification to aid clinical practice and the full CEAP classification for clinical research. 1 B 1.3.3 We recommend distinguishing between primary and secondary venous insufficiency, because the two conditions distinctly differ in pathophysiology and management. 1 B Guidelines 1.4.0 of the American Venous Forum on the pathophysiology and hemodynamics of chronic venous insufficiency 1.4.1 Persistent ambulatory venous hypertension due to venous obstruction or valvular incompetence is the main cause of chronic venous insufficiency. A Guidelines 1.5.0 of the American Venous Forum on the pathogenesis of varicose veins and cellular pathophysiology of chronic venous insufficiency 1.5.1 Genetics and deep venous thrombosis are predisposing factors for varicose veins. A 1.5.2 Age, female gender, pregnancy, weight, height, race, diet, bowel habits, occupation, and posture are predisposing factors for varicose veins. C 1.5.3 Vein wall remodeling and fibrosis, affected by hemodynamic factors, matrix metalloproteinases, and plasminogen activators, lead to varicose vein formation. C 1.5.4 In chronic venous insufficiency, the transmission of high venous pressures to the dermal microcirculation causes extravasation of macromolecules and red blood cells that serves as the underlying stimulus for inflammatory injury. A 1.5.5 Transforming growth factor-β1 and matrix metalloproteinases play key roles in the inflammatory injury that leads to lipodermatosclerosis and chronic skin changes. B Guidelines 1.6.0 of the American Venous Forum on venous ulcer formation and healing at cellular levels 1.6.1 We recommend a basic practical knowledge of venous physiology and venous leg ulcer pathophysiology for all practitioners caring for venous leg ulcers. Best practice 1.6.2 Age, genetic, and environmental factors predispose to venous ulcers. B 1.6.3 Shear stress, glycocalyx injury, and expression of adhesion molecules with venous endothelial activation allow attachment of leukocytes and are key steps in the progression of chronic venous insufficiency. B 7851.6.4 Leukocyte activity and interaction with endothelial cells initiates a cascade of inflammatory events. B 1.6.5 Macrophages have a major role in ulcer formation. C 1.6.6 Dysfunctional leukocytes, senescent fibroblasts, and keratinocytes contribute to delayed ulcer healing. B 1.6.7 Key regulatory cell cycle proteins (p21 and pRb) affect fibroblast proliferation and delay wound healing. B 1.6.8 Venous ulcer fluid has elevated inhibitory cytokines and matrix metalloproteinases (MMPs). MMPs have an integral role in venous ulcer formation. A 1.6.9 Factor XIII, plasminogen, and extracellular MMP inducer modulate MMP activity and contribute to venous ulcers. C Guidelines 1.7.0 of the American Venous Forum on acute and chronic venous thrombosis: pathogenesis and new insights 1.7.1 Acute venous thrombosis causes an acute to chronic inflammatory response in both the vein wall and the thrombus. This leads to thrombus amplification, organization, and recanalization, as well as damage to the vein wall and the valves. A 1.7.2 D-dimer, endothelium, platelet-derived microparticles, and soluble P-selectin are markers of thrombosis and they are increased in patients with acute venous thromboembolism. A 1.7.3 Resolution of the thrombus is modulated by natural anticoagulants such as antithrombin III, protein C, protein S, and thrombin. B 1.7.4 Polymorphonuclear cells promote both fibrinolysis and collagenolysis and they play key roles in thrombus resolution. Monocytes are essential in late thrombus resolution. A Guidelines 1.8.0 of the American Venous Forum on the epidemiology and risk factors of acute venous thrombosis 1.8.1 The prevention and management of venous thromboembolism requires an understanding of the interaction of underlying risk factors. All episodes of venous thromboembolism should be characterized as primary (unprovoked and idiopathic) or secondary (provoked). 1 A 1.8.2 All hospitalized patients should have a thorough assessment of thromboembolic risk factors at the time of admission. 1 A 1.8.3 Recognized models, such as the Rogers or Caprini scores, should be used to assess thromboembolic risk in surgical patients. 1 B 1.8.4 Established evidence-based guidelines should be followed for deep vein thrombosis prophylaxis in high-risk patients. 1 A 1.8.5 Thrombophilia screening should be limited to patients included in established guidelines. 1 A Guidelines 1.9.0 of the American Venous Forum on the epidemiology of chronic venous disorders 1.9.1 The prevalence of varicose veins in the adult population is more than 20% (21.8%-29.4%). A 1.9.2 About 5% (3.6%-9.6%) of the adult population has skin changes or ulcers due to chronic venous insufficiency. A 7861.9.3 Active venous ulcers are present in 0.1%–0.7% of the adult population, and 0.6%–1.4% have healed ulcers. B 1.9.4 Advanced age is a risk factor for varicose veins and chronic venous insufficiency. A 1.9.5 Positive family history, female gender, and multiparity are risk factors for varicose veins. A 1.9.6 Age and obesity are risk factors for chronic venous insufficiency. A Part 2. Diagnostic Evaluations and Venous Imaging Studies Guidelines 2.1.0 of the American Venous Forum on the evaluation of hypercoagulable states and molecular markers of acute venous thrombosis 2.1.1 Patients with the following conditions are considered for evaluation for thrombophilia:1. Unexplained or “idiopathic” thromboembolism (first event)2. Secondary, non-cancer-related first event and age <50 years (includes thrombosis on oral contraceptives and hormone-replacement therapy)3. Recurrent “idiopathic” or secondary non-cancer-related events4. Thrombosis at unusual sites (portal vein, sinus veins, etc.)5. Extensive thrombosis6. Strong family history of venous thromboembolism 1 C 2.1.2 Testing for thrombophilia is recommended to most patients 2–4 weeks after completing the typical course (usually 6 months) of anticoagulant therapy. 1 C 2.1.3 Long-term, primary pharmacologic thromboprophylaxis of asymptomatic thrombophilic patients is not recommended. 2 B 2.1.4 Patients with thrombophilia should be considered for thromboprophylaxis at times of high thrombotic risk such as surgery, trauma, prolonged immobility, pregnancy, or acute illness. 1 A 2.1.5 Patients with thrombophilia should be considered for prolonged anticoagulation following acute deep vein thrombosis. 1 B Guidelines 2.2.0 of the American Venous Forum on duplex ultrasound scanning for acute venous disease 2.2.1 Duplex ultrasound scanning is recommended to be the standard of care for diagnosing acute deep vein thrombosis (DVT) of the limbs. 1 A 2.2.2 We recommend that duplex examination for DVT includes three components in each vein segment studied: thrombus visualization, venous coaptability or compressibility, and detection of venous flow. 1 A 2.2.3 We suggest that duplex scanning has a sensitivity of ≥90% for the detection of symptomatic femoropopliteal thrombosis and a range of 50%–70% for calf vein thrombosis. 2 B 2.2.4 We suggest that duplex scanning for upper extremity DVT has a sensitivity of between 78% and 100% and a specificity of between 82% and 100%. 2 B 787Guidelines 2.3.0 of the American Venous Forum on duplex ultrasound scanning for chronic venous obstruction and valvular incompetence 2.3.1 Duplex scanning is recommended as the first diagnostic test for all patients with suspected chronic venous obstruction or valvular incompetence. The test is safe, noninvasive, cost-effective, and reliable. 1 A 2.3.2 We recommend that four components included in duplex scanning examinations for chronic venous disease are visualization, compressibility, venous flow, and augmentation. 1 A 2.3.3 Duplex scanning is recommended to distinguish acute from chronic venous occlusion. 2 B 2.3.4 We suggest that reflux is elicited in two ways: increased intra-abdominal pressure using a Valsalva maneuver or manual or cuff compression and release of the limb distal to the point of examination. 2 B 2.3.5 We recommend that reflux is elicited in the upright position in one of two ways: either with increased intra-abdominal pressure using a Valsalva maneuver to assess the common femoral vein and the saphenofemoral junction; or, for the more distal veins, use of manual or cuff compression and release of the limb distal to the point of examination. 1 A 2.3.6 A cut-off value of 1 second is recommended to define abnormally reversed flow (reflux) in the femoral and popliteal veins and of 500 ms for the great saphenous vein, the small saphenous vein, and the tibial, deep femoral, and perforating veins. 