Ulcer Management

**Compression as primary therapy:**

Compression remains the cornerstone of venous ulcer management. Multilayer compression bandaging or high-pressure stockings (targeting approximately 40 mmHg at the ankle) should be applied consistently. As with all compression therapy, the ankle-brachial index (ABI) must be checked first,first to assess for concomitant peripheral artery disease (PAD), with compression pressure reduced or withheld in patients with significant arterial disease.[@rutherford2018]disease [@rutherford2018, @svs2024]. Recent guidelines recommend that both ABI and toe-brachial index (TBI) be measured in patients with lower extremity ulcers to evaluate for PAD and determine the safety of compression therapy [@svs2024].

**Pharmacologic adjuncts:**

Pentoxifylline, a hemorrheologic agent, may accelerate ulcer healing when used as an adjunct to compression therapy, though the effect size is modest.[@rutherford2018]

**Early intervention:**

The EVRA (Early Venous Reflux Ablation) trial demonstrated that early endovenous ablation of superficial truncal reflux, combined with compression, significantly accelerates ulcer healing and reduces recurrence compared to compression alone. This has established early ablation as standard of care for C6 patients with superficial reflux [@esvs2015, @gohel2018].