scholarly journals How I treat the postthrombotic syndrome

Blood ◽  
2018 ◽  
Vol 131 (20) ◽  
pp. 2215-2222 ◽  
Author(s):  
Anat Rabinovich ◽  
Susan R. Kahn
Keyword(s):  
Risk Factors ◽  
Bleeding Risk ◽  
Secondary Prophylaxis ◽  
Postthrombotic Syndrome ◽  
Compression Stockings ◽  
Lifestyle Modifications ◽  
Vein Thrombosis ◽  
Endovascular Interventions ◽  
Catheter Directed Thrombolysis ◽  
New Information

Abstract The postthrombotic syndrome (PTS) is a chronic complication of deep vein thrombosis (DVT) that imposes significant morbidity, reduces quality of life, and is costly. After DVT, 20% to 50% of patients will develop PTS, and up to 5% will develop severe PTS. The principal risk factors for PTS are anatomically extensive DVT, recurrent ipsilateral DVT, obesity, and older age. By preventing the initial DVT and DVT recurrence, primary and secondary prophylaxis of DVT will reduce occurrence of PTS. The effectiveness of elastic compression stockings (ECSs) for PTS prevention is controversial. Catheter-directed thrombolysis is not effective to prevent PTS overall but may prevent more severe forms of PTS and should be reserved for select patients with extensive thrombosis, recent symptoms onset, and low bleeding risk. For patients with established PTS, the cornerstone of management is ECS, exercise, and lifestyle modifications. Surgical or endovascular interventions may be considered in refractory cases. Because of a lack of effective therapies, new approaches to preventing and treating PTS are needed. This article uses a case-based approach to discuss risk factors for PTS after DVT, how to diagnose PTS, and available means to prevent and treat PTS, with a focus on new information in the field.

scholarly journals Evaluating the Role of Compression Stockings in Preventing Post thrombotic Syndrome: A Review of the Literature

Thrombosis ◽  
2012 ◽  
Vol 2012 ◽  
pp. 1-9 ◽  
Author(s):  
Abir O. Kanaan ◽  
Jayne E. Lepage ◽  
Shabdis Djazayeri ◽  
Jennifer L. Donovan
Keyword(s):  
Risk Factors ◽  
Controlled Trial ◽  
Postthrombotic Syndrome ◽  
Review Of The Literature ◽  
Compression Stockings ◽  
Double Blind ◽  
Double Blind Placebo ◽  
Vein Thrombosis ◽  
Deep Vein

Background. Postthrombotic syndrome (PTS) is a burdensome and costly complication of deep vein thrombosis (DVT). Up to 50% of patients with DVT will develop the disease within two years following the diagnosis of acute DVT. Various risk factors for developing PTS have been identified and different modalities have been used to prevent its development. Compression stockings have been studied for the prevention of PTS in patients diagnosed with proximal DVT. Methods. MEDLINE and EMBASE databases were searched to identify relevant original articles. Results. Several trials including two metaanalyses have examined the role of compression stockings for the prevention of PTS. Although most trials showed significant reduction in the development of PTS with the use of compression stockings, limitations in study design prevent the generalizability of the data. Two studies supported an individualized tailored duration especially in patients at low risk for developing the syndrome. A randomized double-blind placebo-controlled trial involving 800 patients is currently ongoing and may confirm the results of older studies. Conclusions. Clinical trials support the use of compression stockings in patients diagnosed with proximal DVT for the prevention of PTS.

The Post-Thrombotic Syndrome

Hematology ◽  
2010 ◽  
Vol 2010 (1) ◽  
pp. 216-220 ◽  
Author(s):  
Susan R. Kahn
Keyword(s):  
Risk Factors ◽  
Anticoagulation Therapy ◽  
Compression Therapy ◽  
Secondary Prophylaxis ◽  
Compression Stockings ◽  
Elastic Compression ◽  
Vein Thrombosis ◽  
Post Thrombotic Syndrome ◽  
Venous Ulcers ◽  
Risk Determinants

