Diagnosis and Treatment of Postthrombotic Syndrome

Abstract

After acute treatment of deep vein thrombosis, not only the risk but also associated side effects of postthrombotic syndrome (PTS) are often underestimated.

There are essentially two main types of PTS.

1. Obstructive type—no sufficient recanalization of the deep vein.

2. Refluctive type—sufficient recanalization of the deep vein, but insufficient venous valves in conjunction with venous reflux.

A statement regarding deep vein recanalization and venous valve function can be made at the earliest after 6 months.

PTS is often diagnosed without appropriate medical history. However, the assessment of the degree of recanalization and venous reflux is paramount to the medical prognosis. In our opinion, beside proximal thrombosis, sufficient recanalization combined with a strong venous reflux, especially in the popliteal vein, works as a powerful predictor for an unfavorable and fast progression of PTS and chronic venous insufficiency. Thus, the obstructive type is prognostically more favorable. For PTS in general, consistent compression therapy represents the first-line treatment option.

With concomitant varicosis, one should assess whether the varicose veins represent primary varicosis with reflux or secondary varicosis without reflux. Especially in the presence of venous ulcers, the elimination of concomitant primary varicosis leads to an improved prognosis. Moist wound treatment is considered to be the standard treatment for all wounds undergoing secondary healing. A standardized set of topical therapeutic agents also facilitates the treatment. In individual cases “ulcershaving” and mesh graft transplantation proved to be successful.

Keywords

postthrombotic syndrome - chronic venous insufficiency - leg ulcer - treatment - diagnosis

• References

• 1 Palacios FS, Rathbun SW. Medical treatment for postthrombotic syndrome. SeminInterventRadiol 2017; 34 (01) 61-67
• 2 Kahn SR. The post-thrombotic syndrome. Hematology (Am Soc Hematol Educ Program) 2016; 2016 (01) 413-418
• 3 Galanaud JP, Monreal M, Kahn SR. Epidemiology of the post-thrombotic syndrome. Thromb Res 2018; 164: 100-109
• 4 Hach-Wunderle V, Bauersachs R, Gerlach HE. , et al. Post-thrombotic syndrome 3 years after deep venous thrombosis in the Thrombosis and Pulmonary Embolism in Out-Patients (TULIPA) PLUS Registry. J Vasc Surg Venous LymphatDisord 2013; 1 (01) 5-12
• 5 Rabinovich A, Kahn SR. How to predict and diagnose postthrombotic syndrome. Pol Arch Med Wewn 2014; 124 (7–8): 410-416
• 6 Soosainathan A, Moore HM, Gohel MS, Davies AH. Scoring systems for the post-thrombotic syndrome. J Vasc Surg 2013; 57 (01) 254-261
• 7 Vedantham S, Goldhaber SZ, Julian JA. , et al; ATTRACT Trial Investigators. Pharmacomechanicalcatheter-directed thrombolysis for deep-vein thrombosis. N Engl J Med 2017; 377 (23) 2240-2252
• 8 Stain M, Schönauer V, Minar E. , et al. The post-thrombotic syndrome: risk factors and impact on the course of thrombotic disease. J ThrombHaemost 2005; 3 (12) 2671-2676
• 9 Rabe E, Pannier-Fischer F, Bromen K. , et al. Bonner Venenstudie der Deutschen Gesellschaft für Phlebologie. Phlebologie 2003; 32 (01) 1-14
• 10 Kahn SR, Shapiro S, Wells PS. , et al; SOX trial investigators. Compression stockings to prevent post-thrombotic syndrome: a randomised placebo-controlled trial. Lancet 2014; 383 (9920): 880-888
• 11 Rabinovich A, Ducruet T, Kahn SR. ; SOX Trial Investigators. Development of a clinical prediction model for the postthrombotic syndrome in a prospective cohort of patients with proximal deep vein thrombosis. J ThrombHaemost 2018; 16 (02) 262-270
• 12 Jalaie H, Schleimer K, Barbati ME. , et al. Interventional treatment of postthrombotic syndrome. Gefasschirurgie 2016; 21 (Suppl. 02) 37-44
• 13 Malkani RH, Karia R, Thadani S. A study of risk factors of chronic venous insufficiency and its association with features suggestive of preceding or present deep venous thrombosis. Indian J Dermatol 2019; 64 (05) 366-371
• 14 Heinen MM, van Achterberg T, op Reimer WS, van de Kerkhof PC, de Laat E. Venous leg ulcer patients: a review of the literature on lifestyle and pain-related interventions. J Clin Nurs 2004; 13 (03) 355-366
• 15 Williams KJ, Ayekoloye O, Moore HM, Davies AH. The calf muscle pump revisited. J Vasc Surg Venous LymphatDisord 2014; 2 (03) 329-334
• 16 Lee BB, Nicolaides AN, Myers K. , et al. Venous hemodynamic changes in lower limb venous disease: the UIP consensus according to scientific evidence. IntAngiol 2016; 35 (03) 236-352
• 17 Azirar S, Appelen D, Prins MH, Neumann MH, de Feiter AN, Kolbach DN. Compression therapy for treating post-thrombotic syndrome. Cochrane Database Syst Rev 2019; 9: CD004177
• 18 Prandoni P, Lensing AW, Prins MH. , et al. Below-knee elastic compression stockings to prevent the post-thrombotic syndrome: a randomized, controlled trial. Ann Intern Med 2004; 141 (04) 249-256
• 19 Blecken SR, Villavicencio JL, Kao TC. Comparison of elastic versus nonelastic compression in bilateral venous ulcers: a randomized trial. J Vasc Surg 2005; 42 (06) 1150-1155
• 20 Jünger M, Wollina U, Kohnen R, Rabe E. Efficacy and tolerability of an ulcer compression stocking for therapy of chronic venous ulcer compared with a below-knee compression bandage: results from a prospective, randomized, multicentre trial. Curr Med Res Opin 2004; 20 (10) 1613-1623
• 21 Gohel MS, Barwell JR, Taylor M. , et al. Long term results of compression therapy alone versus compression plus surgery in chronic venous ulceration (ESCHAR): randomised controlled trial. BMJ 2007; 335 (7610): 83
• 22 Barwell JR, Davies CE, Deacon J. , et al. Comparison of surgery and compression with compression alone in chronic venous ulceration (ESCHAR study): randomised controlled trial. Lancet 2004; 363 (9424): 1854-1859
• 23 Metzger S. Clinical and financial advantages of moist wound management. Home Healthc Nurse 2004; 22 (09) 586-590
• 24 Jones J. Winter's concept of moist wound healing: a review of the evidence and impact on clinical practice. J Wound Care 2005; 14 (06) 273-276
• 25 Meaume S, Truchetet F, Cambazard F. , et al; CHALLENGE Study Group. A randomized, controlled, double-blind prospective trial with a Lipido-Colloid Technology-Nano-OligoSaccharide Factor wound dressing in the local management of venous leg ulcers. Wound Repair Regen 2012; 20 (04) 500-511
• 26 Sigal ML, Addala A, Maillard H. , et al. Evaluation of TLC-NOSF dressing with poly-absorbent fibres in exuding leg ulcers: two multicentric, single-arm, prospective, open-label clinical trials. J Wound Care 2019; 28 (03) 164-175