Delphi Consensus on the Role of Venoactive Nutraceuticals in the Management of Chronic Venous Disease: A Position Statement of the Italian Society of Angiology and Vascular Medicine (SIAPAV)

Background: Chronic venous disease (CVD) is a prevalent condition associated with significant morbidity and impaired quality of life. Venoactive nutraceuticals are widely used as part of conservative management and are cited in major guidelines, yet recommendations remain heterogeneous and clinical practice varies substantially. This study aimed to establish expert consensus on the clinical use of these agents in CVD within the Italian vascular community. Methods: A three-round modified Delphi was conducted among 21 Italian vascular specialists (May–July 2025). Consensus was defined as ≥70% agreement. Statements addressed CEAP classification, symptom assessment, use and perceived effectiveness of individual agents, combination regimens, and topical formulations. Results: Consensus supported routine use of CEAP and its 2020 revision, the clinical distinction between CVD (C0–C2) and chronic venous insufficiency (CVI) (C3–C6), and systematic classification of patients as symptomatic or asymptomatic. Strong agreement endorsed the use of selected venoactive nutraceuticals across all CEAP classes and supported combination therapy as more effective than monotherapy. An oral fixed-dose combination of diosmin, ruscus, melilotus, Vitis vinifera, and horse chestnut extract, pre-selected as a test case to evaluate the plausibility of combining agents with complementary mechanisms, was considered a reasonable first-line conservative option. Topical preparations were endorsed across C1–C6, particularly for CVI and to reduce heaviness, reflecting their perceived value as safe adjuncts despite the limited availability of high-quality evidence. No consensus was reached for ruscus, horse chestnut, hydroxyethylrutosides, red vine leaf extract, anthocyanosides, or β-arbutin in monotherapy. The panel agreed on the need to update clinical guidelines to reflect emerging evidence on venoactive nutraceuticals. Conclusions: This Delphi provides structured expert consensus on the use of venoactive nutraceuticals in CVD. Combination therapy integrating multiple physiological effects is considered more effective than single agents. Further research is required to validate combination regimens and topical formulations and to determine their impact on patient-reported outcomes.