AbstractThe post-thrombotic syndrome (PTS) is an important chronic complication of deep vein thrombosis (DVT). The present review focuses on risk determinants of PTS after DVT and available means to prevent and treat PTS. More than one-third of patients with DVT will develop PTS, and 5% to 10% of patients develop severe PTS, which can manifest as venous ulcers. PTS has an adverse impact on quality of life as well as significant socioeconomic consequences. The main risk factors for PTS are persistent leg symptoms 1 month after acute DVT, anatomically extensive DVT, recurrent ipsilateral DVT, obesity, and older age. Subtherapeutic dosing of initial oral anticoagulation therapy for DVT treatment may also be linked to subsequent PTS. By preventing the initial DVT and DVT recurrence, primary and secondary prophylaxis of DVT will prevent cases of PTS. Daily use of elastic compression stockings for 2 years after proximal DVT appears to reduce the risk of PTS; however, uncertainty remains regarding optimal duration of use, optimal compression strength, and usefulness after distal DVT. The cornerstone of managing PTS is compression therapy, primarily using elastic compression stockings. Venoactive medications such as aescin and rutosides may provide short-term relief of PTS symptoms. Further studies to elucidate the pathophysiology of PTS, to identify clinical and biological risk factors, and to test new preventive and therapeutic approaches to PTS are needed.

scholarly journals The post-thrombotic syndrome

Hematology ◽  
2016 ◽  
Vol 2016 (1) ◽  
pp. 413-418 ◽  
Author(s):  
Susan R. Kahn
Keyword(s):  
Risk Factors ◽  
Bleeding Risk ◽  
Multicenter Trial ◽  
Future Research ◽  
Compression Stockings ◽  
Vein Thrombosis ◽  
Post Thrombotic Syndrome ◽  
Supervised Exercise ◽  
Exercise Training Program ◽  
Intermittent Compression

Abstract The post-thrombotic syndrome (PTS) is a frequent, sometimes disabling complication of deep vein thrombosis (DVT) that reduces quality of life and is costly. This article discusses risk factors for PTS after DVT and available means to prevent and treat PTS, with a focus on new information in the field. After DVT, PTS will develop in 20% to 50% of patients, and severe PTS, including venous ulcers, will develop in 5% to 10%. The principal risk factors for PTS are anatomically extensive DVT, recurrent ipsilateral DVT, persistent leg symptoms 1 month after acute DVT, obesity, and older age. By preventing the initial DVT and ipsilateral DVT recurrence, primary and secondary prophylaxes of DVT will prevent cases of PTS. Based on recent evidence from a large multicenter trial, routine use of elastic compression stockings (ECS) after DVT to prevent PTS is not advocated, but in patients with DVT-related leg swelling that is bothersome, a trial of ECS is reasonable. Selecting DVT patients for catheter-directed thrombolytic treatment as a means of preventing PTS should be done on a case-by-case basis, with a focus on patients with extensive thrombosis, recent symptoms onset, and low bleeding risk. For patients with established PTS, daily use of ECS may help to relieve symptoms and edema. Intermittent compression devices can be tried in patients with moderate-to-severe PTS whose symptoms are inadequately controlled with ECS alone. A supervised exercise training program may improve PTS symptoms. Management of post-thrombotic ulcers should ideally involve a multidisciplinary approach. Important areas for future research are summarized.

Risk factors of postthrombotic syndrome before and after deep venous thrombosis treatment

2016 ◽  
Vol 32 (6) ◽  
pp. 384-389 ◽  
Author(s):  
Rob HW Strijkers ◽  
Mark AF de Wolf ◽  
Cees HA Wittens
Keyword(s):  
Risk Factors ◽  
Venous Thrombosis ◽  
Deep Venous Thrombosis ◽  
Treatment Options ◽  
Postthrombotic Syndrome ◽  
Factor X ◽  
Catheter Directed Thrombolysis ◽  
Before And After ◽  
Patient Selection Criteria ◽  
The Moment

Postthrombotic syndrome is the most common complication after deep venous thrombosis. Postthrombotic syndrome is a debilitating disease and associated with decreased quality of life and high healthcare costs. Postthrombotic syndrome is a chronic disease, and causative treatment options are limited. Prevention of postthrombotic syndrome is therefore very important. Not all patients develop postthrombotic syndrome. Risk factors have been identified to try to predict the risk of developing postthrombotic syndrome. Age, gender, and recurrent deep venous thrombosis are factors that cannot be changed. Deep venous thrombosis location and extent seem to predict severity of postthrombotic syndrome and are potentially suitable as patient selection criteria. Residual thrombosis and reflux are known to increase the incidence of postthrombotic syndrome, but are of limited use. More recently developed treatment options for deep venous thrombosis, such as new oral factor X inhibitors and catheter-directed thrombolysis, are available at the moment. Catheter-directed thrombolysis shows promising results in reducing the incidence of postthrombotic syndrome after deep venous thrombosis. The role of new oral factor X inhibitors in preventing postthrombotic syndrome is still to be determined.

