Postthrombotic syndrome (PTS) refers to the spectrum of all unfavourable symptoms and consequences resulting from a history of deep vein thrombosis. 

 

 

dr Cezary Szary, MD

Each advanced form of venous insufficiency of the lower limb is a potentially unrecognized post-thrombotic syndrome. Accurate diagnostics of veins in Doppler ultrasound is the key to the diagnosis of this onerous disease.

Disease description

Following thrombotic incident, a number of reverse changes appear in veins, which damage their structure. Shortly, they include:

  • changes in deep veins resulting from transformation of clots (persistence of blockage, partial recanalization of clots or fibrosis leading to the damage of valves)
  • increase in the pressure in small subcutaneous vessels
  • overburden of perforator veins, i.e. perforator venous insufficiency 
  • secondary damage of superficial veins 
  • skin lesions, i.e. trophic disorders (e.g. lipodermatosclerosis, eczema, ulcer etc.) 

 

What are the typical symptoms of advanced post-thrombotic syndrome?

  • chronic swelling of lower limb with grey-blue dilatations of vessels around the ankle (30-60% of patients) 
  • unsightly trophic lesions (discoloration, hardening of subcutaneous tissue)
  • active ulcers or signs of healed ulcers in the form of scars and malformation of subcutaneous tissue (even up to 15% of patients)
  • leg pain while walking or staying for a long time, i.e. venous claudication

Important issues

1

How frequently is postthrombotic syndrome developed following deep vein thrombosis?

Introduction of low molecular weight heparin, which is easily administered by patient and compression stockings of moderate or strong tension (stage II or III) for a common use substantially decreased the occurrence of postthrombotic syndrome symptoms.

Introduction of low molecular weight heparin, which is easily administered by patient and compression stockings of moderate or strong tension (stage II or III) for a common use substantially decreased the occurrence of postthrombotic syndrome symptoms.

Favourable course of disease is seen, however, exclusively in case of simple, short-time thrombosis of lower limb. A large number of thrombosis gave a multi-segment course. Lesions which are present in femoral or pelvic segment are accompanied more frequently by pulmonary embolism. In such cases, fully symptomatic postthrombotic syndrome is most commonly observed. 

2

What kind of treatment is adopted in advanced postthrombotic syndrome?

In case of patients diagnosed with thrombosis, it is the most important not to allow for developing postthrombotic syndrome via quick initiation of adequate antithrombotic treatment (antithrombotic drugs and compression adjusted to the patient’s leg).

In case of patients diagnosed with thrombosis, it is the most important not to allow for developing postthrombotic syndrome via quick initiation of adequate antithrombotic treatment (antithrombotic drugs and compression adjusted to the patient’s leg).

In our time, besides non-invasive treatment, we also perform minimally invasive procedures which may decrease the symptoms of postthrombotic syndrome. We apply i.a.:

  • percutaneous closure of incompetent perforators of lower limb (sclerotherapy or intravascular laser therapy ELVeS 1470 nm)
  • clearance of postthrombotic affected iliac and femoral veins with simultaneous implantation of venous stent under the guidance of phlebography and intravascular ultrasound (IVUS)

Qualification of patient for implantation of venous stent is always preceded by Doppler ultrasound of veins of lower extremities, abdominal cavity and small pelvis. Qualification procedure often requires to perform CT or MRI venography. More information can be accessed in the section IMAGING DIAGNSOTICS.

Methods of treatment

Leczenie zespołu pozakrzepowego to jedno z największych wyzwań współczesnej flebologii. Do najtrudniejszych przypadków należą osoby z przebytą zakrzepicą żylną lokalizującą się w segmencie proksymalnym (biodrowo-udowym). W skrajnych przypadkach zakrzepica dotyczyć może pnia żyły głównej dolnej i spływów biodrowych. Wówczas objawy są obukończynowe. 

U takich pacjentów stosowane są techniki udrożnienia wraz z implantacją stentów dedykowanych do naczyń żylnych połączone z przewlekłą farmakoterapią i skuteczną kompresjoterapią. Jak dowiodło badanie eksperymentalne prowadzone przez zespół Kliniki Flebologii skuteczny ucisk zapobiegający chromaniu żylnemu stosowany u pacjentów z pełnoobjawowym zespołem pozakrzepowym powinien przekraczać 50 mmHg na poziomie goleni.

Summary

  1. postthrombotic syndrome is a painful consequence of deep vein thrombosis 
  2. it is a relatively common condition, causing discomfort and deteriorating with the years 
  3. it may be quickly prevented if intervention is undertaken, i.e. quick initiation of antithrombotic treatment, using therapeutic dose and adequately adjusted compression
  4. in the most severe cases of thrombosis (iliac-femoral thrombosis), there is a possibility of effective clearance of vein lumen at early stage (up to 2 weeks following thrombosis) or vein repairing with implantation of stent even several months following thrombosis. 

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