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JUNE 2015

Venous leg ulcers: Summary of new clinical

practice guidelines published August 2014 in the
Journal of Vascular Surgery
Jeanne M. Widener, PhD, RN, CNE
The Society for Vascular Surgery (SVS) and the American Venous Forum (AVF) published guidelines for the management of venous leg ulcers in August 2014. The goal of this article (Part 2) is to summarize the guidelines that address diagnosis and treatment recommendations published jointly by the SVS and AVF that may affect the nursing practice of
vascular nurses. Specific sections include wound evaluation, therapies used on the wound bed itself, compression, and
operative or endovascular management. Part 1, published elsewhere in this issue, addressed the epidemiology and financial impact of ulcers, venous anatomy, pathophysiology of venous leg ulcer development, clinical manifestations, and prevention of venous leg ulcers. These 2 parts together provide a comprehensive summary of the joint SVS and AVF guidelines
for care of venous leg ulcers. (J Vasc Nurs 2015;33:60-67)

PURPOSE

The Society for Vascular Surgery (SVS) and the American

Venous Forum (AVF) published guidelines jointly for the management of venous leg ulcers in August 2014.1 The goal of this
article is to summarize the guidelines that address diagnosis
and treatment recommendations published jointly by the SVS
and the AVF that may affect the nursing practice of vascular
nurses. A companion article in this issue, Venous leg ulcers:
Impact and dysfunction of the venous system addresses the
epidemiology and financial impact of venous ulcers, anatomy
and pathophysiology of venous leg ulcer development, clinical
manifestations, and prevention of venous leg ulcers. The companion article is designed to be read first to familiarize vascular
nurses with the issues in the venous system to better understand
the basis for diagnosis and treatment of venous leg ulcers.
The venous leg ulcer guideline committee included members
from both the SVS and AVF and was further divided into 6 subcommittees to address diagnosis, compression issues, endovascular and surgical interventions, general wound care, ancillary
treatments, and preventative care. Each subcommittee was
charged with evaluating the evidence available for quality and
strength. The grading of recommendation assessment, develop-

From the Marshall University, College of Health Professions,

School of Nursing PH room 421, 1 John Marshall Drive,
Huntington, WV, USA.
Corresponding author: Jeanne M. Widener, PhD, RN, CNE,
Marshall University, College of Health Professions, School of
Nursing PH room 421, 1 John Marshall Drive, Huntington, WV
25755-9510. Tel.: +1 304-696-2638. (E-mail: widenerj@
marshall.edu).
1062-0303/$36.00
Copyright 2015 by the Society for Vascular Nursing, Inc.
http://dx.doi.org/10.1016/j.jvn.2015.01.001

ment, and evaluation (GRADE) system used by the American

College of Chest Physicians provided a way to evaluate all the
studies related to venous topics that had been published in a
peer-reviewed journal in any language.1 High-quality evidence
from randomized, controlled trials received an A, whereas moderate quality evidence from RCTs received a B, and lesser evidence from observation or case studies received a C. Strong
recommendations were assigned a 1, indicating greater benefit
than harm from the practice. When weak evidence of benefit or
little difference in risk was found, a suggestion rather than
recommendation was assigned with a 2. Best practice is recommended when no research evidence is available or there is no
alternative to that practice which must be provided. The GRADE
scale then includes 1A, 1B, 1C, 2A, 2B, 2C, and best practice.

WOUND EVALUATION
Best practice is used as the evidence for clinical evaluation of
the leg by a specialist in vascular care. The vascular specialist is
to examine the leg for signs of venous ulcers and the cause of
these ulcers, and to provide specific documentation of the size
and location of any venous ulcer location. Outcome measures after interventions, either beneficial or complications, need to be
documented well to show the impact on venous leg ulcers as a
best practice also. 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 is also a best practice.1
The classification tools are known to nurses who specialize in
venous issues, but these scoring systems may be less well known
by other vascular nurses, so each will be explained briefly. CEAP
stands for Clinical, Etiologic, Anatomic, and Pathophysiologic
classifications. The CEAP measure developed in 1994 and
revised in 2004 is a static scale that is used extensively in clinical
and research settings to establish a baseline for venous disease.1,2
The basic CEAP (Table 1) is a less extensive version of the tool