1 B 2.3.7 We recommend that in patients with chronic venous insufficiency, duplex scanning of the perforating veins is performed selectively. We recommend that the definition of “pathologic” perforating veins includes those with an outward flow of duration of ≥500 ms, with a diameter of ≥3.5 mm and a location beneath healed or open venous ulcers (CEAP class C5–C6). 1 B Guidelines 2.4.0 of the American Venous Forum on the evaluation of venous function by indirect noninvasive testing (plethysmography) 2.4.1 We suggest that venous plethysmography is used selectively for the noninvasive evaluation of the venous system in patients with simple varicose veins (CEAP class C2). 2 C 2.4.2 We suggest that venous plethysmography is used as a noninvasive evaluation of the venous system in patients with advanced chronic venous disease if duplex scanning does not provide definitive information on pathophysiology (CEAP class C3–C6). 2 B Guidelines 2.5.0 of the American Venous Forum on direct contrast venography 2.5.1 We recommend contrast venography before performing endovenous reconstructions for acute or chronic venous disease. 1 B 7882.5.2 We suggest contrast venography for patients suspected of having acute deep vein thrombosis only if other imaging modalities are inconclusive. 2 B Guidelines 2.6.0 of the American Venous Forum on computed tomography and magnetic resonance imaging in venous disease 2.6.1 Computed tomography with intravenous contrast is recommended for evaluation of the obstruction of large veins in the chest, abdomen, and pelvis. Computed tomography accurately depicts the underlying pathology, confirms extrinsic compression, tumor invasion, traumatic disruption, anatomic variations, extent of thrombus, and position of a caval filter. 1 B 2.6.2 Computed tomography with intravenous contrast is recommended to diagnose pulmonary embolism. Sensitivity and specificity approach 100% for central emboli, whereas for small, subsegmental pulmonary emboli, sensitivity and specificity are 83% and 96%, respectively. 1 A 2.6.3 Magnetic resonance venography is recommended for the diagnosis of acute iliofemoral and caval deep vein thrombosis. A sensitivity of 100% and a specificity of 96% were reported. The study is also recommended for diagnosing portal, splenic, or mesenteric venous thrombosis. 1 A 2.6.4 Magnetic resonance imaging and magnetic resonance venography are highly accurate for imaging inferior vena cava thrombus associated with renal, adrenal, retroperitoneal, primary caval, or metastatic malignancies. Magnetic resonance venography reveals the presence or absence of bland thrombus or tumor thrombus in the renal veins and inferior vena cava. 1 A Part 3. Management of Acute Thrombosis Guidelines 3.1.0 of the American Venous Forum on the clinical presentation of the natural history of acute venous thrombosis 3.1.1 Based on differences in natural history, we recommend that lower extremity deep vein thrombosis (DVT) be precisely characterized as involving the iliofemoral veins, the femoropopliteal veins, or being isolated to the calf veins, rather than being simply designated as involving the proximal or distal veins. 1 A 3.1.2 We recommend formal determination of the pre-test probability of DVT using a validated scoring system in all patients presenting with signs and symptoms of acute DVT. 1 A 3.1.3 We recommend that the risk of recurrent venous thromboembolism be thoroughly assessed prior to discontinuing anticoagulation, particularly among those with idiopathic DVT. 1 A 7893.1.4 We suggest a strategy of early thrombus removal in selected patients meeting the following criteria: (A) a first episode of acute iliofemoral DVT; (B) symptoms <14 days in duration; (C) a low risk of bleeding; and (D) ambulatory with good functional capacity and an acceptable life expectancy. 2 C 3.1.5 We recommend the use of 30–40 mmHg knee-high compression stockings to reduce the risk of postthrombotic syndrome in compliant patients after an episode of acute DVT. 1 C Guidelines 3.2.0 of the American Venous Forum on the diagnostic algorithms for acute deep venous thrombosis and pulmonary embolism 3.2.1 In symptomatic outpatients with suspected acute deep vein thrombosis (DVT), we recommend to obtain first a clinical score and D-dimer level to select patients for further diagnostic studies. 1 B 3.2.2 D-dimer levels are inaccurate for diagnosing DVT in several clinical conditions, including recent surgery, pregnancy, malignancy, infection, elevated bilirubin, trauma, and heparin use. In these situations, alternative diagnostic modalities are recommended. 1 B 3.2.3 We recommend to repeat duplex scan or alternative imaging modality in the follow up of patients with negative duplex studies and high clinical suspicion of DVT. 1 B 3.2.4 We suggest that combination of clinical probability score and D-dimer level has similar utility in the diagnosis of DVT to a computed tomography scan. 2 B 3.2.5 We suggest judicious use of Gadolinium in patients with renal insufficiency because of the risk of nephrogenic systemic fibrosis. 2 C Guidelines 3.3.0 Summary of key recommendations to the American Venous Forum on the medical therapy of acute deep vein thrombosis and pulmonary embolism 3.3.1 a If home circumstances are adequate, we recommend that initial treatment of acute deep venous thrombosis (DVT) take place at home rather than in the hospital. 1 B 3.3.2 a We suggest low-molecular-weight heparin (LMWH) over unfractionated heparin for the treatment of acute DVT. 2 B 3.3.3 a We suggest once-over twice-daily administration of LMWH for the treatment of acute DVT. 2 C 3.3.4 b We suggest LMWH over NOACs or VKAs for patients with cancer and acute DVT. 2 C 3.3.5 b In patients with acute DVT and no cancer, as a long-term anticoagulant therapy we susggest dabigatran, rivaroxaban, apixaban, or edoxaban over vitamin K agonist (VKA) therapy. 2 B 3.3.6 b We suggest that patients with an unprovoked proximal DVT who are stopping anticoagulant therapy should take an aspirin to prevent recurrent VTE. 2 B 7903.3.7 b We recommend 3 months of treatment for acute proximal DVT provoked by transient risk factors (surgical or non-surgical). 1 B 3.3.8 b We suggest monitoring over 2 weeks with serial imaging over anticoagulation for the treatment of acute isolated distal DVT without severe symptoms or risk factors. 2 C 3.3.9 b We suggest anticoagulation for acute isolated distal DVT with severe symptoms and risk factors. 2 C 3.3.10 b We suggest extended anticoagulation therapy in patients with an acute unprovoked proximal DVT who have low or moderate bleeding risk. 2 B 3.3.11 b We recommend 3 months of anticoagulant therapy rather than extended therapy in patients with an acute unprovoked proximal DVT who have high bleeding risk. 1 B 3.3.12 b We recommend extended anticoagulation beyond 3 months for acute DVT of the leg in the setting of active cancer if the risk of bleeding is not high. 1 B 3.3.13 b We suggest that anticoagulation be preferred over catheter directed thrombolysis for acute proximal DVT. 2 C 3.3.14 b We suggest systemic thrombolysis for pulmonary embolism associated with hypotension or when hypotension is likely without a high bleeding risk. 2 C Guidelines 3.4.0 of the American Venous Forum on catheter-directed thrombolysis and venous thrombectomy for acute deep vein thrombosis 3.4.1 In patients with symptomatic deep vein thrombosis and large thrombus burden, particularly in iliofemoral deep vein thrombosis, we recommend a treatment strategy that includes thrombus removal. 1 B 3.4.2 In patient with symptomatic iliofemoral deep vein thrombosis with symptoms of <14 days in duration, we recommend catheter-directed thrombolysis if appropriate expertise and resources are available to reduce acute symptoms and post-thrombotic morbidity. 1 B 3.4.3 We suggest pharmacomechanical thrombolysis, with thrombus fragmentation and aspiration, over catheter-directed thrombolysis alone in the treatment of iliofemoral deep vein thrombosis to shorten treatment time if appropriate expertise and resources are available. 2 B 3.4.4 In patients with acute DVT, systemic thrombolysis is not suggested. 2 B 3.4.5 For patients with symptomatic iliofemoral deep vein thrombosis who are not candidates for catheter-directed thrombolysis, we recommend surgical thrombectomy. 