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Postthrombotic Syndrome
Introduction
Postthrombotic syndrome (PTS) is a complication of acute deep vein thrombosis (DVT) that presents with signs and symptoms of chronic venous insufficiency. PTS is characterized by leg discomfort, heaviness, vein dilation, edema, skin discoloration, and venous ulcers. DVT affects approximately 1 in 1000 individuals annually, and despite appropriate anticoagulation, PTS develops in 20% to 50% of cases.[1][2]
PTS is a significant public health concern due to its profound impact on quality of life and healthcare costs. The socioeconomic repercussions of PTS are expected to increase in the coming years. While notable advances have been made in understanding the condition, many unresolved questions remain. Effective and validated treatment protocols for PTS are still under development. Current management strategies focus on preventing DVT, ensuring prompt identification, and reducing the risk of recurrence.[3]
Etiology
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Etiology
The etiology of PTS is not well understood. However, the disorder is believed to result from venous hypertension caused by valvular impairment and restricted venous outflow due to persistent thrombosis and fibrosis of the vessel wall. An acute DVT episode leads to partial or complete venous flow restriction, and failure to recanalize—often observed as early as 6 weeks after diagnosis—results in persistent obstruction and fibrotic damage to the venous wall.[4]
The inflammatory cascade also contributes to direct venous valve damage.[5][6] These postthrombotic changes increase venous pressure, which is transmitted to capillary beds, leading to tissue swelling, lipodermatosclerosis, and, eventually, tissue oxygen deprivation and venous ulcer formation.[7] Recent studies suggest that concurrent arterial disease may also occur with DVT, leading to stiffness and associated symptoms, although the exact mechanism behind this relationship remains unclear.[8]
Epidemiology
Comprehensive epidemiological data on PTS are limited, but some studies report an incidence of 20% to 50% in patients with a history of DVT.[9] Approximately 8% to 10% of cases are severe, significantly reducing the quality of life of affected individuals.[10] A systematic review of 16 cohort studies found variation in occurrence rates across different countries, with an overall 2-year incidence of PTS at 37.5%.[11] Additionally, a registry of 1107 patients with proximal DVT showed a 3-year incidence of 27.8%, with older patients exhibiting a higher incidence and increased prevalence of persistent DVT risk factors.
Another potential contributor to the development of PTS is the presence of varicose veins, which has been observed in female patients only. Studies have also indicated that the occurrence of PTS levels off between 1 and 2 years after an acute DVT episode, although symptoms can emerge within 6 years in approximately one-third of patients.[12]
History and Physical
PTS can present with a range of symptoms, from mild, such as skin pigmentation, telangiectasia, minor discomfort, and edema, to severe, including chronic pain, significant anterior tibial edema, and skin ulceration. Symptoms may develop within weeks or months after a DVT episode or persist from the acute phase of DVT.[13] Edema affects approximately two-thirds of individuals with PTS and is often accompanied by limb heaviness and discomfort, especially after prolonged standing or walking. These symptoms can typically be alleviated by resting or elevating the limb.
Approximately one-third of individuals experience skin changes, including discoloration, telangiectasia, eczema, varicose veins, and lipodermatosclerosis. Ulceration occurs in less than 5% of patients. Dermatological alterations typically manifest 2 to 4 years after an acute DVT episode.[14]
Evaluation
The diagnosis of PTS is primarily based on clinical assessment, as no gold standard test currently exists. Ongoing research is investigating serum biomarkers, including intercellular adhesion molecule-1 (ICAM-1) and matrix metalloproteinases 1 (MMP-1) and 8 (MMP-8), as potential predictors of PTS.[15] The neutrophil-to-lymphocyte ratio is also being investigated for its applicability in iliofemoral DVT.[16] Further diagnostic testing is typically unnecessary, and PTS should be suspected in patients with a history of DVT.[17]
Several clinical scores assist in diagnosing and characterizing PTS. The Villalta scale, developed in 1994, classifies the condition based on severity, incorporating 6 subjective symptoms, 6 objective signs, and the presence of venous ulceration (see the Table below).[18] The presence of a venous ulcer or a score greater than 5 confirms the diagnosis of PTS. A score between 5 and 10 indicates mild disease, 10 to 14 indicates moderate disease, and 15 or higher reflects severe disease.[19][20] The International Society on Thrombosis and Haemostasis recommends using the Villalta score at the initial visit to diagnose PTS and again after 3 months to assess severity and progression.[21]
The Villalta scale is the primary clinical tool for evaluating lower-extremity PTS. However, the condition can also affect the upper extremities, where the upper-extremity PTS (UE-PTS) score is used.[22] This score assesses 5 symptoms—edema, heaviness, fatigue upon use, pain, and functional arm limitations—along with 3 clinical signs—asymmetrical arm circumference, discoloration at rest, and collateral veins around the shoulder, torso, or breast. The Villalta scale categorizes PTS as absent, mild, moderate, or severe.[23] Some sources suggest that patients with mild disease may be overlooked due to subtle symptoms, potentially leading to suboptimal treatment.