Ultrasound-Assisted Catheter-Directed Thrombolysis for Submassive Pulmonary Embolism

2018 ◽  
Vol 52 (3) ◽  
pp. 195-201 ◽  
Author(s):  
Prasoon P. Mohan ◽  
John J. Manov ◽  
Francisco Contreras ◽  
Michael E. Langston ◽  
Mehul H. Doshi ◽  
...  
Keyword(s):  
Risk Factors ◽  
Pulmonary Embolism ◽  
Bleeding Risk ◽  
Right Heart ◽  
Systemic Thrombolysis ◽  
Catheter Directed Thrombolysis ◽  
Ultrasound Assisted ◽  
Vascular Obstruction ◽  
The Right ◽  
Pulmonary Vascular Obstruction

Purpose: Catheter-directed thrombolysis (CDT) is a relatively new therapy for pulmonary embolism that achieves the superior clot resolution compared to systemic thrombolysis while avoiding the high bleeding risk intrinsically associated with that therapy. In order to examine the efficacy and safety of CDT, we conducted a retrospective cohort study of patients undergoing ultrasound-assisted CDT at our institution. Methods: The charts of 30 consecutive patients who underwent CDT as a treatment of pulmonary embolism at our institution were reviewed. Risk factors for bleeding during thrombolysis were noted. Indicators of the right heart strain on computed tomography and echocardiogram, as well as the degree of pulmonary vascular obstruction, were recorded before and after CDT. Thirty-day mortality and occurrence of bleeding events were recorded. Results: Nine (30%) patients had 3 or more minor contraindications to thrombolysis and 14 (47%) had major surgery in the month prior to CDT. Right ventricular systolic pressure and vascular obstruction decreased significantly after CDT. There was a significant decrease in the proportion of patients with right ventricular dilation or hypokinesis. Decrease in pulmonary vascular obstruction was associated with nadir of fibrinogen level. No patients experienced major or moderate bleeding attributed to CDT. Conclusion: Catheter-directed thrombolysis is an effective therapy in rapidly alleviating the right heart strain that is associated with increased mortality and long-term morbidity in patients with pulmonary embolism with minimal bleeding risk. Catheter-directed thrombolysis is a safe alternative to systemic thrombolysis in patients with risk factors for bleeding such as prior surgery. Future studies should examine the safety of CDT in patients with contraindications to systemic thrombolysis.

scholarly journals Postthrombotic Syndrome: Surgical Possibilities

Thrombosis ◽  
2012 ◽  
Vol 2012 ◽  
pp. 1-7 ◽  
Author(s):  
Ajay K. Khanna ◽  
Shivanshu Singh
Keyword(s):  
Promising Result ◽  
Postthrombotic Syndrome ◽  
Axillary Vein ◽  
Foam Sclerotherapy ◽  
Venous Flow ◽  
Vein Thrombosis ◽  
Venous Valves ◽  
Endovascular Interventions ◽  
Deep Vein

Postthrombotic syndrome (PTS) is a late outcome of deep vein thrombosis characterized by cramping pain, swelling, hyperpigmentation, eczema, lipodermatosclerosis, and ulceration in the leg due to increased venous outflow resistance and reflux venous flow. Newer surgical and endovascular interventions have a promising result in the management of postthrombotic syndrome. Early surgical or endovascular interventions in appropriately selected patients may decrease the incidence of recurrent ulceration and skin changes and provide a better quality of life. Duplex and IVUS (intravenous ultrasound) along with venography serve as cornerstone investigative tools for assessment of reflux and obstruction. Venous obstruction, if present, should be addressed earlier than reflux. It requires endovenous stenting, endophlebectomy, or open bypass procedures. Venous stripping, foam sclerotherapy, radiofrequency, or laser ablation are used to abolish superficial venous reflux. Valvuloplasty procedures are useful for incompetent but intact deep venous valves, while transposition or axillary vein autotransplantation is done for completely destroyed valves.