1 B Guidelines 3.5.0 of the American Venous Forum on the endovascular and surgical management of acute pulmonary embolismc 3.5.1 We recommend therapeutic anticoagulation with subcutaneous low-molecular-weight heparin, subcutaneous fondaparinux, or intravenous unfractionated heparin for initial anticoagulation for acute pulmonary embolism (PE). 1 A 7913.5.2 Anticoagulation alone is recommended for low-risk PE or sub-massive PE with mild right ventricle dysfunction. 1 B 3.5.3 Thrombolysis is recommended for massive PE if bleeding risk is acceptable. 1 B 3.5.4 Thrombolysis is suggested for sub-massive acute PE felt to have poor prognosis if bleeding risk is acceptable. 2 C 3.5.5 Catheter thrombectomy, thrombus fragmentation, or surgical embolectomy is recommended for patients with massive PE and who are contraindicated for thrombolysis, depending on local expertise. 1 C 3.5.6 Catheter thrombectomy, thrombus fragmentation, or surgical embolectomy is recommended for patients with massive PE and who remain unstable after thrombolysis if local expertise is available. 1 C 3.5.7 Catheter thrombectomy or surgical embolectomy is suggested for patients with sub-massive PE who are judged to have a poor prognosis. 2 C 3.5.8 We suggest against catheter thrombectomy or surgical embolectomy for low-risk PE or sub-massive PE with minor right ventricle dysfunction. 2 C Guidelines 3.6.0 of the American Venous Forum on the treatment algorithm for acute deep venous thrombosis 3.6.1 Low-molecular-weight heparin (LMWH) is now preferred over standard unfractionated heparin (UFH) for the initial treatment of deep vein thrombosis (DVT). 1 A 3.6.2 The criteria for the discontinuation of oral anticoagulation include thrombosis risk, residual thrombus burden, and coagulation system activation (as suggested by D-dimer measurements). 1 A 3.6.3 Heparin-induced thrombocytopenia remains a problem with all heparin preparations, but is more frequent with UFH than LMWH. Alternative agents include hirudin, argatroban, and fondaparinux. 1 C 3.6.4 The use of strong compression and early ambulation after DVT treatment can significantly reduce the long-term morbidities of pain and swelling resulting from the DVT. 1 A Guidelines 3.7.0 of the American Venous Forum on the current recommendations for the prevention of deep vein thrombosis 3.7.1 When the risk of bleeding from pharmacologic agents is high, we suggest using non-pharmacologic methods of venous thromboembolism prophylaxis, including elastic compressive stockings, intermittent pneumatic compression devices, leg elevation, and early ambulation. Each of these reduces venous thrombotic events by approximately 20%. 2 C 3.7.2 For patients at very high risk of venous thromboembolism, we suggest non-pharmacologic methods of venous thromboembolism prophylaxis in combination with pharmacologic agents. 2 C 7923.7.3 For patients with acute venous thromboembolism within 1 month who undergo urgent/emergency surgery or if other circumstances prohibit anticoagulation, we recommend placement of an inferior vena cava filter. 1 B 3.7.4 We suggest against inferior vena cava filter therapy as primary prophylaxis for unselected trauma patients. 2 C 3.7.5 We suggest that the indications for temporary, retrievable, or optional inferior vena cava filters are the same as those for permanent inferior vena cava filters. 2 C 3.7.6 Aspirin may provide modest risk reduction following major joint surgery when added to other prophylaxis therapies. 1 B 3.7.7 For very-low-risk patients (Caprini score 0), the risk of venous thromboembolism is sufficiently low such that early ambulation alone is recommended. 1 B 3.7.8 For low-risk patients (Caprini score 1–2), intermittent pneumatic compression pumping is suggested. 2 C 3.7.9 For moderate-risk patients (Caprini score 3–4), we suggest low-dose unfractionated heparin, prophylactic-dose low-molecular-weight heparin (LMWH), or intermittent pneumatic compression pumping. 2 B 3.7.10 For high-risk general surgery patients (Caprini score ≥5), either low-dose heparin or prophylactic-dose LMWH are recommended. 1 B 3.7.11 For patients undergoing cancer-related surgery, we recommend pharmacologic prophylaxis extended for 4 weeks post-operatively. 1 B 3.7.12 For surgery patients at high risk of major bleeding, mechanical prophylaxis with intermittent pneumatic compression pumping is suggested over pharmacologic prophylaxis. 2 C 3.7.13 Following total joint replacement or hip fracture surgery, we recommend appropriate venous thromboembolism prophylaxis for 10 days. 1 A 3.7.14 For patients undergoing total hip arthroplasty, we recommend either LMWH, fondaparinux (2.5 mg/day), or vitamin K antagonism with warfarin (goal international normalized ratio: 2.0–3.0) for prophylactic regimens. Based on the RECORD and ADVANCE trials, both rivaroxaban and apixaban are similarly acceptable options for this indication. Neither dabigatran nor edoxaban are Food and Drug Administration (FDA) approved for venous thromboembolism prophylaxis following hip replacement surgery. 1 B 3.7.15 For patients undergoing total knee replacement surgery, either LMWH, fondaparinux (2.5 mg/day), or vitamin K antagonism with warfarin (goal international normalized ratio: 2.0–3.0) are recommended as prophylactic regimens for this indication. The RECORD and ADVANCE trials justify the use of either rivaroxaban or apixaban as reasonable alternative agents. Neither dabigatran nor edoxaban are FDA approved for venous thromboembolism prophylaxis following knee replacement surgery. 1 B 7933.7.16 For patients undergoing hip fracture surgery, fondaparinux, LMWH, or vitamin K antagonism with warfarin are recommended for prophylactic regimens for this indication. 1 B 3.7.17 For patients undergoing hip fracture surgery, intermittent pneumatic compression pumping is recommended as an acceptable alternative for patients at high risk of major bleeding. 1 C 3.7.18 Low-dose unfractionated heparin, LMWH, or fondaparinux are recommended as safe and effective prophylaxis strategies for hospitalized patients with other general medical conditions. 1 B 3.7.19 For bleeding patients, we suggest intermittent pneumatic compression for thrombosis prophylaxis. 2 C Guidelines 3.8.0 of the American Venous Forum on the management of axillosubclavian venous thrombosis in the setting of thoracic outlet syndrome 3.8.1 For primary axillosubclavian venous thrombosis in patients with venous thoracic outlet syndrome, we recommend venous thrombolysis followed by thoracic outlet decompression. This combination is safe and effective. 1 B 3.8.2 We recommend against stenting of the subclavian vein for venous thoracic outlet as an alternative to operative decompression. 1 A 3.8.3 Stenting of the subclavian vein after surgical decompression for venous thoracic outlet syndrome is recommended for significant refractory lesions, but evidence as to the long-term safety of this approach is lacking. 1 C 3.8.4 For patients with residual stenosis following thrombolysis and first rib resection for subclavian vein thrombosis in the setting of venous thoracic outlet syndrome, we recommend observation alone, as most of these patients will do well clinically and many will recanalize/remodel. 1 C 3.8.5 For patients with costoclavicular junction stenosis in the setting of an ipsilateral arteriovenous fistula and swelling, pain, or dysfunction, we recommend thoracic outlet decompression and endolumenal intervention; this approach is safe and effective. 1 B Guidelines 3.9.0 of the American Venous Forum on acute central vein thrombosis in the setting of central lines, pacemaker wires, and dialysis catheters 3.9.1 To decrease the risk of central venous thrombosis, we recommend placement of the tip of the central venous catheter at the junction of right atrium and superior vena cava. 1 B 3.9.2 We recommend 3 to 6 months anticoagulation for treatment of symptomatic acute central venous thrombosis in the setting of central lines, pacemaker wires or dialysis catheter. Removal of central line or catheter is recommended only if they are no longer needed. 