The shortened Disabilities of the Arm, Shoulder, and Hand Questionnaire (QuickDASH) is an 11-item tool used for assessing physical function and symptoms in individuals with upper-extremity musculoskeletal disorders, including UE-PTS. The questionnaire covers daily activities, housework, shopping, recreation, self-care, food preparation, sleep, social interactions, job performance, pain, and tingling or numbness.[24] The International Delphi consensus recommends incorporating the QuickDASH questionnaire to evaluate UE-PTS.
Venous abnormalities, including residual obstruction or proximal venous reflux, should be evaluated in patients with severe symptoms to determine the need for intervention. The primary imaging modalities for this assessment include venous duplex ultrasound, intravascular ultrasonography, and venography.[25] Patients with a history of DVT who remain asymptomatic despite imaging findings of persistent venous obstruction or venous hypertension do not meet the diagnostic criteria for PTS.[26]
Table. The Villalta Scale
| None | Mild | Moderate | Severe | |
| Symptoms | ||||
| Pain | 0 | 1 | 2 | 3 |
| Cramps | 0 | 1 | 2 | 3 |
| Heaviness | 0 | 1 | 2 | 3 |
| Paresthesia | 0 | 1 | 2 | 3 |
| Pruritus | 0 | 1 | 2 | 3 |
| Clinical Signs | ||||
| Pretibial edema | 0 | 1 | 2 | 3 |
| Skin induration | 0 | 1 | 2 | 3 |
| Redness | 0 | 1 | 2 | 3 |
| Hyperpigmentation | 0 | 1 | 2 | 3 |
| Venous stasis | 0 | 1 | 2 | 3 |
| Pain in calf compression | 0 | 1 | 2 | 3 |
| Venous ulcer | Absent | Present |
Treatment / Management
The primary modalities for PTS management include exercise, limb elevation, and compression therapy. However, additional interventional studies are needed to determine the most effective treatment approach.[27](A1)
Exercise enhances venous blood flow, reducing venous stasis and hypercoagulability—key factors in thrombosis development.[28] Recent studies suggest that exercise does not increase the risk of pulmonary embolism in patients with DVT. An inferior vena cava (IVC) filter may be considered in high-risk patients.[29] Physical activity helps alleviate symptoms, and resistance training has been shown to improve muscle strength and walking performance by reducing thrombus size and accelerating its dissolution.[30]
Compression-based therapies help alleviate symptoms and improve daily functionality.[31] These therapies counteract the transcurrent damage caused by venous stasis and hypertension, which result from factors such as delayed outflow, thrombosis, valvular damage, and venous wall scarring (reflux type). Compression therapies offer significant benefits by reducing capillary leakage and edema, supporting venous valvular function, and enhancing skin microcirculation through muscular compression.
Depending on the severity of symptoms and the presence of edema, skin abnormalities, or ulceration, various compression modalities may be used, including compression socks, short stretch bandages, multilayer compression, and zinc paste bandages.[32] For patients with moderate-to-severe PTS who do not experience relief from elastic compression stockings alone, a portable intermittent compression device may be considered as an additional therapeutic option.[33][34] (A1)
Pharmacological therapy, including venoactive drugs such as diosmin and rutosides, is used to manage lower extremity symptoms in PTS. However, high-quality data from randomized trials are insufficient to support the widespread use of pharmacological interventions for PTS.
Local management of skin changes and venous ulcers is essential in treating PTS. Moisturizers and midpotency topical corticosteroids help address dry skin, itching, and eczematous changes, while dressings promote moist wound healing for ulcers.[35]
A randomized clinical trial involving 208 patients with acute lower extremity DVT, divided equally into 4 groups (warfarin alone, warfarin plus rosuvastatin, rivaroxaban alone, and rivaroxaban plus rosuvastatin), found that those taking rosuvastatin experienced a more significant reduction in inflammatory marker levels compared to those on anticoagulants alone (P < .0001). A significant change in lower limb size was observed in 3 groups 3 months after DVT, with the rosuvastatin groups showing a more notable decrease in limb size than those on anticoagulation alone (P < .0001 versus P < .05).[36] The literature generally favors the use of direct oral anticoagulants (DOACs) over low-molecular-weight heparins (LMWH) and vitamin K antagonists for treating upper extremity thromboses, as DOACs are associated with a reduced risk of PTS.[37](A1)
Vascular procedures may be necessary if severe symptoms persist and venous obstruction or reflux is present. Interventions such as percutaneous angioplasty with or without stenting, venous bypass, and endophlebectomy can help reduce ulcer recurrence and skin alterations, thereby improving patients' quality of life.[38][39] Studies have demonstrated that eliminating the source of retrograde flow can improve venous hemodynamics.[40][41](B2)
Although stenting can improve vascular flow and promote ulcer healing, it has notable risks.[42] Mechanical pressure and stress may cause stent fracture, and improper placement could lead to stent migration within the vessel. Stents can cause contralateral thrombosis, a condition known as "jailing," in which an iliac stent obstructs flow through an IVC filter, thereby impeding circulation in the opposite iliac system. Additionally, back pain may develop if the placement site induces venous distortion that compresses surrounding tissues, such as nerves.