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TABLE 1
BASIC REVISED CLINICAL, ETIOLOGIC,
ANATOMIC, AND PATHOPHYSIOLOGIC (CEAP)
CLASSIFICATION SYSTEM
CEAP

Definition

Clinical classification
C0
No visible or palpable signs of venous disease
C1
Telangiectases or reticular veins
C2
Varicose veins
C3
Edema
C4a
Pigmentation and/or eczema
C4b
Lipodermatosclerosis and/or atrophie blanche
C5
Healed venous ulcer
C6
Active venous ulcer
CS
Symptoms, including ache, pain, tightness,
skin irritation, heaviness, muscle cramps,
as well as other complaints attributable to
venous dysfunction
CA
Asymptomatic
Etiologic classification
Ec
Congenital
Ep
Primary
Es
Secondary (post thrombotic)
En
No venous etiology identified
Anatomic classification
As
Superficial veins
Ap
Perforator veins
Ad
Deep veins
An
No venous location identified
Pathophysiologic classification (basic)
Pr
Reflux
Po
Obstruction
Pr,o
Reflux and obstruction
No venous pathophysiology identifiable
Pn
Modified from Ekl
of B, Rutherford RB, Bergan JJ, et al. Revision of the
CEAP classification for chronic venous disorders: consensus statement.
J Vasc Surg 2004; 40:1248-52 with permission from Elsevier.

and more appropriate for clinical use.2 The clinical classification

of an active ulcer as C6 or CEAP-6 and a healed ulcer as C5 or
CEAP-5 are the designations most applicable to these guidelines,
although C4b indicates changes that may lead to venous ulcers
and some later guidelines address this also.
The Venous Clinical Severity Score (VCSS) was published in
2000 and revised in 2010 to provide a measure sensitive to
changes in venous disease following treatment (Table 2).3 The
assessments with this tool document initial status followed by
measurements at intervals to show change after different treat-

PAGE 61

ment options.4 The original and revised VCSS have been shown
to be valid and reliable with the same and different observers over
time. A VCSS score may range from 0 to 30, but a score of >8
should alert the nurse to observe closely for progression of the
current venous problem.1,5
Post-thrombotic syndrome may be associated with venous ulcers in patients who have had deep vein thrombosis. Several
scales are available, but the guidelines recommend the use of
the Villalta score6 (Table 37) with the CEAP for the most accurate diagnosis of post-thrombotic syndrome, especially with a
C5 or C6.1 Mild post-thrombotic syndrome has a score of 5-9,
moderate is 10-15, and severe is >15 points or the presence of
a C6 ulcer.7 Disease-specific quality of life measures are recommended, but no specific tool is named in the guidelines.1
Strong recommendations are available for some diagnostic
procedures. All patients with suspected venous ulceration are
strongly recommended (grade 1B) to undergo venous duplex ultrasonography of the entire venous system, an anklebrachial index measurement and (grade 1C) wound biopsies if the wound
has not healed after 4-6 weeks of treatment.
Suggestions for diagnostics include (grade 2B) venous plethysmography when ultrasonography has been inconclusive, and
(grade 2C) laboratory testing for thrombophilia when venous ulcers recur chronically or a history exists of recurrent thrombosis
and against routine culture of wounds that do not show specific
signs of infection. A grade 2C suggestion to only do extensive
other testing when iliac vein obstruction is suspected or surgical
interventions are planned, so the diagnostics are a necessity is a
cost-saving measure. Cost savings is a consideration in the suggestions made where the benefitrisk balance is equal.