1 B 794Guidelines 3.10.0 of the American Venous Forum on the indications, techniques, and results of inferior vena cava filters 3.10.1 We recommend placement of inferior vena cava (IVC) filters:• In patients with deep vein thrombosis (DVT) and/or pulmonary embolism (PE) and a baseline contraindication to anticoagulation• In patients who suffer a complication from anticoagulation• In patients who develop recurrent DVT or PE despite adequate anticoagulation• In patients who previously have had a massive PE and cannot tolerate further cardiopulmonary insult that would be associated with an additional PE 1 A 3.10.2 We suggest placement of an IVC filter in patients with a free-floating thrombus greater than 5 cm in length within an iliac vein or the IVC. 2 B 3.10.3 We suggest prophylactic filters to patients if their associated medical conditions (malignancy or traumatic injuries) predispose to DVT or PE. 2 B 3.10.4 We suggest caution in special situations prior to filter placement for:• Patients with untreated or uncontrolled bacteremia• Pediatric patients and pregnant women due to the uncertain long-term effects and durability of the filters 2 C 3.10.5 We suggest bedside placement of IVC filters by using either transabdominal duplex or intravascular ultrasound guidance. Both have been shown to be safe and effective. 2 B 3.10.6 We suggest performing additional studies to document the safety and efficacy of the placement of retrievable filters in patients with time-limited contraindications to anticoagulation. 2 B 3.10.7 We suggest follow-up examination annually for patients with vena caval filters to evaluate the mechanical stability of the filter. In addition, the condition of the lower extremities is evaluated to monitor the ongoing risk for recurrent thrombosis. 2 B Guidelines 3.11.0 of the American Venous Forum on superficial thrombophlebitis 3.11.1 For saphenous vein thrombophlebitis within 3 cm of the saphenofemoral or saphenopopliteal junctions, we recommend therapeutic anticoagulation. 1 B 3.11.2 For moderate thrombophlebitis with at least 5-cm thrombus length and at least 3 cm distal to the saphenofemoral junction, we recommend fondaparinux 2.5 mg daily or low-molecular-weight heparin 40 mg daily for 45 days. 1 B 3.11.3 For thrombophlebitis localized in the distal segment or in tributaries of the great saphenous vein with thrombus length <5 cm, we suggest ambulation, warm soaks, and non-steroidal anti-inflammatory agents. 2 B 7953.11.4 For moderate thrombophlebitis as described above or thrombophlebitis within 3 cm of the saphenofemoral junction, if anticoagulation is contraindicated, high ligation and division of the great saphenous vein is suggested. 2 B 3.11.5 In patients with saphenous thrombophlebitis, we suggest ablation, once the inflammation resolves, if there is evidence of venous insufficiency confirmed by duplex ultrasound scanning. 2 B Guidelines 3.12.0 of the American Venous Forum on mesenteric vein thrombosis 3.12.1 We recommend computed tomography angiography and magnetic resonance angiography for the diagnosis of mesenteric venous thrombosis (MVT). 1 B 3.12.2 We recommend immediate anticoagulation for the treatment of MVT to improve outcomes. 1 B 3.12.3 We recommend surgery to patients with MVT if they have evidence of peritonitis or perforation. 1 B 3.12.4 In patients with high-risk inherited thrombotic disorders or other permanent risks for thrombosis, we recommend long-term anticoagulation. 1 B Part 4. Management of Chronic Venous Disorders Guidelines 4.1.0 of the American Venous Forum on the clinical presentation and assessment of patients with venous disease 4.1.1 For clinical examination of the upper limb, we recommend inspection with comparison with the contralateral limb, palpation, auscultation, and examination of the axilla for adenopathy. In patients with adenopathy or swollen arms, we recommend examination of the breast to exclude malignancy. 1 B 4.1.2 For clinical examination of the lower limbs in patients with suspected acute deep vein thrombosis, we recommend inspection (edema, cyanosis, and varicosity), palpation (tenderness and pitting edema), auscultation (arterial bruit and heart and lung examination), and examination of the deep and superficial veins and calf muscles. 1 B 4.1.3 We suggest the use of the clinical scoring system of Wells to predict the pre-test probability of deep vein thrombosis. 2 B 4.1.4 For clinical examination of the lower limbs for varicosity and chronic venous insufficiency, we recommend inspection (varicosity, edema, skin discoloration, corona phlebectatica, ulcer, and lipodermatosclerosis) palpation (cord, varicosity, tenderness, induration, reflux, pulses, and thrill) auscultation (bruit), and examination of the groin and abdomen (masses, collateral veins, or lymphadenopathy) and ankle mobility. 1 B 7964.1.5 Clinical presentation of patients with varicose veins may include symptoms such as aching, heaviness and tension, sensation of swelling, tiredness, restless legs, nocturnal cramps, and itching. We suggest that there is little or no relationship between these symptoms and the presence and severity of varicose veins or the pattern and severity of reflux. 2 B Guidelines 4.2.0 of the American Venous Forum on the diagnostic algorithm for telangiectasia, varicose veins, and venous ulcers 4.2.1 We recommend that in patients with telangiectasia, varicose veins, and chronic venous insufficiency, a complete history and detailed physical examination is complemented by duplex scanning of the deep, superficial, and, selectively, the perforating veins to evaluate valvular incompetence. 1 B 4.2.2 We recommend that in patients with telangiectasia, varicose veins, and chronic venous insufficiency, laboratory examination is needed selectively for those with a personal or family history of thrombophilia (screening for hypercoagulability), in patients with long-standing venous stasis ulcers (blood count and metabolic panel), and in a case of general anesthesia for the treatment of chronic venous disease. 1 B 4.2.3 We recommend in patients with telangiectasia, varicose veins, and chronic venous insufficiency selective use of plethysmography, computed tomography, magnetic resonance imaging, ascending and descending venography, and intravascular ultrasound. 1 B 4.2.4 We suggest laboratory evaluation for thrombophilia in patients with a history of recurrent venous thrombosis and chronic recurrent venous leg ulcers. 2 C 4.2.5 We recommend arterial pulse examination and measurement of Ankle–Brachial Index in all patients with venous leg ulcer. 1 B Guidelines 4.3.0 of the American Venous Forum on compression therapy for venous ulceration 4.3.1 We recommend compression therapy to heal venous ulcers. 1 A 4.3.2 We suggest compression therapy to decrease the risk of ulcer recurrence. 2 B 4.3.3 We suggest the use of multicomponent compression bandage over single-component bandages for the treatment of venous leg ulcers. 2 B 4.3.4 We suggest enforcing compliance since it is integral to the success of compression therapy. 2 B 4.3.5 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 797Guidelines 4.4.0 of the American Venous Forum on the drug treatment of varicose veins, venous edema, and ulcers 4.4.1 We suggest venoactive drugs (Diosmin, Hesperidin, rutosides, sulodexide, micronized purified flavonoid fraction, horse chestnut seed extract [aescin], ruscus, and dobesilate) in addition to compression for patients with pain and swelling due to chronic venous disease in countries where these drugs are available. 2 B 4.4.2 Long-standing or large venous ulcers may benefit from treatment with either pentoxifylline or micronized purified flavonoid fraction used in combination with compression. 1 B 4.4.3 We suggest Diosmin and Hesperidin in trophic disorders, as well as cramps and swelling. We suggest rutosides in patients with venous edema. 2 B Guidelines 4.5.0 of the American Venous Forum on liquid sclerotherapy for telangiectasia and varicose veins 4.5.1 We recommend liquid or foam sclerotherapy for telangiectasia, reticular veins, and varicose veins. 1 B 4.5.2 For the treatment of the incompetent saphenous vein, we recommend endovenous thermal ablation over chemical ablation with foam. 1 B Guidelines 4.6.0 of the American Venous Forum on percutaneous laser therapy of telangiectasia and varicose veins 4.6.1 For telangiectasias with vein diameters below 0.5 mm and for telangiectatic matting, we recommend flashlamp pumped dye lasers at 595-nm wavelengths. 1 C 4.6.2 For telangiectasias with diameters below 0.7 mm, we recommend the potassium titanyl phosphate laser at 532-nm wavelengths. 1 C 4.6.3 For large telangiectasias of up to 3 mm vein diameter, we suggest treatment with long-pulse neodymium-doped yttrium aluminum garnet lasers at 1064-nm wavelengths. 