Evidence-Based Venous & Lymphatic Care

At Indiana Vein & Lymphatic, we base our diagnostic and treatment protocols on evidence-based research. Our team works diligently to follow the latest articles and developments so that we can achieve the best possible results for our patients.

This page is intended for referring physicians and curious patients interested in the pivotal articles that inform our diagnosis and treatment plans.

Chronic Venous Disease Classification and Guidelines

2020 CEAP Update (J Vasc Surg Venous Lymphat Disord 2020;8:505-525)

This article updates the CEAP chronic venous disease (CVD) classification to preserve continuity with prior versions while adding refinements that better reflect the current understanding of CVD.

Key changes include:

• Introducing corona phlebectatica as a subclass C4c.
• Adding the modifier “r” for recurrent varicose veins and venous ulcers.
• Using standard anatomic abbreviations instead of numeric vein codes.

CEAP 2020 – Practical Application, Corona Phlebectatica and Recurrence

This interview helps explain how to apply the updated CEAP 2020 scheme in daily practice, emphasizing consistent documentation and communication across providers.

It also highlights the reclassification of corona phlebectatica into the C4 spectrum and clarifies coding for recurrent varicose veins after both open and endovenous interventions. This will improve reporting and outcome comparisons.

Systemic Review for SVS, AVF, AVLS Varicose Vein Guidelines

This review synthesizes contemporary evidence on duplex ultrasound and interventional options for varicose veins to underpin the SVS, AVF, and AVLS guideline recommendations.

It confirms duplex ultrasound as the primary imaging test, shows high closure durability for endovenous thermal ablation, and contrasts quality of life and recurrence outcomes between thermal, nonthermal, and foam techniques.

2022 SVS, AVF, AVLS Guidelines Part I – Duplex and Truncal Reflux

This article is a collaboration between the Society for Vascular Surgery, American Venous Forum, and American Vein and Lymphatic Society to update the 2011 SVS and AVF clinical practice guidelines. It provides evidence-based recommendations for evaluation of superficial venous disease and treatment of superficial truncal reflux in symptomatic lower-extremity varicose veins.

Part I stresses standardized duplex scanning protocols and generally favors endovenous ablation over surgical stripping for appropriate patients, while individualizing modality choice based on anatomy, expertise and patient preference.

2023 SVS, AVF, AVLS Guidelines Part II – Compression, Tributaries, SVT, Complications

Part II extends the varicose vein guidelines to cover compression therapy, medications and supplements, treatment of tributary veins, and management of superficial vein thrombosis and post-procedural thrombotic events.

It also addresses management of bleeding varicose veins and superficial venous aneurysms, consolidating all recommendations and best-practice statements for CEAP C2 disease into a single reference.

Lipedema and Lymphedema – Standards, Mechanisms, and Therapy

Standard of Care for Lipedema in the United States

This article offers consensus-based guidance on lipedema pathophysiology, recognition, and management, distinguishing it from obesity and lymphedema.

The standard of care recommends comprehensive conservative therapy including:

• Nutrition
• Exercise
• Manual therapy
• Compression
• Pneumatic pumps

It also outlines indications and perioperative principles for lipedema-directed surgery.

Physical Therapy in Women with Early Stage Lipedema

This proof-of-principle study shows that a 6-week multimodal physical therapy program (manual therapy, compression, exercise, and education) in women with early-stage lipedema leads to clinically meaningful reductions in leg pain and functional limitations.

MRI evidence of decreased skin and subcutaneous tissue sodium supports a reduction in tissue inflammation, suggesting that structured conservative therapy can improve both symptoms and objective tissue characteristics in early lipedema.

Lipedema: Progress, Challenges, and the Road Ahead

This comprehensive systemic review assesses the current understanding of lipedema pathophysiology and treatment options. It emphasizes multidisciplinary, research-informed care that combines conservative therapies (CDT, compression, exercise, manual therapy) with liposuction for advanced cases is essential. It also stresses the need for more research to improve diagnostic accuracy and inform standardized, evidence-based care.

Adipose Tissue Biology and Effect of Weight Loss in Women with Lipedema

This article demonstrates that lipedema adipose tissue is characterized by increased inflammation and fibrogenesis with reduced lymphatic/angiogenesis-related expression.

It also demonstrates that moderate weight loss improves metabolic function and decreases lower-body adipose tissue mass without changing inflammation markers, supporting individualized conservative management approaches.

AVF, AVLS, SVM Lymphedema Expert Consensus

This article summarizes expert consensus on risk factors, diagnostic workup, and treatment principles for lymphedema and phlebolymphedema.

The document underscores the high variability in current care, advocates systemic clinical and imaging evaluation, and identifies priority areas for future evidence-based lymphedema guidelines.

Diagnostic Approach to Lower Limb Edema

This article proposes a practical diagnostic algorithm for patients with leg swelling that integrates history, examination, and targeted testing.

The authors emphasize differentiating venous, lymphatic, an systemic causes, using duplex ultrasound as a cornerstone investigation and reserving specialized lymphatic imaging for selected cases.

Clinical Characteristics of Lower Extremity Lymphedema in 440 Patients

This study found in a large cohort, chronic venous insufficiency-related phlebolymphedema emerged as the most common cause of lower-extremity lymphedema rather than cancer.

The authors highlight typical features:

• Predominantly women
• Bilateral, often left-dominant swelling
• Frequent cellulitis
• High rates of morbid obesity and multifactorial etiologies

Degradation of Lymphatic Anatomy and Function in Early Venous Insufficiency

This study shows that even early venous insufficiency is associated with structural and functional impairment of the lymphatic system.

