Suspected CVI
Leg symptoms suggestive of venous disease
All Pathways
Vascular SurgeryManagement
Chronic Venous Insufficiency Management (SVS/AVF 2022)
Chronic Venous Insufficiency Management (SVS/AVF 2022): Suspected CVI → Clinical Assessment → CEAP Classification → Duplex Ultrasound → Disease Severity.
Pathway Overview
17 steps
Algorithm Steps
17 total
01Start 02Action Clinical Assessment
History and examination
- Symptoms: heaviness, aching, swelling, cramps
- Worse with standing, better with elevation
- History of DVT (post-thrombotic syndrome)
- Examine: varicosities, edema, skin changes
- Check pulses - rule out PAD
03Action CEAP Classification
Standardized clinical staging
- C0: No visible venous disease
- C1: Telangiectasias/reticular veins
- C2: Varicose veins >3mm
- C3: Edema
- C4a: Pigmentation/eczema; C4b: Lipodermatosclerosis
- C5: Healed ulcer; C6: Active ulcer
04Action Duplex Ultrasound
Essential for treatment planning
- Map superficial system (GSV, SSV, AASV)
- Reflux: >0.5s for superficial, >1.0s for deep
- Assess deep system patency
- Identify incompetent perforators (>3.5mm, >0.5s)
- Rule out DVT/obstruction
05Decision Disease Severity
Based on CEAP and symptoms
06Action Mild CVI (C1-C2)
Cosmetic concerns, minimal symptoms
- Compression stockings 15-20 mmHg
- Lifestyle modification (exercise, elevation)
- Sclerotherapy for telangiectasias
- Phlebectomy for isolated varicosities
- Reassess if symptoms worsen
07Action Conservative Management Trial
3 months before intervention
- Compression therapy daily
- Leg elevation when possible
- Regular walking exercise
- Weight management
- Document response to therapy
08Decision Saphenous Reflux?
GSV/SSV involvement
09Action Endovenous Ablation
First-line for saphenous reflux
- Thermal: RFA or EVLA (equivalent outcomes)
- Non-thermal: cyanoacrylate, MOCA
- Tumescent anesthesia for thermal
- Treat from SFJ/SPJ to point of competence
- Combined with phlebectomies if needed
10Action Post-Procedure Follow-up
Surveillance and ongoing management
- Duplex at 1-4 weeks post-ablation
- Compression for 1-2 weeks
- Check for DVT (rare but possible)
- Assess symptom improvement
- Long-term compression if deep disease
11Outcome Symptoms Improved
Annual clinical follow-up; PRN compression
12Outcome Recurrence
Repeat duplex; treat new reflux sources; 15-20% at 5 years
13Action Deep Venous Disease
Post-thrombotic syndrome or obstruction
- Consider if superficial treatment fails
- Iliac vein stenting for obstruction
- IVUS assessment recommended
- Anticoagulation may be ongoing
- Specialized venous center referral
- Path rejoins step 10Shared downstream outcome
14Action Perforator Treatment
If significant incompetence
- Pathologic: >3.5mm, reflux >0.5s
- SEPS or percutaneous ablation
- Consider in C5-C6 disease
- After saphenous treatment fails
- Particularly paratibial perforators
- Path rejoins step 10Shared downstream outcome
15Action Moderate CVI (C3-C4)
Symptomatic with skin changes
- Compression stockings 20-30 mmHg
- Treat underlying saphenous reflux
- Endovenous ablation preferred
- Address incompetent perforators
- Skin care for dermatitis/LDS
- Path rejoins step 08Shared downstream outcome
16Action Severe CVI (C5-C6)
Healed or active venous ulcer
- Compression 30-40 mmHg (multi-layer)
- Wound care for active ulcers
- MUST treat superficial reflux
- Consider perforator ablation
- Deep venous intervention if indicated
17Action Venous Ulcer Management
Multimodal approach
- Multi-layer compression bandaging
- Wound debridement as needed
- Moist wound healing environment
- Treat infection if present
- Early superficial ablation accelerates healing
- Path rejoins step 08Shared downstream outcome
Guideline Source
SVS/AVF Clinical Practice Guidelines on Management of Varicose Veins and Chronic Venous Disease
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- CEAP classification is descriptive, not prescriptive
- Compression compliance varies significantly
- May not address mixed arterial-venous disease
- Recurrence rates 15-20% at 5 years regardless of treatment
- Does not cover acute DVT management (separate algorithm)
Contraindicated Populations
Severe PAD (ABI <0.5) - compression contraindicated
Applicable Regions
USEUGlobal
EU: ESVS guidelines similar approach
US: SVS/AVF 2022 is current standard
Version 1Next review: 2027-01-01
Next steps
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Related Resources
Frequently Asked Questions
What is the Chronic Venous Insufficiency Management (SVS/AVF 2022)?
The Chronic Venous Insufficiency Management (SVS/AVF 2022) is a management clinical algorithm for Vascular Surgery. It provides a structured decision tree to guide clinical decision-making, based on SVS/AVF Clinical Practice Guidelines on Management of Varicose Veins and Chronic Venous Disease.
What guideline is the Chronic Venous Insufficiency Management (SVS/AVF 2022) based on?
This algorithm is based on SVS/AVF Clinical Practice Guidelines on Management of Varicose Veins and Chronic Venous Disease (DOI: 10.1016/j.jvs.2021.12.057).
What are the limitations of the Chronic Venous Insufficiency Management (SVS/AVF 2022)?
Known limitations include: CEAP classification is descriptive, not prescriptive; Compression compliance varies significantly; May not address mixed arterial-venous disease; Recurrence rates 15-20% at 5 years regardless of treatment; Does not cover acute DVT management (separate algorithm). Individual patient factors may require deviation from these recommendations.
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