WOUND THERAPY
Many direct wound therapies are available for management
of venous leg ulcers. This section addresses the wound bed,
infection control, primary dressings, and adjuvant therapy. The
underlying venous hypertension must be controlled for these
measures to work, so each is used concurrently with compression
or other venous interventions that will be addressed elsewhere.1

Wound bed
Cleansers and debridement are the main ways of preparing
the wound bed, but neither is effective without good nutrition
and careful documentation at each dressing change.1 Nurses
may be the ones doing these dressing changes, so remembering
to measure height, width, and depth and documenting those on
a regular basis is necessary. Cleansing the wound with a nonirritating solution with minimal trauma from chemical or mechanical sources initially and during each dressing change is suggested
(grade 2C). Debridement during the initial evaluation is recommended (grade 1B) to remove the burden of necrotic tissue,
excess bacteria, and nonviable cells. Further debridement is suggested (grade 2B) on a maintenance basis to improve appearance
and ability of the wound to heal, although the method of debridement is left to the providers choice.1
Several methods of debridement are used with varying
recommendation. A strong recommendation (grade 1B) for the
use of local or stronger anesthesia was given for surgical debridement. The use of eutectic mixture of local anesthetics cream was

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TABLE 2
REVISED VENOUS CLINICAL SEVERITY SCORE
Characteristic

None (0)

Pain or other discomfort (ie, aching, heaviness,

fatigue, soreness,
burning); presumes venous origin

Varicose veins
Varicose veins must be $3 mm in
diameter to qualify in the standing position

Skin pigmentation
Presumes venous origin; does not include
focal pigmentation over varicose veins or
pigmentation owing to other chronic
diseases
Inflammation
More than just recent pigmentation
(ie, erythema, cellulitis, venous
eczema, dermatitis)
Induration
Presumes venous origin of secondary
skin and subcutaneous changes
(ie, chronic edema with fibrosis,
hypodermitis). Includes white atrophy
and lipodermatosclerosis

None or
focal

Moderate (2)

Severe (3)

Occasional pain or other

discomfort (ie, not
restricting regular daily
activities)

Daily pain or other

discomfort (ie,
interfering with but
not preventing regular
daily activities)

Daily pain or discomfort

(ie, limits most regular
daily activities)

Few: scattered (ie, isolated

branch varicosities or
clusters); also includes
corona phlebectatica
(ankle flare)

Confined to calf or thigh

Involves calf and thigh

Limited to foot and ankle

area

Extends above ankle

but below knee

Extends to knee and above

Limited to perimalleolar
area

Diffuse over lower

third of calf

Wider distribution above

lower third of calf

Limited to perimalleolar
area

Diffuse over lower

third of calf

Wider distribution above

lower third of calf

Limited to perimalleolar
area

Diffuse over lower

third of calf

Wider distribution above

lower third of calf

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Venous edema
Presumes venous origin

Mild (1)

JUNE 2015

Full compliance: stockings

Wears stockings most days
Intermittent use of stockings
Not used

JOURNAL OF VASCULAR NURSING

www.jvascnurs.net
Reprinted from Vasquez MA, Rabe E, McLafferty RB, et al. Revision of the Venous Clinical Severity Score: venous outcomes consensus statement: special communication of the American Venous Forum Ad
Hoc Outcomes Working Group. J Vasc Surg 2010; 52:1387-96 with permission of Elsevier.

$3
Not healed for >1 y
>6 cm
1
<3 mo
<2 cm

Active ulcers (n)

Active ulcer duration (longest active)
Diameter of active ulcer size
(largest active)
Use of compression therapy

0
N/A
N/A

2
>3 mo but <1 y
2-6 cm

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reported from studies in the Cochrane Database to be effective at

reducing debridement pain.1 Standard or hydrosurgical debridement are recommended (grade 1B), but the guidelines suggest
against ultrasonic debridement (grade 2C). The guidelines stress
that surgical debridement is always superior to any other debridement method and should be used whenever possible over any
other alternative.1 Enzymatic (grade 2C) or biologic (larva, grade
2B) debridement are suggested only when surgical debridement
cannot be done owing to the lack of a trained clinician, excessive
pain in the wound in a nonsurgical candidate, or unstable comorbidities. Biological debridement with larva may be accepted
more readily when bio-bag containment of the larva is used.
Healing occurs more slowly when nonoperative debridement is
used.1 Vascular nurses may be responsible for applying the enzymatic or biological agents when these are used for debridement,
so careful review of those procedures and consistent documentation is necessary.