It supports the concept of a venolymphatic continuum, where increased venous pressure and inflammation progressively damage lymphatic vessels, predisposing to phlebolymphedema.

Lymphedema-Associated Comorbidities and Treatment Gap

This paper evaluates real-world lymphedema populations and documents high burdens of obesity, venous disease, cellulitis, and impaired mobility alongside underuse of guideline-concordant therapy.

It emphasizes a substantial treatment gap, with many patients lacking access to compression, specialized therapy, or advanced devices despite marked quality-of-life impact.

Patient-Centered Outcomes of a Lymphedema Pump (AVS 2024)

This article assess outcomes of an advanced pneumatic compression device prescribed for patients with symptomatic lower-extremity edema, including lymphedema and phlebolymphedema.

Use of the pump was associated with improvements in limb symptoms and function and high patient satisfaction, supporting its role as part of comprehensive home-based management.

QoL Changes with At-Home APCD (J Vasc Surg 2018)

This study found that in patients with lower-extremity lymphedema, home use of an advanced pneumatic compression device significantly improved limb volume, lymphedema severity, and health-related quality of life.

It also reported reductions in cellulitis episodes and health care utilization, suggesting both clinical and economic benefits.

Longitudinal APCD Outcomes in Lower-Extremity Lymphedema (JVS:VL 2024)

This article demonstrated that long-term follow-up of patients using at-home advanced pneumatic compression therapy showed sustained quality-of-life gains and stable or improved limb measurements.

It reinforces the value of ongoing device use in chronic lymphedema and phlebolymphedema and supports its inclusion in long-term management plans.

GOG 244 – LeG Study: Lymphedema After Gynecologic Cancer

This multicenter study in gynecologic cancer survivors documents the profound impact of lower-extremity lymphedema on physical functioning, body image, psychological well-being, and overall quality of life.

Findings highlight the need for early recognition, routine screening, and proactive management of lymphedema in oncology survivorship care.

Venoactive Drugs and Varicose Vein

The Role of Venoactive Compounds in Chronic Venous Disease

This article reviews the pharmacology and clinical data for venoactive compounds, showing that they improve venous symptoms, reduce edema, and may support ulcer healing in chronic venous disease.

The authors position venoactive drugs as adjuncts to compression and procedural therapy rather than stand-alone treatments. They also highlight where evidence is strongest, such as micronized purified flavonoid fraction and Diosmin.

Early Endovenous Ablation in Venous Ulceration (EVRA Trial)

This randomized trial found that, in patients with active venous leg ulcers, adding early endovenous ablation of superficial reflux to compression significantly shortened time to healing compared with deferred ablation.

Early intervention also increased ulcer-free days over the first year, supporting prompt treatment of reflux once adequate compression has been initiated.

Efficacy of UGFS in Venous Leg Ulcer Healing

This multicenter randomized trial demonstrated that treating the distal refluxing venous network around venous leg ulcers with ultrasound-guided foam sclerotherapy (UGFS) plus standard care accelerates healing compared with standard care alone.

UGFS reduced time to complete healing and increased the proportion of ulcers healed by three months without compromising safety.

UGFS Safety and Efficacy for Superficial Venous Reflux

This large prospective database analysis showed that UGFS is a safe and durable treatment for superficial venous reflux across CEAP C2-C6 disease.

The study reported high anatomic closure and symptom improvement with low serious complication rates, supporting UGFS as a minimally invasive alternative to surgery or thermal ablation.

UGFS of Saphenous Trunks – 5 Year Outcomes

This multicenter study of UGFS to the saphenous trunks found low five-year recurrence rates and sustained improvement in quality of life in patients with chronic venous disease.

The results support UGFS as an effective long-term option for truncal reflux when performed with standardized protocols and appropriate follow-up.

UGFS for Superficial Venous Insufficiency of the Lower Extremity

This article reviewed prospective data and confirmed that UGFS is safe and effective for managing superficial venous insufficiency of the lower extremity, with significant symptom relief and improved clinical severity scores.

The authors emphasize careful duplex-guided technique and patient selection to maximize efficacy while minimizing thrombotic complications.

Proximal Tumescence During PEM Treatment of Saphenous Veins

This single-center study shows that adding a small volume of proximal tumescence during polidocanol endovenous microfoam (PEM) ablation safely achieves high closure rates in larger saphenous veins.

Proximal tumescence is associated with reduced microfoam volume requirements and maintains low rates of ablation-related thrombus extension, supporting this technique as a useful adjunct in PEM treatment protocols.

Periprocedural Anticoagulation and Thromboprophylaxis

Pharmacologic Thromboprophylaxis for Endovenous Varicose Vein Interventions

This systemic review and meta-analysis found that adding pharmacological thromboprophylaxis to mechanical measures for endovenous varicose vein procedures significantly reduces deep vein thrombosis risk.

The authors suggest routine consideration of anticoagulation after endovenous interventions, while calling for better risk-stratification tools and randomized data to refine patient selection.

DOACs with Endovenous RFA and EVLA

This study found observational data indicates that continuing direct oral anticoagulants in patients undergoing endovenous radiofrequency or laser ablation does not increase major bleeding or thrombotic complications. It supports the procedural safety of DOACs in this setting and suggests that routine interruption may not be necessary for many patients.

Antithrombotic Strategies After Polidocanol Microfoam (Varithena)

This prospective randomized trial compared different post-procedure antithrombotic regimens following great saphenous vein ablation with polidocanol endovenous microfoam.

The Results inform balancing thrombotic risk and bleeding, helping clinicians select practical antithrombotic strategies after foam-based truncal ablation.