2 C 4.6.4 During laser treatment, we recommend cooling to avoid thermal skin damage using dynamic spray cooling, contact cooling, or cooled air. 1 C 4.6.5 We do not recommend cosmetic laser treatment of leg telangiectasia in tanned skin with increased melanin content after sun exposure. 1 A Guidelines 4.7.0 of the American Venous Forum on foam sclerotherapy 4.7.1 We recommend foam sclerotherapy in the treatment of truncal primary and recurrent varicose veins. This is applicable to patients with CEAP clinical grade C2–C6. 1 A 4.7.2 We recommend using ultrasound-guided foam sclerotherapy over liquid sclerotherapy for the treatment of truncal varicose veins. 1 B Guidelines 4.8.0 of the American Venous Forum on the surgical treatment of the incompetent saphenous vein 4.8.1 For the treatment of the incompetent saphenous vein in association with symptomatic varicose veins, we recommend saphenous vein ablation over compression therapy for appropriate candidates. 1 B 7984.8.2 For the treatment of the incompetent great saphenous vein in association with symptomatic varicose veins, we suggest high ligation and inversion stripping of the saphenous vein to the level of the knee. 2 B 4.8.3 For the treatment of the incompetent small saphenous vein associated with symptomatic various veins, we suggest high ligation at the knee crease 3–5 cm distal to the saphenopopliteal junction and selective stripping of the vein. 2 B 4.8.4 To decrease the risk of infection during open saphenous surgery, we recommend prophylactic systemic antibiotics. 1 B 4.8.5 To reduce swelling, hematoma formation, and pain, we recommend post-operative compression for a period of 1 week. 1 B Guidelines 4.9.0 of the American Venous Forum on radiofrequency ablation of the incompetent saphenous vein 4.9.1 Endovenous thermal ablations (laser and radiofrequency ablations) are safe and effective, and we recommend them for the treatment of saphenous incompetence. 1 B 4.9.2 Because of reduced convalescence and less pain and morbidity, we recommend endovenous thermal ablation of the incompetent saphenous vein over open surgery. 1 B Guidelines 4.10.0 of the American Venous Forum on the laser treatment of the incompetent saphenous vein 4.10.1 Endovenous laser therapy of the great saphenous vein is safe and effective and we recommend it for the treatment of saphenous incompetence. 1 A 4.10.2 Clinical outcome after endovenous laser therapy at up to 3 years is comparable to traditional stripping and ligation and we recommend it for the treatment of the incompetent great saphenous vein. 1 C Guidelines 4.11.0 of the American Venous Forum on emerging endovenous technology for chronic venous disease: mechanical occlusion chemically assisted ablation, cyanoacrylate embolization, and V block-assisted sclerotherapy 4.11.1 We suggest mechanical occlusion chemically assisted (MOCA) ablation for:
Small saphenous vein (SSV) incompetence with diameter <10 mm
Mildly tortuous great saphenous vein (GSV)/SSV due to steerable wire
Below-knee (BK) GSV incompetence to the ankle for C2–C6 disease
2 B 4.11.2 We also suggest MOCA ablation for epifascial axial vein incompetence. 2 C 4.11.3 We suggest cyanoacrylate embolization (CAE) for:• BK GSV incompetence in C2–C6 disease• SSV incompetence 2 C 4.11.4 We suggest against CAE treatment of epifascial axial veins. 2 C 4.11.5 We suggest V block-assisted sclerotherapy (VBAS) for above-knee (AK) GSV incompetence with diameter <12 mm. 2 C 7994.11.6 We suggest polidocanol endovenous microfoam (PEM) for tortuous axial veins (GSV). 2 B 4.11.7 We suggest PEM for branch varicosities <6 mm. 2 C 4.11.8 As overall non-thermal non-tumescent (NTNT) technique guidelines, we recommend MOCA ablation, CAE, and PEM for AK GSV treatment for diameters <12 mm. 1 B 4.11.9 We recommend thermal tumescent techniques for vein diameters >12 mm. 1 C 4.11.10 We suggest NTNT not be used for vein diameters >12 mm. 2 B 4.11.11 We suggest NTNT not be used for post-thrombotic recanalized veins. 2 C Guidelines 4.12.0 of the American Venous Forum on phlebectomy 4.12.1 We recommend ambulatory phlebectomy—an outpatient procedure performed under local anesthesia—as an effective and definitive treatment for varicose veins. The procedure is performed after saphenous ablation, either during the same procedure or at a later stage. 1 B 4.12.2 Transilluminated powered phlebectomy has been shown to be effective in multiple studies for the treatment of varicose veins. We suggest it as an option. 2 C 4.12.3 We suggest phlebectomy over sclerotherapy for the 2 treatment of varicose veins. B Guidelines 4.13.0 of the American Venous Forum on the management of recurrent varicose veins 4.13.1 For clinical description of varicose vein recurrence, we recommend using the recurrent varices after surgery classification. 1 B 4.13.2 For evaluation of varicose vein recurrence, we recommend duplex ultrasound scanning of the location of the varicosities, as well as the source of the recurrence. 1 B 4.13.3 For the treatment of varicose vein recurrence, we suggest endovenous techniques, ultrasound-guided foam sclerotherapy, or phlebectomies, depending on the etiology and extent of varices. 2 C Guidelines 4.14.0 of the American Venous Forum on the treatment of varicose veins 4.14.1 We suggest venoactive drugs (Diosmin, Hesperidin, rutosides, sulodexide, micronized purified flavonoid fraction, or horse chestnut seed extract [aescin]) in addition to compression for patients with pain and swelling due to chronic venous disease in countries where these drugs are available. 2 B 4.14.2 We recommend ablation or stripping as the primary treatments for varicose veins. We recommend compression therapy using moderate pressure (20–30 mmHg) for those who are not candidates for a procedure. 1 B 4.14.3 We recommend endovenous thermal ablation in preference to high ligation and stripping or foam sclerotherapy for the management of saphenous vein incompetence. 1 B 8004.14.4 In highly selected patients, we suggest using non-thermal venous ablation procedures in preference to high ligation and stripping or endothermal venous ablation for the management of saphenous vein incompetence. 2 C 4.14.5 We suggest mini-phlebectomy, foam sclerotherapy, or endovenous thermal ablation for recurrent varicose veins. 2 B 4.14.6 We suggest mini-phlebectomy over sclerotherapy for the treatment of tributary varicosities once axial reflux has been addressed. 2 B 4.14.7 In the clinical practice, we recommend that the basic CEAP clinical classification in combination with the revised Venous Clinical Severity Score should be used to follow outcomes. 1 B Guidelines 4.15 of the American Venous Forum on the surgical repair of deep vein valve incompetence for primary reflux 4.15.1 For deep venous reflux with 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. Valve reconstruction should be considered in primary valvular incompetence after less invasive therapies have failed. 2 C Guidelines 4.16.0 of the American Venous Forum on the surgical treatment of post-thrombotic valvular incompetence 4.16.1 Surgical treatment of postthrombotic valvular incompetence is suggested in patients with infrainguinal deep venous reflux and skin changes at risk for venous leg ulcer (C4b), or healed/active venous leg ulcer (C5–C6). These procedures should be done in addition to standard compression therapy to aid in venous ulcer healing and to prevent recurrence. 2 C 4.16.2 In a patient with advanced postthrombotic syndrome (C4b, C5–C6), we suggest against ligation of the femoral or popliteal veins as a routine treatment. 2 C 4.16.3 In a patient with advanced postthrombotic syndrome (C4b, C5–C6), we suggest individual valve repair in addition to standard compression therapy for those who have axial reflux with structurally preserved deep venous valves, to aid in venous ulcer healing and to prevent recurrence. 2 C 4.16.4 In a patient with advanced postthrombotic syndrome (C4b, C5–C6), we suggest valve transposition or transplantation for those with absence of structurally preserved axial deep venous valves and competent outflow venous pathways that are anatomically appropriate for venous outflow. This procedure should be done in addition to standard compression therapy to aid in venous leg ulcer healing and to prevent recurrence. 2 C 8014.16.5 In a patient with advanced postthrombotic syndrome (C4b, C5–C6), we suggest consideration of autogenous valve substitutes such as a neovalve by surgeons experienced in these techniques in those with no other option available. This procedure should be done in addition to standard compression therapy to aid in venous ulcer healing and to prevent recurrence. 