Infection control and primary dressings

Infection and bacterial control within the wound and surrounding tissue guidelines are conservative. The guidelines
recommend (grade 1B) the use of systemic gram-positive antibiotics in the treatment of cellulitis of the skin, subcutaneous tissue, or lymphatic system, because the most common source is
streptococci or staphylococci. Obvious infection in the venous
ulcer is also recommended (grade 1C) to be treated with oral
systemic antibiotics for a 2-week period and the type of antibiotic
guided by the wound culture and sensitivity report. A combination of debridement and systemic antibiotic is suggested (grade
2C) for highly infected wounds or those that contain lower levels
of virulent or resistant bacteria. The guidelines suggest against
the use of topical antibiotics (grade 2C) and antimicrobialcontaining dressing (grade 2A). Dressings applied topically to
the skin surface are suggested to be absorbent of exudate (alginates or foams) while protecting the periulcer skin (grade 2B),
but providing a moist, warm wound bed (grade 2C) under additional dressings. Skin lubricants and topical steroids (grade 2C)
are suggested for application to the periulcer skin, but the guidelines suggest against (grade 2C) anti-inflammatory therapies at
this time.1

Adjuvant therapy
Adjuvant wound therapy is recommended (grade 1B) for
wounds that have not healed after 46 weeks of other wound
therapy. The suggestion with the strongest evidence (grade 2A)
is for cellular therapy; cultured allogeneic skin replacements
that include the epidural and dermal layers of the skin are used
with compression therapy to increase the chances of healing
these venous leg ulcers. Split-thickness skin grafts are suggested
against as a primary therapy, but may be used with very large
venous ulcers in conjunction with compression therapy while
the wound decreases in size (grade 2B). The guidelines suggest
(grade 2C) compression therapy with wound bed control before
cellular therapy. Debridement of the wound bed before application of a bilayer graft and continued debridement as needed is
recommended (grade 1C). The guidelines recommend against
negative pressure therapy (grade 2C), electric stimulation (grade
2C) and ultrasound therapy (Grade 2B) on a routine basis.1

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TABLE 3
SUMMARY OF THE SCORING USED IN THE
VILLALTA SCALE
None Mild Moderate Severe
Symptoms
Pain
Cramps
Heaviness
Paresthesia
Pruritis
Signs
Pretibial edema
Skin induration
Hyperpigmentation
Redness
Venous ecrasia
Pain on calf
compression

0
0
0
0
0
0

1
1
1
1
1
1

2
2
2
2
2
2

3
3
3
3
3
3

0
0
0
0
0
0

1
1
1
1
1
1

2
2
2
2
2
2

3
3
3
3
3
3

Modified from Lattimer CR, Kldiki E, Assam M, Geroulakos G. Validation of the Villalta scale I assessing post-thrombotic syndrome using clinical, duplex, and hemodynamic comparators. J Vasc Surg: Venous Lymph
Dis 2014; 2(1):8-14 with permission from Elsevier.

COMPRESSION
Compression therapy comes in many different forms, but all
use the concept that pressure on the outside of the leg can counteract mechanically the venous hypertension and increase
venous blood return. Sustained compression can be obtained using several different types of single bandages, systems of bandages, or compression garments. Pneumatic compression
devices provide intermittent compression. Elastic bandage wraps
and elastic stockings alone can reduce edema, but they do not
counteract effectively venous hypertension as well as a stiff
bandage that will not expand with muscle contraction during
walking. Continuous compression can be provided using short
stretch textiles or multilayered bandages that may need to be
applied by trained staff or self applied short-stretch devices
with Velcro closures.1
Short-stretch textiles are used in graduated compression
stockings that provide a single layer of compression at a set
dose of compression when used alone. Compression stockings
combined with other dressing materials may become a multicomponent dressing with greater levels of compression. Four
different layers are used in 1 multicomponent dressing found
in the research reviewed for the guidelines, which applies overlapping layers of orthopedic wool, followed by crepe bandage,
elastic bandage, and an elastic cohesive outer layer (4LB).1
Describing all compression alternatives is beyond the scope of
this review; readers interested in more information about specific
compression therapies are referred to Up to Date (http://www.

