Tag Archives: DVT

Diagnosis & Treatment of Post Thrombotic Syndrome (PTS)

Incidence and Prevalence of PTS

Deep Vein Thrombosis (DVT) affects 1 to 3 of 1000 people in the general population annually (1,2)Between 20% to 50% of patients with DVT develop post thrombotic syndrome (PTS)(3-8). PTS usually develops within a few months to a few years after DVT. Incidence of PTS continues to increase, even 10 to 20 years after DVT diagnosis and up to 10% of patients develop severe PTS, which may include venous ulcers (9-10).

Signs and symptoms

Post-thrombotic syndrome symptoms and signs include swelling, heaviness, fatigue, itch, pain or cramps and also skin discolouration (pigmentation, redness, eczema) and skin breakdown (ulcers). Symptoms usually get worse at the end of the day or after standing, and improve with rest or limb elevation.

Post Thrombotic Syndrome

Pathophysiology of PTS

It is believed that that major trigger is venous hypertension(high pressure in the venous not arterial system). Normally, when an individual isat rest in the supine position, venous pressure is low. When a personstands up and remain motionless, venous pressure is highest. While an individual is walking, venous pressure is reduces asblood is ejected by contraction of the calf muscles. Well working venous valves then help out to keep blood moving towards the hart. Any damage to the venous valves impedes venous return.This leads to venous hypertension. Any obstruction in the venous system again works against the flow and increases venous pressure in the leg and foot. Combination of reflux and obstruction causes usually the worst symptoms 11).

Diagnosis

Clinical assessment, venous ultrasound scan and CT or MRI are usually necessary to correctly diagnose the problem.

In selected patients in whom iliac vein obstruction is suspected on also invasive imagining is needed and includes contrast venography with or without intravascular ultrasound (IVUS). In those cases where obstruction or compression was verified an endovascular techniques can be used at the same time to correct the problem.

Treatment

Compression should be used to treat all patients with venous ulcers. A number of reports describe the technical success rate and short-term outcome after percutaneous relief of iliac vein obstruction. The largest, most carefully studied cohort was that of Neglen et al,150 who reported results of venoplasty and stenting in 464 limbs of patients with PTS followed up for at least 5 years. Ulcer healing occurred in 55%. Resting arm-foot pres- sure differential and QoL significantly improved after venoplasty and stenting. Procedure-related thrombosis occurred in 2.6% (10). There are however number of other procedures to help to get the venous pressure under control. These include sclerotherapy, laser saphenous vein ablation, stripping, phlebotomy and other techniques. These have to be taken into account as every patient is different and all interventions have to be “tailored” individually.

