Prevention of the Postthrombotic Syndrome with Anticoagulation: A Narrative Review

Abstract

The post thrombotic syndrome (PTS) is chronic venous insufficiency secondary to a prior deep vein thrombosis (DVT). It is the most common complication of VTE and, while not fatal, it can lead to chronic, unremitting symptoms as well as societal and economic consequences. The cornerstone of PTS treatment lies in its prevention after DVT. Specific PTS preventative measures include the use of elastic compression stockings (ECS) and pharmacomechanical catheter directed thrombolysis (PCDT). However, the efficacy of these treatments has been questioned by large RCTs. So far, anticoagulation, primarily prescribed to prevent DVT extension and recurrence, appears to be the only unquestionably effective treatment for the prevention of PTS. In this literature review we present pathophysiological, biological, radiological and clinical data supporting the efficacy of anticoagulants to prevent PTS and the possible differential efficacy among available classes of anticoagulants (vitamin K antagonists (VKA), low molecular weight heparins (LMWHs) and direct oral anticoagulants (DOACs)). Data suggest that LMWHs and DOACs are superior to VKAs, but no head-to-head comparison is available between DOACs and LMWHs. Owing to their potentially greater anti-inflammatory properties, LMWHs could be superior to DOACs. This finding may be of interest particularly in patients with extensive DVT at high risk of moderate to severe PTS, but needs to be confirmed by a dedicated RCT.

A Systematic Review and Bayesian Network Meta-Analysis on the Effect of Different Anticoagulants on the Prophylaxis of Post-Thrombotic Syndrome after Deep Venous Thrombosis

“…The TFPI further inhibits the release of P-selectin and chemokines. Thus, the proliferation of lymphocytes and fibroblast endothelial proliferation are also blocked [52]. In summation, an elevated inflammatory marker indicated subsequent PTS and an anticoagulant with significant anti-inflammatory quality could be beneficial during the preliminary months of treatments.…”

Current challenges in the prevention and management of post-thrombotic syndrome—towards improved prevention

“…Effective anticoagulation is one of the most effective strategies to prevent PTS, through early thrombus resolution by preventing thrombus propagation, and therefore reducing valve damage and residual vein obstruction, two of the major causes of PTS [ 54 ]. However, the duration of anticoagulation to treat DVT is not associated with improved clinical outcome, which was demonstrated in the ExACT randomised controlled trial (RCT) [ 55 ].…”

New perspectives for prevention of the post-thrombotic syndrome

“…28 By converse, the use of lowmolecular-weight heparin (LMWH) as a standalone therapy in place of VKAs is associated with a lower risk of PTS, most likely because of its strong anti-inflammatory properties coupled with a more stable anticoagulant effect. 29,30 A cohort study addressing value of an initial 3-4 week period of LMWH therapy before shifting to conventional DOAC treatment in patients reputed at a higher risk of PTS is currently ongoing. 30 The DOACs have now become commercially available worldwide.…”

“…29,30 A cohort study addressing value of an initial 3-4 week period of LMWH therapy before shifting to conventional DOAC treatment in patients reputed at a higher risk of PTS is currently ongoing. 30 The DOACs have now become commercially available worldwide. Because of their predictable pharmacokinetics, they can be used in fixed dose, without laboratory monitoring, and result in a much more stable anticoagulation than that induced by VKAs.…”