JUNE 2015

uptodate.com/contents/compression-therapy-for-the-treatmentof-chronic-venous-insufficiency).
Current evidence does not differentiate between multiple
continuous compression techniques that are available for use
and conflicting evidence for 1 bandage system or another limits
the current level of evidence. The guidelines can strongly recommend (grade 1A) the use of compression with venous leg ulcers
(C6) as opposed to no compression. Reoccurrence of venous ulcers after they have healed (C5) is common, so the guidelines suggest the use of ongoing compression therapy (grade 2B).
Multicomponent compression bandages are suggested (grade
2B) over single-component bandages for the treatment of C6 unless the patient has severe arterial insufficiency. When the ankle
brachial index is <0.5 or the absolute ankle pressure is <60 mmHg,
the guidelines do not suggest the use of compression (grade 2C),
because the evidence has mixed results even with higher arterial
flow values.1 Arterial flow must be maintained for healing to occur
and compression pressures in the available garments and dressings vary from <20 to >50 mmHg, which may decrease flow to
the peripheral tissues by that amount of pressure.
Intermittent pneumatic compression is suggested (grade
2C) when sustained compression measures are ineffective or
cannot be used. Compression is valued highly in the guidelines
and is part of the standard therapy for any venous leg ulcer, no
matter what other therapy may be used.1 Many of the bandage
systems require special training that nurses receive before
applying the bandages. Clinics and other outpatient settings
are the likely location for the care that may take weeks to
months before healing is complete. Education for the patient
and family about maintenance of the dressing and timing of
dressing changes is provided by nurses in the outpatient or hospital settings. Careful application of compression and close
monitoring by nurses are needed when the patient has been
hospitalized for other reasons or changes in leg ulcer care
are made.

OPERATIVE OR ENDOVASCULAR MANAGEMENT

The guidelines stress that all noninvasive management options in the peripheral vessels need to be exhausted before evaluation for operative or endovascular management occurs.
Operative and endovascular management within the venous system have a goal of ulcer healing and prevention of ulcer reoccurrence. The guidelines and this summary are organized
anatomically: superficial to perforator disease to deep infrainguinal and iliocaval venous disease. Figure 1 shows an algorithm
published with the guidelines to show the least to the greatest
risk procedures.1 Procedures with equal benefit/risk ratios are
listed at the same level in the figure whether endovascular or
operative. A slight preference was expressed for the least invasive procedure initially at an equal level of disease.1 Some recommendations are made, but the lack of quality evidence
limits the guidelines to suggestions in most areas.

Superficial venous disease

Compression therapy is used as a standard of care for all patients receiving any further intervention operatively or endovascular in these guidelines; therefore, that point will not be repeated
with each recommendation or suggestion. A recommendation

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Figure 1. Proposed algorithm for operative and endovascular treatment of patients with venous leg ulcer based on involved anatomic venous
system and presence of venous reflux or obstruction. The riskbenefit ratio is weighed for those procedures with more risk (lower, moderate,
higher) considered later in the treatment when the benefit is similar. Rx endo = endovascular treatment. Reprinted from Journal of Vascular
Surgery, 60, Thomas F. ODonnell, Marc A. Passman, William A. Marston, William J. Ennis, Michael Dalsing, Robert L. Kistner, Fedor Lurie,
Peter K. Henke, Monika L. Gloviczki, Bo G. Eklof, Julianne Stoughton, Sesadri Raju, Cynthia K. Shortell, Joseph D. Raffetto, Hugo Partsch
et al, Management of venous leg ulcers: Clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum,
34S, 2014, with permission from Elsevier.

(grade 1B) is made for ablation of any incompetent superficial

veins that reflux into the area of a healed wound (C5) to prevent
recurrence and a suggestion (grade 2C) for the same ablation
when there is an active ulcer (C6) to aid healing. Ablation is suggested (grade 2C) for patients with skin changes that predispose
them to venous leg ulcers (C4b) before the ulcers develop. The
type of ablation is not specified, because the research supports
equal effectiveness for open ligation and stripping, radiofrequency, laser, and endovenous ablation. Several newer therapies
are under investigation, so no 1 therapy is suggested over others.
Some of these procedures can be done outpatient or in a surgeons office. The advantage of treating the patient in the outpatient setting may shift the riskbenefit balance in favor of those
outpatient procedures over time.1 Nurses may be responsible
for patient preparation, assisting during the procedure, postprocedure monitoring, assessment and care if hospitalized, and
teaching patient/families about home care.

