Post-thrombotic syndrome

The Phlebology Clinic / Post-thrombotic syndrome

Venous thrombosis

Introduction

Post-thrombotic syndrome (English. post-thrombotic syndrome, PTS) is the most common long-term complication of deep vein thrombosis (DVT). According to the latest epidemiological data, 20-50% patients diagnosed with deep vein thrombosis will develop post-thrombotic syndrome within the next 2 years. In the case of iliac-femoral thrombosis, the risk of developing PTS is particularly high and can reach as high as 50%. It is estimated that the number of adults with deep vein thrombosis in Western countries will double by 2050, which will also significantly increase the population of patients with post-thrombotic syndrome.

Studies indicate that approximately 5-10% patients with post-thrombotic syndrome develop its severe form. These patients have hard-to-heal venous ulcers of the shin (C5-C6 according to CEAP). In this group, quality of life is particularly poor and treatment costs are the highest. Importantly, even patients with mild to moderate PTS experience significant impairment in daily functioning. According to the study, approximately 40% Patients report a significant reduction in physical activity and 60% Patients experience chronic pain affecting their daily life.

Symptoms of post-thrombotic syndrome

Post-thrombotic syndrome is characterised by a range of limbic symptoms associated with chronic venous insufficiency. These are a consequence of a history of venous thrombosis, whose descent (secondary changes in the venous system) leads to impaired venous blood outflow, persistent venous reflux and impaired function of the shin muscles, including their significant atrophy and decreased ejection fraction. This process fuels the reduced ability to pump venous blood out of the shin area by which intravenous pressure builds up in the veins of the feet and shin.

Symptoms of post-thrombotic syndrome occur as a consequence of a history of deep vein thrombosis. Typical symptoms of post-thrombotic syndrome include:

pain in a limb
a feeling of heaviness in the legs
swelling of the lower extremities increasing during the day and with prolonged standing
calf muscle cramps
itching of the skin
skin discolouration - especially around the ankles
secondary varicose veins
trophic skin lesions (C4 according to CEAP)
Venous ulcers of the shin (C5-C6 according to CEAP) in the form of severe PTS.

Factors that increase the risk
occurrence of post-thrombotic syndrome

proximal thrombosis (especially hip thrombosis)
a history of recurrent venous thrombosis in the same lower limb
finding of extensive deep vein thrombosis
inadequate anticoagulant and compression therapy in the acute phase of deep vein thrombosis
congenital thrombophilia

seniority
obesity (BMI >30)
female gender
pre-existing venous insufficiency of the lower limbs
reduced mobility of the patient leading to progressive muscular atrophy

Mechanism of development of post-thrombotic syndrome

Development mechanism post-thrombotic syndrome is complex and not fully understood. It is known to start as early as the onset of deep vein thrombosis. During the thrombotic process, there is an intense inflammatory reaction in the venous vessel wall. The inflammation and its descent cause damage to the delicate venous valves, which under normal conditions prevent backflow of blood. The damaged valves cease to function properly, leading to their failure and the appearance of venous reflux, i.e. backward flow of blood in the veins resulting from the action of gravity.

In parallel with the process of valve damage, thrombus dissolution and various retrograde changes occur in the thrombosed segment. The thrombus gradually transforms into fibrous tissue, leading to fibrosis and hardening of the vessel wall. This process results in a narrowing of the vein lumen and a significant reduction in its elasticity. As a result, the vessel loses its natural ability to expand and contract in response to changes in blood flow. Occasionally, full recanalisation does not occur, but rather the opposite. A clogged and fibrotic outflow vessel causes a significant increase in venous pressure at the bottom of the leg. Backlogged blood causes fluid to leak from the vessels into the tissues, leading to oedema.

Long-term venous hypertension impairs microcirculation in the tissues, resulting in the formation of trophic changes - initially in the form of discolouration and induration of the skin and subcutaneous tissue (C4) and, in the most advanced cases, venous ulcers of the shin (C5-C6).

It is worth noting that PTS is a chronic and usually progressive process. Even after complete healing of the primary thrombosis, the changes in the venous vessel wall are usually irreversible, which explains the chronic nature of post-thrombotic syndrome and the difficulty in treating it.

Dr Cezary Szary, MD. Department of Phlebology. Warsaw

Did you know?

In the case of post-thrombotic syndrome, prevention is better than cure, and how to cure is as early as possible. Proper management in the first few weeks after the onset of venous thrombosis can determine the patient's quality of life for life!

dr n. med. Cezary Szary

Villalta scale in the assessment of post-thrombotic syndrome

Villalta scale is a diagnostic tool used to assess the severity of the symptoms of post-thrombotic syndrome. It was developed by a group of scientists led by the Sergio Villalty and published in 1994. It has served phlebologists for years as the gold standard for diagnosing post-thrombotic syndrome.