References

  1. White RH. The epidemiology of venous thromboembolism. Circulation. 2003;107(suppl 1):I4–I8.
  2. Cohen AT, Agnelli G, Anderson FA, Arcelus JI, Bergqvist D, Brecht JG, Greer IA, Heit JA, Hutchinson JL, Kakkar AK, Mottier D, Oger E, Samama MM, Spannagl M: VTE Impact Assessment Group in Europe (VITAE). Venous thromboembolism (VTE) in Europe: the number of VTE events and associated morbidity and mortality. Thromb Haemost. 2007;98:756–764.
  3. Prandoni P, Lensing AWA, Cogo A, Cuppini S, Villalta S, Carta M, Cattelan AM, Polistena P, Bernardi E, Prins MH. The long-term clinical course of acute deep venous thrombosis. Ann Intern Med. 1996;125:1–7
  4. Kahn SR, Shrier I, Julian JA, Ducruet T, Arsenault L, Miron MJ, Roussin A, Desmarais S, Joyal F, Kassis J, Solymoss S, Desjardins L, Lamping DL, Johri M, Ginsberg J. Determinants and time course of the post-throm- botic syndrome after acute deep venous thrombosis. Ann Intern Med. 2008;149:698–707.
  5. Ginsberg JS, Hirsh J, Julian J, Vander LaandeVries M, Magier D, MacKinnon B, Gent M. Prevention and treatment of postphlebitic syn- drome: results of a 3-part study. Arch Intern Med. 2001;161:2105–2109.
  6. Stain M, Schonauer V, Minar E, Bialonczyk C, Hirschl M, Weltermann A, Kyrle PA, Eichinger S. The post-thrombotic syndrome: risk factors and impact on the course of thrombotic disease. J Thromb Haemost. 2005;3:2671–2676.
  7. Schulman S, Lindmarker P, Holmstrom M, Larfars G, Carlsson A, Nicol P, Svensson E, Ljungberg B, Viering S, Nordlander S, Leijd B, Jahed K, Hjorth M, Linder O, Becknam M. Post-thrombotic syndrome, recur- rence, and death 10 years after the first episode of venous thromboembo- lism treated with warfarin for 6 weeks or 6 months. J Thromb Haemost. 2006;4:734–742.
  8. Aschwanden M, Jeanneret C, Koller MT, Thalhammer C, Bucher HC, Jaeger KA. Effect of prolonged treatment with compression stockings to prevent post-thrombotic sequelae: a randomized controlled trial. J Vasc Surg. 2008;47:1015–1021.
  9. Kahn SR, Partsch H, Vedantham S, Prandoni P, Kearon C; Subcommittee on Control of Anticoagulation of the Scientific and Standardization Committee of the International Society on Thrombosis and Haemostasis. Definition of post-thrombotic syndrome of the leg for use in clinical investigations: a recommendation for standardization. J Thromb Haemost. 2009;7:879–883.
  10. Kahn, S. The Postthrombotic Syndrome: Evidence-Based Prevention, Diagnosis, and Treatment Strategies A Scientific Statement From the American Heart Association. Downloaded from http://circ.ahajou1r6n3a6ls.org/ by guest on February 3, 2016.
  1. Prandoni P, Frulla M, Sartor D, Concolato A, Girolami A. Vein abnor- malities and the post-thrombotic syndrome. J Thromb Haemost. 2005;3:401–402.

Chronic Venous Insufficiency and Post-thrombotic Syndrome (PTS)

Every year,large number of people suffer from acute Deep Vein Thrombosis (DVT; blood clots in a vein). Many of them, later on, develop symptoms affecting their legs. Chronic complications of DVT affecting legs is called “Post-thrombotic Syndrome” (PTS).

Venous blood is normally being pushed through healthy vein to the heart but in cases of PTS when veins are blocked with old or fresh clots the blood is “sitting” in the veins increasing venous pressure (high blood pressure in the veins). This has long-term consequences on the leg resulting in skin pigmentation, skin hardening, eczema, inflammation, and ultimately a skin defect or ulcer which are difficult to heal. Some DVT sufferers can’t walk, have chronic swelling and many people spend hours getting their ulcers re-dressed by their GPs. We also know that even if the ulcer heals eventually it often reoccurs and this can happen in up to 70% of people.

The DVT itself is also major issue as the clot can travel up to the lungs and can cause a permanent damage or death.

In order to prevent complications after DVT we recommend (for suitable candidates) urgent appointment (within days) with vascular specialist to discuss an intervention that can help avoid PTS. The idea is to remove the clot early so it does not cause vein damage and allow the blood to return back to heart. It also can prevent recurrent DVT which happens more often to those who already had one before.

Part of every assessment is a scan (ultrasound or CT – “cat scan”). Treatment traditionally only consisted of wearing elastic compression hosiery (bandages or stockings) but this was not optimal management as the veins remained untreated. Technology has advanced during last 5-10 years therefore we have new safe treatment options available. Most patients can be treated with keyhole surgery (“through a needle” ) and usually only under local anaesthetics. There are number of techniques that can be used to improve quality of life and in many cases it helps to get rid of elastic stockings for good.

Results of such mini invasive treatment are very encouraging and it is now more then ever before obvious that these interventions improve quality of life of people with acute and chronic Deep Vein Thrombosis.