Perforator venous reflux

Pathologic perforator veins (>3.5 mm in diameter and outward flow duration of >500 milliseconds) may occur alone or
in combination with superficial venous reflux. The guidelines
provide only suggestions (grade 2C) in this section that are all

combined with compression therapy. Ablation of both the pathologic perforator veins and superficial vein reflux is suggested
when both problems are present in patients with C6 ulcers.1 Subfascial endoscopic perforator vein surgery for perforator ablation
allowed concurrent treatment of superficial venous reflux in a
Dutch study, which found no significant difference in healing
(C6), but recurrent ulcers (C5 becomes C6) were more common
months later when both procedures were not completed at the
same time.8,9 The guidelines suggest ablation of the superficial
veins initially with the perforator vein ablation at the same
time or a later time to prevent ulcer formation in patients who
have not previously received ablation therapy when skin
changes (C4b) or a healed ulcer (C5) are associated with
pathologic perforator veins and superficial venous reflux to the
ulcer bed. When there is perforator vein pathology, but not
superficial vein involvement, the guidelines suggest ablation of
the perforator veins located beneath the active (C6) or healed
(C5) ulcer area. The least invasive therapy is recommended
(grade 1C) over open therapy when only the perforator veins
will be treated, because many percutaneous methods exist with
minimal risks and comparable benefits. Several methods are
listed, but none is favored over others at this time.1 Benefit
risk ratios may drive more of these procedures to be undertaken
in outpatient areas where nurses may be assisting with some

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aspect of the procedure or teaching the patient and family about

home care needs.

Infrainguinal, iliac, and interior vena cava problems

Treatment for deep vein obstruction or reflux occurs after the
superficial and perforator vein issues have been evaluated and
treated as needed. In this section, only the deep vein problems
are addressed in situations where skin changes (C4b), healed ulcers (C5), or active leg ulcer (C6) exist. Interventions are suggested only in addition to compression to encourage healing or
prevent reoccurrence of venous leg ulcers. Suggestions are at
grade 2C unless otherwise noted, because there is a lack of evidence. Endophlebectomy or autogenous venous bypass is suggested for infrainguinal deep venous obstruction. The
guidelines suggest against ligation of femoral or popliteal veins
unless collateral vessel flow is competent. Individual valve repair
is suggested when the valves are preserved and valve transposition or transplant when outflow is competent and anastomosis
sites are available anatomically. Autogenous valve substitution,
which uses venous tissue to construct a valve, is suggested
when no other alternative is possible and surgeons who have
done this procedure are available.1
The 1 recommendation (grade 1C) from the guidelines is the
use of initial percutaneous treatment with angioplasty and stenting when chronic occlusion or stenosis occurs in the inferior vena
cava or iliac veins. When endovascular treatment fails, open surgical bypass procedures are suggested specific to the anatomic
needs. An externally supported and expanded polytetrafluoroethylene graft is suggested to bypass a chronic occlusion or severe stenosis of the iliac or inferior vena cava. A saphenous
vein cross-pubic bypass (Palma procedure) is suggested for a unilateral occlusion or stenosis in the iliofemoral area above a
chronic nonhealing C6 ulcer. The guidelines suggest that temporary small (4-6 mm) arteriovenous fistulas may be necessary to
maintain patency in the bypass during healing and the fistulas
be closed at a different time or coiled to prevent added venous
hypertension burden in the lower venous system.1
Nursing may have varied involvement in the care of the patients undergoing these endovascular and operative procedures.
The changes in the patients limbs may not be dramatic after
these procedures, because the venous leg ulcers may still take
months to heal. Monitoring for complications from excessive
bleeding, thrombosis, and infection would be needed for these interventions post procedure.

