Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ONGOING

all symptomatic patients

1st line – graded compression stockings

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ONGOING
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all symptomatic patients
1st line – 

graded compression stockings

The mainstay of treatment for CVI-related oedema, stasis dermatitis, and small venous leg ulcers is use of graded compression knee-high stockings.[19][20] [ Cochrane Clinical Answers logo ]

Shown to be more effective in healing venous ulcers than no compression therapy.[22][23] [ Cochrane Clinical Answers logo ] For ulcer healing, multi-layer dressings are more effective than single-layer dressings.[24]

Stockings must be put on first thing in the morning and should be removed only when the patient is recumbent (usually just before going to bed).

In general, there are three classes of compression stockings: class 1 stockings (light compression) control oedema; class 2 (medium compression) and class 3 (high compression) are usually required for more advanced CVI. Patients with severe CVI or previous ulcers generally require lifelong graded compression stockings of at least 30 to 40 mmHg.

Consider – moisturiser

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all symptomatic patients
Consider – 

moisturiser

Additional treatment recommended for SOME patients in selected patient group

Applying a simple moisturising cream to combat skin dryness and flaking in eczematous skin changes and mild stasis dermatitis is generally thought to be beneficial.

Consider – pentoxifylline or diosmin

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ONGOING
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all symptomatic patients
Consider – 

pentoxifylline or diosmin

Additional treatment recommended for SOME patients in selected patient group

Pentoxifylline has shown some benefit in venous leg ulcer healing in randomised clinical trials.[25]

Pentoxifylline is used to treat claudication. A meta-analysis of five trials showed a minimal benefit to venous leg ulcer healing with oral pentoxifylline (odds ratio 1:3) compared with compression therapy and placebo.[26] [ Cochrane Clinical Answers logo ] A later systematic review determined that, while data were limited by heterogeneity and small sample sizes, pentoxifylline demonstrated clinical benefits when used in conjunction with compression therapy.[28]

A meta-analysis of prospective randomised trials of micronised purified flavonoid fraction (MPFF) in the treatment of venous leg ulcer compared compression and local care with and without the addition of oral MPFF.[27] A later systematic review determined that, while data were limited by heterogeneity and small sample sizes, MPFF has demonstrated clinical benefits when used In conjunction with compression therapy.[28] The data suggest that MPFF may be a useful adjunct to conventional therapy in large and long-standing venous leg ulcer.

Venoactive drugs, such as diosmin, can be considered for the treatment of CVI pain.[2]

Diosmin (an MPFF) is available in some European, Asian, and South American countries, and in Canada, but not in the US or the UK.

Primary options

pentoxifylline: 400 mg orally three times daily

Secondary options

diosmin: consult specialist for guidance on dose

Consider – intermittent pneumatic compression

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all symptomatic patients
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with post-thrombotic syndrome
Consider – 

intermittent pneumatic compression

Additional treatment recommended for SOME patients in selected patient group

Intermittent pneumatic compression may also be considered in patients with post-thrombotic syndrome, to reduce severity.[2]

Plus – endovenous ablation or saphenectomy or foam sclerotherapy

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all symptomatic patients
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with superficial venous reflux
Plus – 

endovenous ablation or saphenectomy or foam sclerotherapy

Treatment recommended for ALL patients in selected patient group

Saphenectomy (surgical stripping) confers long-term benefit in patients with CVI with associated superficial venous reflux. Patients with significant great or small saphenous vein reflux on duplex ultrasound have ulcer recurrence rates at 4 years of 24% with saphenectomy and compression and 52% with compression alone.[29]

Endovenous laser therapy or radiofrequency ablation of the great saphenous vein (GSV) can be done with outpatients under local tumescent anaesthesia and have replaced surgical stripping for most patients.​ Following endovenous ablation, compression stockings should be worn for 24 hours per day for 1-3 days, then during the day for 1-2 weeks. Postoperatively, normal activities can be resumed, but strenuous leg activity (e.g., running, weighted leg exercises, cycling) should be avoided for 1 week. Continued use of compression stockings during the day is recommended if there is ongoing evidence of reflux (i.e., deep system insufficiency).

A randomised controlled trial comparing endovenous laser ablation therapy with saphenopopliteal junction ligation plus attempted stripping/excision for the treatment of small saphenous vein insufficiency has reported similar 2-year outcomes, but with the possible benefit of fewer short-term sensory deficits with endovenous laser ablation therapy.[30]

Early endovenous ablation of the superficial venous reflux (within 2 weeks) has been found to result in faster healing of venous leg ulcers and more time free from ulcers than deferred endovenous ablation (considered after ulcer has healed or at least 6 months if ulcer was not healed).[31]

The major complication of these techniques is deep vein thrombosis, occurring in 1% to 3% of patients.[33]​ Individualised thromboprophylaxis strategies should be considered.[2]

Foam sclerotherapy can also be used to ablate the GSV.[32]​​​ The sclerosant agent is mixed with air to produce foam, which is then injected into the vein under ultrasound guidance. The foam displaces blood in the vein and causes spasm of the vein and endothelial injury, resulting in thrombosis of the vessel. Retinal or cerebral emboli (causing migraine, but rarely stroke) may occur with the use of foam in 2% to 6% of patients, but these adverse sequelae are almost always minor and transient.[33]

Consider – endovenous ablation or injection sclerotherapy

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ONGOING
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all symptomatic patients
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with angiomata and varicosities
Consider – 

endovenous ablation or injection sclerotherapy

Additional treatment recommended for SOME patients in selected patient group

These lesions may occasionally cause symptoms of sufficient severity to warrant laser or radiofrequency ablation or injection sclerotherapy, which may be liquid or, increasingly, foam sclerotherapy.

Plus – endovenous ablation or ligation

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ONGOING
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all symptomatic patients
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with perforating vein incompetence
Plus – 

endovenous ablation or ligation

Treatment recommended for ALL patients in selected patient group

Incompetent perforating veins may be treated with endovenous ablation (laser or radiofrequency) or ligation.[2]

Consider – percutaneous iliac angioplasty and stenting

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ONGOING
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all symptomatic patients
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with iliac vein obstruction
Consider – 

percutaneous iliac angioplasty and stenting

Additional treatment recommended for SOME patients in selected patient group

An important subset of patients with CVI have iliac vein obstruction, more commonly on the left than the right. In selected patients (determined by a vascular specialist), symptoms may be substantially improved by percutaneous iliac angioplasty and stenting. These procedures are performed in significant numbers only in selected centres, and the indications for such procedures are still developing.[34]

Consider – venous valvular reconstruction

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ONGOING
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all symptomatic patients
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with deep venous reflux
Consider – 

venous valvular reconstruction

Additional treatment recommended for SOME patients in selected patient group

Venous valvular reconstruction (either with leaflet repair or with axillary valve transplantation) is rarely performed, and its use is generally confined to selected centres. Results are far better when performed in patients with primary rather than post-thrombotic venous reflux.[35] The operation is generally reserved for patients in whom conventional therapy has failed.

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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