Algorithm for initial conservative management of chronic venous insufficiency

ABI: ankle-brachial index.
* Patient with typical symptoms and signs of chronic venous insufficiency (edema, skin changes, venous ulcer) and documented ultrasound evidence of superficial or deep venous reflux.
¶ Ideally, the extremity should be elevated above the heart for optimal effect, though this is often not possible.
Δ The accuracy of the pulse examination is variable. ABI should be obtained for any ulcer. A large percentage of patients have mixed venous/arterial components.
◊ Infection may manifest as excessive exudation, purulent discharge from the surface of the ulcer, or erythema evident at margins of ulceration possibly extending into the adjacent tissue.
§ Graduated compression hosiery consists of typically knee-high stockings that provide graded compression (20 to 40 mmHg) with the highest level of compression exerted at the ankle.
¥ Multilayer compression bandaging systems are composed of three or four elastic layers and are placed by a trained clinician. Multilayer compression bandaging systems are more effective compared with inelastic compression (eg, Unna boot) for healing venous ulceration.
‡ Follow-up is typically weekly, although depending on the size of the ulcer and amount of exudation, more frequent follow-up may be needed.
† Venous intervention may improve healing rates and time to healing and reduces venous ulcer recurrence. Early intervention may be preferred to a prolonged course of conservative treatment for active or recurrent venous ulceration.
** Venoactive agents include: hydroxyethylrutoside, escin (horse chestnut seed extract), and micronized purified flavonoid fraction.