2 C Guidelines 4.17.0 of the American Venous Forum on endovascular reconstruction for primary iliac vein obstruction 4.17.1 We recommend endovenous stenting as the current “method of choice” for the treatment of primary iliac vein obstruction. 1 B 4.17.2 To alleviate pain and swelling and promote sustained ulcer healing, we recommend venous stenting for the treatment of primary iliac vein obstruction. Venous stenting improves the quality of life of the patients. 1 B Guidelines 4.18.0 of the American Venous Forum on the endovascular treatment of lower extremity post-thrombotic iliofemoral venous obstruction 4.18.1 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 severe limb swelling (C3), 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 B Guidelines 4.19.0 of the American Venous Forum on the endovascular reconstruction of complex iliocaval venous occlusions 4.19.1 We suggest endovascular stents for the reconstruction of complex iliocaval venous occlusions. 2 B Guidelines 4.20.0 of the American Venous Forum on open surgical reconstructions for non-malignant occlusion of the inferior vena cava and iliofemoral veins 4.20.1 For symptomatic patients with unilateral iliofemoral venous occlusions who fail attempts at endovascular reconstruction or in whom endovascular intervention is not feasible, we recommend open surgical bypass using the saphenous vein as a cross-pubic bypass (Palma procedure). 1 B 4.20.2 For symptomatic patients with iliac vein or inferior vena cava obstruction, we suggest open surgical bypass using externally supported polytetrafluoroethylene prosthesis if endovascular options fail or they are not possible. 2 B Guidelines 4.21.0 of the American Venous Forum on the management of incompetent perforating veins with open and endoscopic surgery 4.21.1 For open surgical treatment of incompetent pathologic perforating veins (outward flow of >500 ms duration, with a diameter of >3.5 mm) located beneath a healed or active ulcer, we suggest against the modified open Linton procedure owing to associated morbidities. 2 C 8024.21.2 For those patients who would benefit from pathologic perforator vein ablation, we suggest treatment by percutaneous techniques over subfascial endoscopic perforator surgery. 2 C Guidelines 4.22.0 of the American Venous Forum on the radiofrequency and laser treatment of incompetent perforating veins 4.22.1 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 4.22.2 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. Treatment of the incompetent perforating veins can be performed simultaneously or staged. 2 C 4.22.3 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 4.22.4 For those patients who would benefit from pathologic perforator vein ablation, we suggest 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. 2 C Guidelines 4.23.0 of the American Venous Forum on the local treatment of venous ulcers d 4.23.1 592For wound cleansing, we suggest that venous leg ulcers be cleansed initially and at each dressing change with a neutral, non-irritating, non-toxic solution, performed with a minimum of chemical or mechanical trauma. 2 C 4.23.2 We recommend that venous leg ulcers receive thorough debridement at their initial evaluation to remove obvious necrotic tissue, excessive bacterial burden, and cellular burden of dead and senescent cells. 1 B 8034.23.3 We suggest maintenance debridement to maintain the appearance and readiness of the wound bed for healing and suggest choosing one or more from several debridement methods, including sharp, enzymatic, mechanical, biologic, and autolytic. 2 B 4.23.4 We recommend local anesthesia (topical or local injection) to minimize the discomfort associated with surgical ulcer debridement. In selected cases, regional block or general anesthesia may be required. 1 B 4.23.5 We recommend surgical debridement for venous leg ulcers with slough, non-viable tissue, or eschar. Serial wound assessment will determine the need for repeated debridement. 1 B 4.23.6 We suggest hydrosurgical debridement as an alternative to standard surgical debridement. 2 B 4.23.7 We suggest against ultrasonic debridement over surgical debridement. 2 C 4.23.8 We suggest against enzymatic debridement over surgical debridement, with the exception of when no clinician trained in surgical debridement is available. 2 C 4.23.9 We suggest larval therapy for ulcers as an alternative to surgical debridement. 2 B 4.23.10 We recommend systemic Gram-positive antibiotic treatment for cellulitis surrounding the ulcer. 1 B 4.23.11 We suggest against systemic antimicrobial treatment of venous leg ulcer colonization or biofilms without clinical evidence of infection. 2 C 4.23.12 We suggest antimicrobial therapy for ulcers with clinical evidence of infection and >1 × 106Colony-forming unit (CFU)/g of tissue, or at lower levels of colony-forming units per gram of tissue in the presence of virulent or difficult-to-eradicate bacteria (such as P-hemolytic streptococci, Pseudomonas, and resistant staphylococcal species). We suggest a combination of mechanical disruption and antibiotic therapy as being most successful in eradicating venous leg ulcer infection. 2 C 4.23.13 We recommend oral systemic antibiotics, guided by sensitivities performed on wound culture, for ulcers with clinical evidence of infection. The duration of antibiotic therapy should be limited to 2 weeks unless wound infection persists. 1 C 4.23.14 We suggest against the use of topical antimicrobial agents for the treatment of infected ulcers. 2 C 4.23.15 We suggest a topical dressing that will manage ulcer exudate and maintain a moist, warm wound bed. 2 C 4.23.16 We suggest selection of a primary wound dressing for absorbing the wound exudate produced by the ulcer (alginates and foams) and for protecting the skin around the ulcer. 2 B 8044.23.17 We suggest against the routine use of topical antimicrobial-containing dressings in the absence of infection. 2 A 4.23.18 We suggest lubricants underneath compression to reduce the dermatitis that commonly affects periulcer skin. If severe dermatitis is associated, we suggest topical steroids. 2 C 4.23.19 We suggest against the use of anti-inflammatory therapies for the treatment of venous leg ulcers. 2 C 4.23.20 We recommend adjuvant wound therapy options for non-healing ulcers after standard therapy for 4–6 weeks. 1 B 4.23.21 We suggest against split-thickness skin grafting as a primary therapy of venous ulcers, but suggest it for large ulcers without signs of healing for 4–6 weeks. 2 B 4.23.22 We suggest the use of cultured allogeneic bilayer skin replacements (with both epidermal and dermal layers) in non-healing ulcers after standard therapy for 4–6 weeks. 2 A 4.23.23 We suggest a trial of compression and wound moisture control before cellular therapy. 2 C 4.23.24 Before using a bi-layered cellular graft, we recommend wound bed preparation including complete removal of slough, debris, and any necrotic tissue. We also recommend additional evaluation and management of increased bioburden levels. 1 C 4.23.25 We suggest reapplication of cellular therapy as long as the ulcer continues to respond. 2 C 4.23.26 We suggest porcine small intestinal submucosal tissue construct for the treatment of non-healing ulcers after standard therapy for 4–6 weeks. 2 B 4.23.27 We suggest against routine primary use of negative pressure wound therapy for venous leg ulcers. 2 C 4.23.28 We suggest against electrical stimulation therapy for venous leg ulcers. 2 C 4.23.29 We suggest against routine ultrasound therapy for venous leg ulcers. 2 B Guidelines 4.24.0 of the American Venous Forum on the treatment of chronic venous disease in patients with venous ulcers e 4.24.1 Definition of Venous Ulcer, Venous Anatomy, and Pathophysiology 4.24.1.1 We suggest the 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) 4.24.1.2 We recommend the use of the International Consensus Committee on Venous Anatomical Terminology for standardized venous anatomy nomenclature. (BEST PRACTICE) 4.24.1.3 We recommend a basic practical knowledge of venous physiology and venous leg ulcer pathophysiology for all practitioners caring for venous leg ulcers. (BEST PRACTICE) 805 4.24.2 Clinical Evaluation 4.24.2.1 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. (BEST PRACTICE) 4.24.2.2 We recommend the identification of medical conditions that affect ulcer healing and other non-venous causes of ulcers. (BEST PRACTICE) 4.24.2.3 We recommend serial venous leg ulcer wound measurement and documentation. (BEST PRACTICE) 4.24.2.4 We suggest against routine culture of venous leg ulcers and to only obtain wound cultures when clinical evidence of infection is present. 