**7. Conservative treatment of CVD**

The main goals of conservative treatment for CVD, used as an adjunctive treatment or in isolation, focus on both the symptoms and secondary changes of the disease, such as for instance, edema, skin and subcutaneous changes or ulcers [33], and the prevention of secondary complications, like venous thrombosis [114]. Usually, initial treatment of CVD involves a noninvasive conservative treatment to reduce symptoms and help prevent the development of secondary complications and the progression of the disease [66]. Complementary, or posteriorly, some interventional or surgical treatments can be undertaken [33, 66].

Behavioural education, like giving advices to raise the legs to minimize edema and reducing intra-abdominal pressure, about the right exercises, for using compressive stockings and proper care of the skin and wounds, together with pharmacological therapy, is the most common referred conservative treatments [33, 66]. The conservative pharmacological treatment with venoactive drugs may be indicated for patients with pain and edema and should be implemented in association with compression for healing venous ulcers [33]. If conservative treatment is unsuccessful or provides an unsatisfactory response, then further treatment, including surgery, should be considered based on anatomic and pathophysiological features [66].

Interventional treatments, like sclerotherapy, ablative therapy with endovenous radiofrequency and laser, endovascular therapy, are less invasive than surgery for treating CVD [66]. It has been recommended to use these techniques to treat superficial incompetence (endovenous thermal ablation, as laser and radiofrequency) and varicose veins (sclerotherapy) [33].

Surgical treatments are recommended in severe forms of CVD, like venous ulcers that did not heal after 6 months of treatment [66]. There are several surgical procedures described in the literature, like ligation, stripping and venous phlebectomy, subfascial endoscopic perforator surgery or valve reconstruction [66].

In CVD, compression, like that provided by stockings, is recommended as a primary treatment, except when patients are candidates for vein ablation, in which case compression is also suggested as an adjuvant treatment, particularly to prevent ulcer recurrence [33]. Compression therapy is recommended as a complement to surgery (like stripping), and to venoactive drug treatment, in order to control edema and pain, and to enhance venous ulcer healing [33].

The severity of the disease is related with the difficulty of the peripheral venous system to evacuate the venous blood from the periphery in the direction of the heart [33], resulting in venous stasis [33, 115]. Furthermore, it is assumed that there is a strict relation between blood flow velocity and secondary deep vein thrombosis [114]. The prevention of stasis is a main goal in CVD treatment and decisive in preventing venous complications and is frequently done through conservative approaches. Conservative CVD treatment might include intermittent pneumatic compression [116], compression stockings and bandages [77, 117, 118], and muscle pump activation using electrical muscle stimulation [77, 119], transcutaneous electrical nerve stimulation [119], or active and passive movements [103, 119]. In this regard, MLD maneuvers may be an alternative treatment to enhance venous flow [21–23]. Nevertheless, this intervention needs specialized professionals and could be an expensive health care treatment. Teaching caregivers or patients simple lymphatic drainage, despite the lower efficacy showed in the treatment of lymphedema, when compared with MLD applied by professionals [25], could be an alternative.

The important role played by the ankle range of motion and calf muscle strength in the efficacy of CMPF is now widely recognized [30, 36, 43, 45, 90]. Likewise, altered CMPF seems to play a key role in the physiopathology of CVD [30, 36, 43, 45]. Physical exercise is nowadays widely recommended for CVD management [90, 120]. In previously conducted randomized controlled trials, exercise training in patients with CVD [90] or with post-thrombotic syndrome [120] was shown to improve calf muscles' peak torque at slow (60º/s) and fast (120º/s) speeds [90], maximal heel rise repetitions [120], CMPF [90], and HRQL [120]. However, the role of physical exercise in ameliorating the measures of clinical severity of CVD or in improving few performance features, such as joint range of motion or work and power ability of ankle plantarflexors could not be clearly demonstrated [90, 120].
