9. We recommend comprehensive venous duplex ultrasound examination of the lower extremity in all patients with suspected venous leg ulcer (Grade 1 , Level B).
10. Comprehensive venous duplex ultrasound evaluates for both venous obstruction/DVT and venous reflux is the preferred first-line diagnostic test for all patients with suspected VLU.
11. Most studies suggest criteria for valvular incompetence when valve closure time exceeds ≥ 1 second for femoral and popliteal veins and ≥0.5 second for great saphenous vein, small saphenous vein, tibial veins, deep femoral vein, and perforating veins.However, use of ≥0.5 second for all superficial and deep vein segments can significantly improve the reliability of reflux detection. Perforator vein is defined as pathologic when directional flow is from deep to superficial, valve closure time is ≥0.5 second, vein diameter exceeds 3.5 mm, and location of perforator is beneath healed or active VLU.