scholarly journals Prevention of the post thrombotic syndrome with anticoagulation: a narrative review

2021 ◽  
Author(s):  
Ilia Makedonov ◽  
Susan R Kahn ◽  
Jameel Abdulrehman ◽  
Sam Schulman ◽  
Aurélien Delluc ◽  
...  
Keyword(s):  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Economic Consequences ◽  
Compression Stockings ◽  
Vein Thrombosis ◽  
Post Thrombotic Syndrome ◽  
Preventative Measures ◽  
Catheter Directed Thrombolysis ◽  
Deep Vein

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.

scholarly journals Iliofemoral deep vein thrombosis and the problem of post-thrombotic syndrome

2018 ◽  
Vol 17 (2) ◽  
pp. 99-103
Author(s):  
Nicholas Denny ◽  
◽  
Shreshta Musale ◽  
Helena Edlin ◽  
Jecko Thachil ◽  
...  
Keyword(s):  
Deep Vein Thrombosis ◽  
Compression Stockings ◽  
Short Term ◽  
Vein Thrombosis ◽  
Post Thrombotic Syndrome ◽  
Catheter Directed Thrombolysis ◽  
Short Term Mortality ◽  
Considerable Morbidity ◽  
Deep Vein

Deep vein thrombosis (DVT) is an important cause of short-term mortality and long-term morbidity. Among the different presentations of DVT, thrombus in the iliofemoral veins may be considered the severest form. Although anticoagulation is the mainstay of the management of iliofemoral thrombosis, despite adequate anticoagulant treatment, complications including post-thrombotic syndrome is not uncommon. The latter is often overlooked but can cause considerable morbidity to the affected individuals. Preventing this condition remains a challenge but recent clinical trials of catheter directed thrombolysis and elasticated compression stockings provide some advance in this context. In this article, with the aid of a clinical case, we review the particular considerations to take into account when managing patients with an iliofemoral DVT.

Prevention of Recurrent Thrombotic Events in Children with Central Venous Catheter-Associated Venous Thrombosis

Blood ◽  
2021 ◽  
Author(s):  
Helen Havens Clark ◽  
Lance Ballester ◽  
Hilary B Whitworth ◽  
Leslie Raffini ◽  
Char Witmer
Keyword(s):  
Risk Factors ◽  
Significant Risk ◽  
Venous Catheter ◽  
Significant Risk Factor ◽  
Bleeding Risk ◽  
Secondary Prophylaxis ◽  
Central Venous ◽  
Full Dose ◽  
Increased Risk ◽  
Recurrent Vte

Central venous catheters (CVC) are the most significant risk factor for pediatric venous thromboembolism (VTE). After an index CVC-associated VTE (CVC-VTE), the role of secondary prophylaxis for subsequent CVC placement is uncertain. Aims of this single center retrospective study were to evaluate the efficacy of secondary prophylaxis for patients with a prior CVC-VTE and identify risk factors associated with recurrent VTE in patients less than 19 years with an index CVC-VTE between 2003 and 2013. Data collection included clinical and demographic factors, subsequent CVC placement, secondary prophylaxis strategy, recurrent VTE, and bleeding. Risk factors for recurrence and effectiveness of secondary prophylaxis were evaluated using survival and binomial models. Among 373 patients with an index CVC-VTE, 239 (64.1%) had subsequent CVC placement. 17.4% (65/373) of patients had recurrent VTE, 90.8% (59/65) were CVC-associated. On multivariable survival analysis, each additional CVC (HR 12.00; 95% CI 2.78 - 51.91), congenital heart disease (HR 3.70; 95% CI 1.97 - 6.95), and total parenteral nutrition dependence (HR 4.02; 95% CI 2.23 - 7.28) were associated with an increased hazard of recurrence. Full dose anticoagulation for secondary prophylaxis was associated with decreased odds of recurrent CVC-VTE (OR 0.35; 95% CI 0.19 - 0.65) but not prophylactic dosing (OR 0.61; 95% CI 0.28 - 1.30). Only 1.3% of CVCs experienced major bleeding with prophylactic or full dose anticoagulation. In summary, children with CVC-VTE are at increased risk for recurrent VTE. Secondary prophylaxis with full dose anticoagulation was associated with a 65% reduction in odds of thrombotic events.

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