General/Conservative

in Chronic Venous Insufficiency and Varicose Veins

Applied

Type

Addition

Confidence

90%

Created

Mar 19, 2026

Evidence

1 source

Rationale

The integration of the 2025 ACC Scientific Statement is critical for the 'Contraindications and precautions' section. In patients with diabetes, ABI can be falsely elevated due to arterial calcification; therefore, the guideline emphasizes the use of TBI for accurate arterial assessment. This addition ensures patient safety when prescribing compression therapy in a high-risk population.

Evidence

Das SR et al. Management of Peripheral Artery Disease in Adults With Diabetes: 2025 ACC Scientific Statement: A Report of the American College of Cardiology. J Am Coll Cardiol. 2025. PMID: 41405527.
Verified source
PubMedDOI

Content Changes

<!-- type: treatment -->

**Compression therapy dosing:**

Compression stockings should be prescribed based on disease severity:
* **C2–C3 (symptomatic varicose veins/edema):** 20–30 mmHg
* **C4 (skin changes):** 30–40 mmHg
* **C5–C6 (ulcers):** 30–40 mmHg, with higher pressures (~40 mmHg at ankle) during active ulceration[@rutherford2018]

Donning aids (stocking applicators, glides) significantly improve adherence, particularly in elderly patients or those with limited mobility.[@rutherford2018]

**Contraindications and precautions:**

Arterial disease must be screened before prescribing compression. Check ankle-brachial index (ABI)[@aboyans2012](ABI) or toe-brachial index (TBI) in patients with diabetes or non-compressible vessels [@aboyans2012, @acc2025] (see [[Diagnostics in Vascular Surgery|Ch. 3]] for technique) or [[Peripheral Artery Disease|Ch. 10]] for interpretation:
* **ABI <0.5:** avoid compression or use very low pressure (<15 mmHg)
* **ABI 0.5–0.8:** modified compression (20–25 mmHg) with close monitoring
* **ABI >0.8:** standard compression safe[@rutherford2018]

**Adjunctive conservative measures:**

Patients should be counseled on exercise (walking improves calf pump function), weight reduction (reduces venous pressure), and leg elevation (facilitates venous return). Venoactive drugs such as micronized purified flavonoid fraction (MPFF) or horse chestnut extract may reduce symptoms but do not replace compression therapy [@esvs2015, @bergan2006].
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