2 C 4.24.2.5 We recommend wound biopsy for venous 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 4.24.2.6 We suggest laboratory evaluation for thrombophilia for patients with a history of recurrent venous thrombosis and chronic recurrent venous leg ulcers. 2 C 4.24.2.7 We recommend arterial pulse examination and 1 B measurement of Ankle–Brachial Index (ABI) for all patients with venous leg ulcer. 4.24.2.8 We suggest against routine microcirculation assessment of venous leg ulcers, but suggest selective consideration as an adjunctive assessment for the monitoring of advanced wound therapy. 2 C 4.24.2.9 We recommend comprehensive venous duplex ultrasound examination of the lower extremity in all patients with suspected venous leg ulcer. 1 B 4.24.2.10 We suggest selective use of venous plethysmography in the evaluation of patients with suspected venous leg ulcer if venous duplex ultrasound does not provided definitive diagnostic information. 2 B 4.24.2.11 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 non-thrombotic iliac vein obstruction, or for operative planning prior to open or endovenous interventions. 2 C 4.24.2.12 We recommend that all patients with venous leg ulcer should be classified based on venous disease classification assessment including clinical CEAP, revised Venous Clinical Severity Scoring, and venous disease-specific quality of life assessment. (BEST PRACTICE) 8064.24.2.13 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. (BEST PRACTICE) 4.24.3 Compression 4.24.3.1 In a patient with a venous leg ulcer, we recommend compression therapy over no compression therapy to increase the venous leg ulcer healing rate. 1 A 4.24.3.2 In a patient with a healed venous leg ulcer, we suggest compression therapy to decrease the risk of ulcer recurrence. 2 B 4.24.3.3 We suggest the use of multicomponent compression bandages over single-component bandages for the treatment of venous leg ulcers. 2 B 4.24.3.4 In a patient with a venous leg ulcer and underlying arterial disease, we do not suggest compression bandages or stockings if the ABI is 0.5 or less or if the absolute ankle pressure is less than 60 mmHg. 2 C 4.24.3.5 We suggest using 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 4.24.4 Operative and Endovascular Treatment 4.24.4.1 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 4.24.4.2 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 4.24.4.3 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 4.24.4.4 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 8074.24.4.5 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 4.24.4.6 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. 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 4.24.4.7 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 4.24.4.8 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 4.24.4.9 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 4.24.4.10 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 8084.24.4.11 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 4.24.4.12 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 an absence of structurally preserved axial deep venous valve(s) 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 4.24.4.13 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 4.24.4.14 In a patient with inferior vena cava and/or iliac vein chronic total occlusion or severe stenosis, with or without lower extremity deep venous reflux disease, which 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 4.24.4.15 In a patient with inferior vena cava and/or iliac vein chronic occlusion or severe stenosis, with or without lower extremity deep venous reflux disease, which is associated with a recalcitrant venous leg ulcer, and who have failed endovascular treatment, we suggest open surgical bypass using an externally supported expanded polytetrafluroethylene (ePTFE) graft, in addition to standard compression therapy to aid in venous leg ulcer healing and to prevent recurrence. 2 C 4.24.4.16 In a patient with unilateral iliofemoral venous occlusion/severe stenosis with recalcitrant venous leg ulcer who failed attempts at endovascular reconstruction, we suggest open surgical bypass using the 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 8094.24.4.17 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 4.24.5 Ancillary Therapy 4.24.5.1 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. (BEST PRACTICE) 4.24.5.2 For long-standing or large venous leg ulcers, we recommend treatment with either pentoxifylline or micronized purified flavonoid fraction used in combination with compression therapy. 1 B 4.24.5.3 We suggest supervised active exercise to improve muscle pump function and reduce pain and edema in patients with venous leg ulcers. 2 B 4.24.5.4 We suggest against adjunctive lymphatic drainage for the healing of the chronic venous leg ulcers. 2 C 4.24.5.5 We suggest balneotherapy to improve skin trophic changes and quality of life in patients with advanced venous disease. 2 B 4.24.5.6 We suggest against using ultraviolet light for the treatment of venous leg ulcers. 2 C 4.24.6 Primary Prevention 4.24.6.1 In patients with clinical CEAP C3–C4 disease due to primary valvular reflux, we recommend 20–30 mmHg compression, knee or thigh high. 2 C 4.24.6.2 In patients with clinical CEAP C1–C4 disease related to prior deep vein thrombosis (DVT), we recommend compression, 30–40 mmHg, knee or thigh high. 1 B 4.24.6.3 As post-thrombotic syndrome (PTS) is a common preceding event for venous leg ulcers, we recommend current evidence-based therapies for acute DVT treatment. 1 B 4.24.6.4 For acute DVT treatment, we suggest the use of low-molecular-weight heparin over vitamin K antagonist therapy of 3 months’ duration to decrease PTS. We also suggest catheter-directed thrombolysis in low-bleeding-risk patients with iliofemoral DVT of <14 days’ duration. 2 B 4.24.6.5 In patients with C1–C4 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) 4.24.6.6 In patients with asymptomatic C1-C2 disease from either primary or secondary causes, we suggest against prophylactic interventional therapies to prevent venous leg ulcer. 2 C 810 Part 5. Special Venous Problems Guidelines 5.1.0 of the American Venous Forum on the surgical and endovenous treatment of superior vena cava syndrome 5.1.1 In patients with malignant superior vena cava obstruction, we recommend stenting as the primary therapy, unless the malignancy can be excised. 1 A 5.1.2 In patients with superior vena cava syndrome due to non-malignant etiology, we recommend endovascular treatment as the initial therapy. 1 B 5.1.3 We recommend open surgical reconstruction of the superior vena cava with spiral vein graft, autologous femoral vein, or expanded polytetrafluoroethylene graft if the patient is not suitable for or failed endovascular therapy. 1 B Guidelines 5.2.0 of the American Venous Forum on the management of traumatic injuries of large veins 5.2.1 For management of a grade I puncture injury, we recommend pressure or suture repair. 1 B 5.2.2 For management of a grade II injury—a laceration in a hemodynamically stable patient—we recommend lateral venorraphy or consideration of endovascular treatment. 1 B 5.2.3 For management of a grade III injury—a transection of a large vein in a hemodynamically stable patient—we recommend end-to-end anastomosis or interposition graft. 1 B 5.2.4 For management of a grade IV large vein injury in a hemodynamically unstable patient, we recommend bypass over ligation. 1 B Guidelines 5.3.0 of the American Venous Forum on primary and secondary tumors of the inferior vena cava and iliac veins 5.3.1 For patients with invasion of the wall of the inferior vena cava by primary or secondary tumor, we recommend caval replacement if the vein was patent before surgery and if the collateral circulation appears inadequate following caval resection. Repair with externally supported polytetrafluoroethylene graft is safe, effective, and durable. 1 B 5.3.2 For inferior vena cava tumor thrombus—usually a renal cell carcinoma—that extends into the right heart, we recommend removal with cardiopulmonary bypass, with or without hypothermic circulatory arrest. 