Guidance for the prevention and treatment of the post-thrombotic syndrome

Abstract

The post-thrombotic syndrome (PTS) is a frequent, potentially disabling complication of deep vein thrombosis (DVT) that reduces quality of life and is costly. Clinical manifestations 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. The best way to prevent PTS is to prevent DVT with pharmacologic or mechanical thromboprophylaxis used in high risk patients and settings. In patients whose DVT is treated with a vitamin K antagonist, subtherapeutic INRs should be avoided. We do not suggest routine use of elastic compression stockings (ECS) after DVT to prevent PTS, but in patients with acute DVT-related leg swelling that is bothersome, a trial of ECS is reasonable. We suggest that selecting patients for catheter-directed thrombolytic techniques be done on a case-by-case basis, with a focus on patients with extensive thrombosis, recent symptoms onset, and low bleeding risk, who are seen at experienced hospital centers. For patients with established PTS, we suggest prescribing 20–30 mm Hg knee-length ECS to be worn daily. If ineffective, a stronger pressure stocking can be tried. We suggest that intermittent compression devices or pneumatic compression sleeve units be tried in patients with moderate-to-severe PTS whose symptoms are inadequately controlled with ECS alone. We suggest that a supervised exercise training program for 6 months or more is reasonable for PTS patients who can tolerate it. We suggest that management of post-thrombotic ulcers should involve a multidisciplinary approach. We briefly discuss upper extremity PTS and PTS in children.

Deep Vein Thrombosis Interventions in Cancer Patients

“…However, the risk of developing PTS does not appear to be influenced by the cause of DVT (unprovoked or secondary to time-limited reversible risk factor). 28 In the general population, PTS develops in approximately 20 to 50% of patients following DVT with significant adverse financial and QOL effects. 29 In fact, 2 years post-DVT, the development of PTS remained the primary determinant of health-related QOL scores.…”

Phase 3, single‐arm, multicenter study of dabigatran etexilate for secondary prevention of venous thromboembolism in children: Rationale and design

“…Further, although estimates of rates of PTS in children vary considerably,7, 9, 10, 11 it has been found to be associated with increased morbidity and cost 39. There have been far fewer studies on the natural history, treatment, and secondary prevention of VTE in children than in adults 1, 9, 40.…”

Incidence and interventions for post-thrombotic syndrome

“…Prompt clearance of thrombus burden in DVT decreases the risk of subsequent PTS, as it opens the vein, relieving venous outflow obstruction immediately, maintaining valvular function, and preventing venous hypertension. CDT or pharmacomechanical catheter directed thrombolysis (PCDT) has a decreased risk of systemic side effects (34). Current recommendations state that CDT and PCDT may be considered in a selected patient with acute (<14 days) symptomatic DVT, extensive proximal DVT with good functional capacity, >1 year life expectancy, and low expected bleeding risk (34).…”

“…CDT or pharmacomechanical catheter directed thrombolysis (PCDT) has a decreased risk of systemic side effects (34). Current recommendations state that CDT and PCDT may be considered in a selected patient with acute (<14 days) symptomatic DVT, extensive proximal DVT with good functional capacity, >1 year life expectancy, and low expected bleeding risk (34). Systemic anticoagulation should be used before and after CDT or PCDT.…”