Relationship between changes in the deep venous system and the development of the postthrombotic syndrome after an acute episode of lower limb deep vein thrombosis: A one- to six-year follow-up

Abstract

This study investigated changes in the deep venous system and the development of the postthrombotic syndrome (PTS) after an episode of acute deep vein thrombosis (DVT). Methods: Seventy-eight patients (41 male patients, 37 female patients) with acute DVT in 83 legs (31 right, 42 left, five bilateral) underwent annual follow-up examinations for 1 to 6 years (median, 3 years) for symptoms and signs of the PTS. A venous duplex scan was performed at each visit to detect obstruction and reflux in the veins, both of which may contribute to the development of the PTS. DVT was primal, in 69 limbs and recurrent in 14 limbs. Results: When last examined 49 limbs were free of symptoms, and 34 had the PTS (23 edema only, 11 hyperpigmentation). Only two patients had ulcers during the follow-up period; both patients had the ulcers in areas of hyperpigmentation in limbs with recurrent DVT. The extent of disease was similar in limbs with the PTS (79% multisegment, 18% single segment) and those without the PTS (69% multisegment, 12% single segment). In limbs with the PTS the deep veins were normal in only one (3%), six (18%) showed reflux only, five (15%) obstruction only, and 22 had features of both obstruction and reflux (65%). In limbs without the PTS the deep veins showed no abnormality in nine (18%), reflux only in 17 (35%), obstruction only in six (12%), and reflux with obstruction in 17 (35%). In the 11 limbs with hyperpigmentation nine had obstruction and reflux noted, one had obstruction only, and one had reflux alone. Conclusions: After an episode of acute DVT 12% of the limbs returned to normal by duplex criteria. Although only 13% developed skin complications, 41% had features of the PTS. Limbs with the PTS had more than three times the odds of having combined reflux and obstruction than did limbs without the PTS (odds ratio -3.5, 0.95 confidence intervals = 1.4, 8.6). Continued study of these patients will determine the course of those limbs with venous abnormalities that have not yet developed symptoms and signs of the PTS.

CIRSE Standards of Practice Guidelines on Iliocaval Stenting

“…CVD has either a nonthrombotic (primary or idiopathic) or postthrombotic (secondary) cause. Either type can involve reflux, obstruction, or a combination of both [4,5]. The role of venous obstruction is increasingly recognized as a major cause of CVD, with obstructive lesions in the iliocaval segment being markedly more relevant than lesions at the levels of the crural and femoral veins [4][5][6][7][8].…”

Diagnosis and Treatment of Lower Extremity Deep Vein Thrombosis: Korean Practice Guidelines

“…The signs and symptoms of DVT are non-specific and may be associated with other lower extremity disorders, including lymphedema, PTS, superficial venous thrombosis, cellulitis, musculoskeletal trauma, and Baker's cysts. Among patients referred to the vascular laboratory for exclusion of DVT, only 12%-31% will have a positive ultrasound (US) study [10][11][12].The most common presenting symptoms have a wide range of reported sensitivities and specificities: calf pain, sensitivity 75%-91% and specificity 3%-87%; and calf swelling, sensitivity 35%-97% and specificity 8%-88% [13][14][15][16][17][18]. None of the signs or symptoms is sufficiently sensitive or specific, either alone or in combination, to accurately diagnose or exclude thrombosis [19].…”

Chronic Venous Insufficiency and Venous Ulceration

“…These studies report the occurrence of edema in about two thirds of patients, skin pigmentation in one third, and venous ulceration in about 4%. [20][21][22][23] Trophic skin changes tend to occur between 2 and 4 years after the diagnosis of DVT, with no further changes between 5 and 12 years. 21 In general, the absolute risk of trophic skin changes appears to be greatest with proximal thrombosis, as compared with distal thrombosis, and with deep, or deep and superficial thrombosis, as compared with superficial thrombosis.…”

“…21 In general, the absolute risk of trophic skin changes appears to be greatest with proximal thrombosis, as compared with distal thrombosis, and with deep, or deep and superficial thrombosis, as compared with superficial thrombosis. 20,22,[24][25][26][27][28] These studies have also correlated the severity of skin changes to the number of thrombosed venous segments, and the degree of venous reflux.…”

“…19,24,30 In addition, up to 40% of patients with DVT will develop signs of CVI in the opposite, uninvolved limb. 22 Other conditions that may be important in the development of CVI include previous leg injury or surgery, primary valve or venous wall degeneration, congenital absence of valves, and arteriovenous shunts. 11,12 …”