1 B Guidelines 5.4.0 of the American Venous Forum on arteriovenous malformations: evaluation and treatment 5.4.1 For symptomatic arteriovenous malformations, we recommend endovascular treatment with embolization or sclerotherapy. We recommend it for both definitive treatment of surgically “inaccessible” lesions and for initial therapy of surgically “accessible” lesions. 1 B Guidelines 5.5.0 of the American Venous Forum on the management of venous malformations 5.5.1 For symptomatic venous malformations not responding to compression treatment, we suggest foam sclerotherapy over sclerotherapy with alcohol. 2 C 8115.5.2 For surgically accessible and localized symptomatic venous malformations, we suggest surgical excision as an alternative to sclerotherapy. 2 C Guidelines 5.6.0 of the American Venous Forum on the management of venous aneurysms 5.6.1 We recommend surgical repair of even asymptomatic lower extremity venous aneurysms because of the risk of thromboembolic complications. 1 B 5.6.2 For aneurysms of superficial veins of the arm or leg or of deep veins of the arm, we suggest observation unless cosmetic reasons or complications warrant repair. 2 B 5.6.3 For jugular vein aneurysms, we suggest observation unless cosmetic reasons or psychological reasons warrant surgical repair. 2 C 5.6.4 For abdominal venous aneurysms, we suggest repair because of the risk of rupture and thromboembolism. 2 C 5.6.5 Thoracic venous aneurysms are infrequently associated with rupture or thromboembolic complications and can be observed in most cases. 2 C Guidelines 5.7.0 of the American Venous Forum on the management of pelvic venous congestion and perineal varicosities 5.7.1 We recommend pelvic ultrasonography for the initial evaluation of patients with suspected pelvic varicose veins. Ultrasound will confirm pelvic varicose veins and may determine their etiology. We recommend computed tomographic venography or magnetic resonance venography for further evaluation. 1 B 5.7.2 We recommend selective contrast pelvic venography in the reversed Trendelenburg position to confirm the diagnosis and etiology of pelvic and perineal varicose veins, to delineate the anatomy, and to plan endovenous treatment. 1 B 5.7.3 We recommend endovenous ablation of the refluxing ovarian vein with coil embolization, with or without liquid or foam sclerotherapy. 1 B 5.7.4 We recommend an open surgical approach to ligate the refluxing symptomatic ovarian vein if endovascular treatment fails or is not possible. 1 B 5.7.5 We suggest liquid or foam sclerotherapy for the treatment of perineal and vulvar varicosities. 2 B Guidelines 5.8.0 of the American Venous Forum on the management of nutcracker syndrome 5.8.1 We suggest open surgical interventions, such as left renal vein transposition, as the primary treatment of nutcracker syndrome. 2 B 5.8.2 We suggest left renal vein stenting for the treatment of nutcracker syndrome in those patients who are not candidates for open surgery or who failed open surgical treatment. 2 C 812 Part 6. Lymphedema Guidelines 6.1.0 of the American Venous Forum on lymphedema: pathophysiology, classification, and clinical evaluation 6.1.1 Lymphedema is divided into two major categories: primary and secondary. Primary lymphedema may be further subdivided into three categories:Congenital lymphedema (10%) develops within 2 years of birth. Some of the congenital forms are hereditary.
Lymphedema praecox (80%) occurs between the ages of 2 and 25 years. Although sporadic cases are most common, a few forms are hereditary.
Lymphedema tarda (10%) has its onset in those over 35 years of age.
B Secondary lymphedema is caused by inflammation or obstruction of the lymph vessels. Some of the most common causes include filariasis, cancer, trauma (mostly iatrogenic), and infection/inflammation. 6.1.2 Lymphatic abnormalities can be divided into four anatomical categories: aplasia, hypoplasia, numerical hyperplasia, and hyperplasia. B 6.1.3 There are three major categories of lymphatic pathophysiological abnormalities: obstruction, reflux, and overproduction of lymph fluid. B Guidelines 6.2.0 of the American Venous Forum on lymphoscintigraphy and lymphangiography 6.2.1 We recommend lymphoscintigraphy and not contrast lymphangiography for the initial evaluation of patients with lymphedema. 1 B 6.2.2 We suggest lymphoscintigraphy, using visual interpretation of the images with a semi-quantitative scoring index, for documenting responses to the treatment of lymphedema. 2 B Guidelines 6.3.0 of the American Venous Forum on lymphedema: physical and medical therapy 6.3.1 To reduce lymphedema, we recommend multimodal complex decongestive therapy that includes manual lymphatic drainage, multilayer short-stretch bandaging, remedial exercise, skin care, and instruction in long-term management. 1 B 6.3.2 To reduce lymphedema, we recommend short-stretch bandages that remain in place for >22 hours per day. 1 B 6.3.3 To reduce lymphedema, we recommend daily treatment for a minimum of 5 days per week and continuing until normal anatomy or a volumetric plateau is established. 1 B 6.3.4 To reduce lymphedema, we suggest compression pumps in some patients. 2 B 6.3.5 For maintenance of lymphedema, we recommend an appropriately fitting compression garment. 1 A 6.3.6 For the maintenance of lymphedema in patients with advanced (stage II and III) disease, we recommend using short-stretch bandages during the night. Alternative compression devices may substitute for short-stretch bandages. 1 B 8136.3.7 For remedial exercises, we recommend wearing compression garment or bandages. 1 C 6.3.8 For cellulitis or lymphangitis, we recommend antibiotics with superior coverage of Gram-positive cocci, particularly streptococci. Examples include cephalexin, penicillin, clindamycin, and erythromycin. 1 A 6.3.9 For prophylaxis of cellulitis in patients with more than three episodes of infection, we recommend antibiotics with superior coverage of Gram-positive cocci, particularly streptococci, at full strength for 1 week per month. Examples include cephalexin, penicillin, clindamycin, and erythromycin. 1 A 6.3.10 For patients with lymphedema we recommend risk factor modifications by decreasing obesity, treating chronic venous insufficiency, and promoting skin care and exercise. 1 C Guidelines 6.4.0 of the American Venous Forum on the principles of the surgical treatment of chronic lymphedema 6.4.1 All interventions for chronic lymphedema should be preceded by at least 6 months of non-operative compression treatment. 1 C 6.4.2 We suggest excisional operations or liposuction only to patients with late-stage non-pitting lymphedema who fail conservative measures. 2 C 6.4.3 We suggest microsurgical lymphatic reconstructions in centers of excellence for selected patients with secondary lymphedema if performed early in the course of the disease. 2 C Guidelines 6.5.0 of the American Venous Forum on the medical, open surgical, and endovascular treatment of chylous disorders 6.5.1 For the primary treatment of chylous effusions and fistulas due to reflux, we recommend first a low-fat or medium-chain triglyceride diet, followed by drug therapy that may include somatostatin and its analogs, diuretics, and sympathomimetic drugs to enhance thoracic duct contractions. This is followed by percutaneous aspirations of chylous fluid by thoracentesis or paracentesis. 1 B 6.5.2 In patients with chylous effusions, we suggest percutaneous embolization using coils or glue as the first line of treatment once conservative management fails. 2 B 6.5.3 If endovascular treatment is not possible or fails, we suggest open surgery for the treatment of chylous effusions and symptomatic lymphangiectasia. These procedures include ligation of lymphatic fistulas, excision of dilated lymphatics, sclerotherapy, video-assisted thoracoscopy with pleurodesis, and ligation of the thoracic duct, lymphatic reconstruction, or, as a last resort, placement of a peritoneovenous shunt. 2 CBased on the recommendations of: Kearon C et al. Chest 2012;142:1698–704;
Kearon C et al. Chest 2016;149(2):315–352, and Meissner MH et al. J Vasc Surg 2012;55:1449–1462.
Adapted from Jaff MR et al. Circulation 2011;123(16):1788–830.
Adapted from O’Donnell TF Jr., Passman MA, Marston WA et al. J Vasc Surg 2014;60:3S-59S.
Local treatment of venous ulcer corresponds to Chapter 51 and guidelines 4.23.0.
Note: LMWH: low-molecular-weight heparin; IV: intravenous; UFH: unfractionated heparin; PE: pulmonary embolism; RV: right ventricle.