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dr Cezary Szary

Each advanced form of venous insufficiency of lower extremity is a potential undiagnosed postthrombotic syndrome. A detailed diagnostics of veins via Doppler ultrasound is a key for diagnosis of this severe disease.

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

 

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)
  • overburden of perforator veins, i.e. perforator venous insufficiency 
  • secondary damage of superficial veins 
  • increase in the pressure in small subcutaneous vessels
  • skin lesions, i.e. trophic disorders (e.g. lipodermatosclerosis, eczema, ulcer etc.) 

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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

From our every day practice transpires that a number of patients with a history of deep vein thrombosis after several years suffer from its inadequate diagnosis or misdiagnosis. It should be remembered that thrombosis in peroneal vein on lower limb have different consequences for organism compared to proximal thrombosis, iliac-femoral vein thrombosis, which involves several segments. The latter is usually of the most severe course. Leg lesions after years are quiet painful. A number of patients with hard-to-heal venous ulcers of lower limb are patients who experience iliac-femoral vein thrombosis, predisposing frequently to the appearance of postthrombotic syndrome. 

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.

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. 

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 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. 

Information to remember:

  • postthrombotic syndrome is a painful consequence of deep vein thrombosis 
  • it is a relatively common condition, causing discomfort and deteriorating with the years 
  • it may be quickly prevented if intervention is undertaken, i.e. quick initiation of antithrombotic treatment, using therapeutic dose and adequately adjusted compression
  • 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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