Ancillary measures
The guidelines reviewed several ancillary measures,
including drug therapy, nutrition, physiotherapy, balneotherapy,
lymphatic therapy, and ultraviolet light therapy, to improve
healing in C6 ulcers or prevent recurrence for C5 ulcer areas.
The guidelines recommend (grade 1B) the use of 2 types of systemic drug in the treatment of large leg ulcers or long-standing
ulcer in combination with compression therapy. Studies of
several drugs were reviewed, but only pentoxifylline and
micronized purified flavonoid fraction (MPFF) were recommended.1 The 2 drugs are used worldwide, but MPFF is not
approved by the US Food and Drug Administration for use in
the United States and pentoxifylline use may be off-label in

JUNE 2015

the United States. Many other drugs are in investigation, but

intravenous route administration or low relative risk ratios
limited recommendation at this time.
A best practice recommendation is to assess for malnutrition
in patients with C6 ulcers and treat those specific deficiencies
with appropriate supplements. The deficiencies to assess are
low protein, vitamins (specifically A and E), carotene, and
zinc, but the vitamin and mineral deficiencies may be broader
in the elderly with poor appetite. Correcting deficiencies
improved healing, but general supplementation was not effective
in the studies reviewed.1 Supervised active exercise is suggested
to improve calf muscle pump function and reduce pain and
edema. Specific ankle exercises or biomechanical stimulation
can decrease venous pressure and edema. Individual or group exercise programs both contributed to lifestyle changes supported
by medical programs to show improvement in calf muscle
pump function and ankle mobility. Many approaches to support
the increase in activity were reviewed, but no 1 approach was
found more useful than others at improving healing of C6 ulcers,
increasing time to recurrence in C5 ulcers or increasing compliance with compression therapy.1
Balneotherapy (spa hydromassage with thermal waters) is
suggested (grade 2B) to reduce trophic skin changes and improve
quality of life in patients with advanced venous disease.1
Research has been done in European centers that specialize in
the treatment of chronic venous disease, but the benefits have
not included increased healing of C6 ulcers.10 The guidelines
suggest against either manual lymphatic drainage or the use of
ultraviolet light to treat C6 leg ulcers because there is minimal
evidence about the therapy and that did not support either suggested therapy as a way to improve ulcer healing.

CONCLUSION
The goal of this article was to summarize the guidelines that
address diagnosis and treatment recommendations published
jointly by the SVS and AVF, which may affect the nursing practice of vascular nurses. Specific sections included wound evaluation, therapies used on the wound bed itself, compression, and
operative or endovascular management. When the benefit
clearly outweighed the risks, a recommendation was provided
in the guidelines and the level of evidence noted. Suggestions
in the guidelines varied in research evidence strength, but addressed issues where there is not a clearly greater benefit than
risk for the difference in cost. Best practice guidelines were
also provided in areas where care is needed, but no clear evidence is available for care that is necessary. This article has provided a summary of the guidelines for the care of venous leg
ulcers published in the Journal of Vascular Surgery in
August 2014.

REFERENCES
1. ODonnel TF Jr, Passman MA, Marston WA, et al. Management of venous leg ulcers: clinical practice guidelines of the
Society for Vascular Surgery and the American Venous
Forum. J Vasc Surg 2014;60:3S-59S.

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2. Eklof B, Rutherford RB, Bergan JJ, et al. Revision of the

CEAP classification for chronic venous disorders: consensus
statement. J Vasc Surg 2004;40:1248-52.
3. Vasquez MA, Rabe E, McLafferty RB, et al. Revision of the
Venous Clinical Severity Score: venous outcomes consensus
statement: special communication of the American Venous
Forum Ad Hoc Outcomes Working Group. J Vasc Surg
2010;52:1387-96.
4. Passman MA, McLafferty RB, Lentz MF, et al. Validation of
Venous Clinical Severity Score (VCSS) with other venous
severity assessment tools from the American Venous Forum,
National Venous Screening Program. J Vasc Surg 2011;54(6
Suppl):2S-9S.
5. Jayaraj A, Meissner MH. A comparison of VillaltaPrandoni scale and Venous Clinical Severity Score in
the assessment of post thrombotic syndrome. Ann Vasc
Surg 2014;28:313-7.

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