From the Guidelines
Post-thrombotic syndrome (PTS) is a chronic complication that develops in approximately 20-50% of patients following deep vein thrombosis (DVT), characterized by chronic leg pain, swelling, skin changes, and in severe cases, venous ulcers, as a result of valve damage and persistent venous hypertension following DVT, which leads to chronic inflammation and tissue changes 1.
Definition and Pathophysiology
PTS may be characterized by physical signs in an affected limb such as edema, dilated superficial collateral veins, stasis dermatitis and/or ulceration, and functional consequences such as limitation in activities due to associated pain 1. The pathophysiology of PTS involves venous hypertension, which may result from persistent thrombotic veno-occlusion, venous valvular reflux due to damage from previous thrombosis, or other causes of impaired venous return, with inflammation contributing to venous valvular damage 1.
Management and Prevention
The primary management approach involves wearing graduated compression stockings (30-40 mmHg pressure) daily, put on first thing in the morning and worn throughout the day, with replacement every 6 months as they lose elasticity over time 1. For symptom relief, medications like diosmin-hesperidin (500 mg twice daily) or horse chestnut seed extract (300 mg twice daily) may help reduce swelling and discomfort. Patients should elevate their legs above heart level several times daily for 30 minutes and engage in regular exercise like walking to improve calf muscle pump function. For severe cases with venous ulcers, specialized wound care and sometimes surgical interventions like endovenous procedures may be necessary, with selection of patients for these procedures taking into account the surgical risk, clinical severity of PTS, specific venous anatomy, and expected life span 1.
Key Considerations
Prevention is crucial and involves appropriate anticoagulation therapy for DVT, early mobilization, and possibly early use of compression stockings after acute DVT diagnosis, with an estimated frequency of PTS following upper/lower extremity DVT in children being 26%, based on a systematic review involving approximately 20 eligible studies and nearly 1000 patients 1.
From the Research
Definition and Clinical Manifestations of Post-Thrombotic Syndrome (PTS)
- Post-thrombotic syndrome (PTS) is a frequent, potentially disabling complication of deep vein thrombosis (DVT) that reduces quality of life and is costly 2.
- Clinical manifestations of PTS include symptoms and signs such as leg pain and heaviness, edema, redness, telangiectasia, new varicose veins, hyperpigmentation, skin thickening, and in severe cases, leg ulcers 2.
Prevention of Post-Thrombotic Syndrome (PTS)
- The best way to prevent PTS is to prevent DVT with pharmacologic or mechanical thromboprophylaxis used in high-risk patients and settings 2.
- In patients whose DVT is treated with a vitamin K antagonist, subtherapeutic INRs should be avoided 2.
- The use of elastic compression stockings (ECS) to prevent PTS is still a topic of debate, with some studies suggesting a reduction in the incidence of PTS 3, while others found no significant difference 4, 5.
Treatment of Post-Thrombotic Syndrome (PTS)
- For patients with established PTS, prescribing 20-30 mm Hg knee-length ECS to be worn daily is suggested 2.
- If ineffective, a stronger pressure stocking can be tried, or intermittent compression devices or pneumatic compression sleeve units can be used in patients with moderate-to-severe PTS whose symptoms are inadequately controlled with ECS alone 2.
- A supervised exercise training program for 6 months or more is also reasonable for PTS patients who can tolerate it 2.
- Management of post-thrombotic ulcers should involve a multidisciplinary approach 2.
Compression Therapy for PTS
- Compression therapy, including elastic compression stockings and mechanical devices, has been studied as a treatment for stage I and II post-thrombotic syndrome, but the evidence is limited and inconclusive 6.
- Some studies suggest a beneficial effect of intermittent pneumatic compression units, but further research is needed to assess their long-term effectiveness 6.