Prompt treatment of acute DVT is essential in preventing PTS. A meta-analysis comparing various anticoagulants showed that edoxaban was more effective than rivaroxaban in preventing PTS.[43](A1)
Differential Diagnosis
PTS manifestations, such as lower extremity pain, heaviness, and edema, are also seen in various conditions, including primary venous insufficiency, increased body mass index (BMI), lipedema, lymphedema, soft tissue masses, and posttraumatic changes. A prior history of DVT can help differentiate PTS from primary venous insufficiency. While PTS symptoms are typically isolated to the limb where the DVT occurred, primary venous insufficiency tends to occur bilaterally.
Masses causing venous obstruction, such as arterial aneurysms, Baker cysts, and soft tissue tumors, may be readily detectable during physical examination of the groin and popliteal fossa. However, these growths can be challenging to detect in patients with obesity or significant limb swelling. Ultrasound or cross-sectional imaging techniques can help detect and distinguish these lesions.
Prognosis
Despite recent advancements, PTS remains one of the most prevalent, chronic, and debilitating complications of acute DVT, with limited treatment options. More than 50% of patients prescribed elastic compression stockings and receiving appropriate follow-up experience stability or improvement, regardless of the initial severity of the syndrome.[44]
However, some studies present mixed evidence regarding the benefits of elastic compression stockings. For example, the largest placebo-controlled trial, the Study on the Efficacy of Stockings (SOX) for PTS, failed to show a significant interventional effect. In the trial, 14.2% of patients using elastic compression stockings developed PTS compared to 12.7% in the placebo group. However, these results may be influenced by low compliance rates due to factors such as discomfort, cost, and difficulty in putting on the stockings.
Complications
A proximal DVT is associated with a greater risk of occurrence and more severe PTS symptoms compared to distal DVT.[45] However, complications in both types primarily affect patients who continue to experience the initial venous symptoms associated with DVT. Notably, catheter-directed thrombolysis complicated by PTS in acute lower DVT is more common in patients with a BMI greater than 24.33 kg/m², mixed DVT, a history of varicose veins, and an IVC filter, among other factors.[46]
Leg ulceration is a major complication of PTS, contributing to significant disability and financial burdens for both individuals and healthcare systems. Venous ulcers are typically painless, superficial lesions with irregular borders, red granulation tissue, yellow fibrin at the base, and exudates. Poor prognostic factors for ulcer healing include a duration longer than 3 months, an initial size greater than 10 cm, the presence of arterial disease, advanced age, and an elevated BMI. The patient's quality of life, a subjective measure, is greatly influenced by the prevention, detection, and management of complications such as PTS.
Deterrence and Patient Education
The following measures are recommended to prevent PTS:
- Regular ambulation
- Frequent physical activity
- Use of compression stockings
- Adherence to anticoagulation therapy after an acute DVT
By emphasizing these practical strategies, healthcare providers can better support patients adhering to them. As with all aspects of medicine, education fosters compliance.
Enhancing Healthcare Team Outcomes
Collaboration among healthcare providers, including physicians, nurses, and physical therapists, is essential for delivering patient-centered care for PTS. Healthcare professionals must have the clinical skills and expertise required to diagnose, evaluate, and treat the condition effectively. Key competencies include identifying PTS symptoms, recognizing potential complications, and implementing appropriate management strategies. Depending on the severity of the symptoms, consultation with a vascular surgery specialist may be necessary. A personalized care plan tailored to each patient's unique needs is crucial for mitigating complications such as venous ulcers.
Interprofessional healthcare team members must understand their roles and actively contribute their specialized expertise to the care plan. Effective communication within the team is essential for smooth information exchange and collaborative decision-making. By adopting the best practices in communication and care coordination, healthcare professionals can improve patient outcomes and enhance team performance in managing PTS.
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