Table 3. Procedural therapy recommendations for venous insufficiency associated with ulceration 42 .
| Anatomic disease classification | Management guidelines |
|---|---|
| Superficial venous reflux and active or healed venous leg ulcer | • Closure of the axial incompetent veins directed to the ulcer |
| Combined superficial and perforator venous reflux with or without deep venous reflux and active venous leg ulcer | • Closure of both the incompetent superficial veins directed to the ulcer and pathologic perforator vein if it is beneath or associated with the ulcer bed |
| Combined superficial and perforator venous reflux with or without deep venous reflux and healed venous leg ulcer or at risk for venous leg ulcer | • Staged treatment with reevaluation of the perforator after correction of axial reflux |
| Pathologic perforator in the absence of superficial venous disease, with or without deep venous reflux and a healed or active ulcer | • Closure by ablation or sclerotherapy of the perforator or open venous perforator surgery |
| Infrainguinal deep venous obstruction and skin changes at risk for venous leg ulcer or healed or active venous leg ulcer | • Autogenous venous bypass or endophlebectomy |
| Infrainguinal deep venous reflux with skin changes at risk for venous leg ulcer, or healed or active venous leg ulcer | • Deep vein ligation of the femoral or popliteal veins (if collateral pathways exist), primary valve repair (external banding or valvuloplasty), valve transposition/transplantation, or autogenous valve substitute |
| Proximal chronic total venous occlusion/severe stenosis (inferior vena cava or iliac veins) with or without deep venous reflux with skin changes at risk for venous leg ulcer, healed or active venous leg ulcer | • Endovascular repair with venous angioplasty and stent recanalization • If failure of endovascular reconstruction, open surgical bypass |