9: Infrainguinal Deep Venous Obstruction and Skin Changes at Risk for Venous Leg Ulcer (C4b), Healed (C5) or Active (C6) Venous Leg Ulcer

• In a patient with infrainguinal deep venous obstruction and skin changes at risk for venous leg ulcer (C4b), healed venous leg ulcer (C5), or active venous leg ulcer (C6), we suggest autogenous venous bypass or endophlebectomy in addition to standard compression therapy to aid in venous ulcer healing and to prevent recurrence (Grade 2, Level C).

10: Deep Venous Reflux With Skin Changes at Risk for Venous Leg Ulcer (C4b), Healed (C5) or Active (C6) Venous Leg Ulcer - Ligation

• In a patient with infrainguinal deep venous reflux and skin changes at risk for venous leg ulcer (C4b), healed venous leg ulcer (C5), or active venous leg ulcer (C6), we suggest against deep vein ligation of the femoral or popliteal veins as a routine treatment (Grade 2, Level C).

11: Deep Venous Reflux With Skin Changes at Risk for Venous Leg Ulcer (C4b), Healed (C5) or Active (C6) Venous Leg Ulcer - Primary Valve Repair

• In a patient with infrainguinal deep venous reflux and skin changes at risk for venous leg ulcer (C4b), healed venous leg ulcer (C5), or active venous leg ulcer (C6), we suggest individual valve repair for those who have axial reflux with structurally preserved deep venous valves in addition to standard compression therapy to aid in venous ulcer healing and to prevent recurrence (Grade 2, Level C).

12: Deep Venous Reflux With Skin Changes at Risk for Venous Leg Ulcer (C4b), Healed (C5) or Active (C6) Venous Leg Ulcer - Valve Transposition or Transplantation

• In a patient with infrainguinal deep venous reflux and skin changes at risk for venous leg ulcer (C4b), healed venous leg ulcer (C5), or active venous leg ulcer (C6), we suggest valve transposition or transplantation for those with absence of structurally preserved axial deep venous valves when competent outflow venous pathways are anatomically appropriate for surgical anastomosis in addition to standard compression therapy to aid in venous leg ulcer healing and to prevent recurrence (Grade 2, Level C).

13: Deep Venous Reflux With Skin Changes at Risk for Venous Leg Ulcer (C4b), Healed (C5) or Active (C6) Venous Leg Ulcer - Autogenous Valve Substitute

• In a patient with infrainguinal deep venous reflux and skin changes at risk for venous leg ulcer (C4b), healed venous leg ulcer (C5), or active venous leg ulcer (C6), we suggest consideration of autogenous valve substitutes by surgeons experienced in these techniques to facilitate ulcer healing and to prevent recurrence in those with no other option available in addition to standard compression therapy to aid in venous ulcer healing and to prevent recurrence (Grade 2, Level C).

14: Proximal Chronic Total Venous Occlusion/Severe Stenosis With Skin Changes at Risk for Venous Leg Ulcer (C4b), Healed (C5) or Active (C6) Venous Leg Ulcer - Endovascular Repair

• In a patient with inferior vena cava or iliac vein chronic total occlusion or severe stenosis, with or without lower extremity deep venous reflux disease, that is associated with skin changes at risk for venous leg ulcer (C4b), healed venous leg ulcer (C5), or active venous leg ulcer (C6), we recommend venous angioplasty and stent recanalization in addition to standard compression therapy to aid in venous ulcer healing and to prevent recurrence (Grade 1, Level C).

15: Proximal Chronic Venous Occlusion/Severe Stenosis (Bilateral) With Recalcitrant Venous Ulcer - Open Repair

• In a patient with inferior vena cava or iliac vein chronic occlusion or severe stenosis, with or without lower extremity deep venous reflux disease, that is associated with a recalcitrant venous leg ulcer and failed endovascular treatment, we suggest open surgical bypass with use of an externally supported expanded polytetrafluoroethylene graft in addition to standard compression therapy to aid in venous leg ulcer healing and to prevent recurrence (Grade 2, Level C).

16: Unilateral Iliofemoral Venous Occlusion/Severe Stenosis With Recalcitrant Venous Ulcer - Open Repair

• In a patient with unilateral iliofemoral venous occlusion/severe stenosis with recalcitrant venous leg ulcer for whom attempts at endovascular reconstruction have failed, we suggest open surgical bypass with use of saphenous vein as a cross-pubic bypass (Palma procedure) to aid in venous ulcer healing and to prevent recurrence. A synthetic graft is an alternative in the absence of autogenous tissue (Grade 2, Level C).

17: Proximal Chronic Total Venous Occlusion/Severe Stenosis (Bilateral or Unilateral) With Recalcitrant Venous Ulcer - Adjunctive Arteriovenous Fistula

• For those patients who would benefit from an open venous bypass, we suggest the addition of an adjunctive arteriovenous fistula (4-6 mm in size) as an adjunct to improve inflow into autologous or prosthetic crossover bypasses when the inflow is judged to be poor to aid in venous leg ulcer healing and to prevent recurrence (Grade 2, Level C).