This classification assesses 6 physical symptoms (swelling, hardening of the skin, discolouration, redness, venous dilatation, pain on calf pressure) and 5 subjective symptomssuch as pain, cramps, heaviness, paresthesias and pruritus. Each symptom is graded on a 4-point scale from 0 (no symptom) to 3 (high severity). In addition, the presence of venous ulceration of the shin automatically classifies post-thrombotic syndrome as severe.

Villalta scale. Post-thrombotic syndrome. Department of Phlebology.

The interpretation of the results according to the Villalta scale is as follows:

0-4 points - no PTS
5-9 points - mild PTS
10-14 points - moderate PTS
≥15 points (or presence of venous ulceration) - severe PTS

Despite its widespread use, the Villalta scale is not without its limitations. Its drawbacks include low specificity - it may give false-positive results in people with non-thrombotic venous insufficiency and insufficient sensitivity - some post-thrombotic syndrome patients may have low Villalta scale scores, which may lead to an underestimation of the severity of their venous problem. Additionally, the scale does not take into account all the relevant symptoms of post-thrombotic syndrome, such as chroma of venous origin.

Despite its limitations, the Villalta scale has been validated in a number of clinical studies and shows good correlation with Patients' quality of life and other measures of venous disease severity. In clinical practice, however, it is recommended that the Villalta scale results be interpreted in a broader clinical context, also taking into account other diagnostic methods and the individual situation of the Patient.

Imaging diagnostics

Imaging diagnosis of the venous system in post-thrombotic syndrome is absolutely crucial for the comprehensive assessment of the patient. It plays a fundamental role not only in determining the severity of the disease, but also in accurately planning the optimal treatment strategy and in the long-term monitoring of its effects and possible recurrence. Venous Doppler ultrasound is the gold standard and the primary non-invasive diagnostic tool used in the evaluation of post-thrombotic syndrome. It allows accurate imaging of venous morphology, assessment of blood flow, detection of the presence and location of any residual thrombi, stenosis or venous obstruction, as well as assessment of venous valve function.

Post-thrombotic syndrome in ultrasound evaluation (Doppler ultrasound) © Department of Phlebology

Modern ultrasound in the hands of an experienced ultrasonographer allows:

assessment of venous patency
detection of venous reflux and evaluation of valve function and morphology
measuring the diameter of venous vessels
assessment of vein wall thickness and elasticity
detection of post-thrombotic and obstructed segments
evaluation of post-thrombotic changes in the lumen of vessels
accurate assessment of free flows

It is important to remember that a patient with post-thrombotic syndrome should always have a comprehensive examination, i.e. from the level of the feet up to the iliac veins, the veins of the retroperitoneal space, the inferior vena cava and its drainage to the right atrium of the heart. It is also necessary to perform the examination in both the supine and standing positions, using functional tests and during venous reflux provocation manoeuvres. An accurate assessment of the inflow from the level of the popliteal, femoral and deep femoral veins, as well as the outflow including the collateral circulation, is important. Only such an assessment allows stenting of the femoral-iliac bed to be planned, less frequently of the inferior vena cava.

In patients in whom a venous Doppler ultrasound examination may be considered for obstruction, a so-called 'Doppler' is performed. diagnostic imaging extendedą. Other indications for enhanced diagnostic imaging include:

qualification for reconstructive surgery (e.g. venous valveoplasty)
treatment planning and surgery
atypical course of the disease
ineffectiveness of standard treatment
suspicion of other - complex - vascular pathologies

Magnetic resonance venography (English. magnetic resonance venography, MRV) is an advanced imaging technique that offers detailed insight into the anatomy and pathophysiology of the venous system in patients with post-thrombotic syndrome. It has several advantages over CT venography and classic phlebography. Although performed with the administration of a gadolinium contrast agent, it is a less invasive method and does not require exposure to ionising radiation. It is based on the phenomenon of blood flow (movement of protons), which provides better imaging quality and a more detailed assessment of changes in the lumen of post-thrombotic vessels.

MRV examination provides an accurate anatomical evaluation of the venous system. Using MR venography, we can accurately visualise the course of the venous vessels, visualise anatomical variants and identify the collateral circulation, as well as assess the relationship of the veins to surrounding structures and organs. This is crucial in the treatment of post-thrombotic lesions in the course of venous pressure phenomena (e.g. in May-Thurner syndrome). With MRV, it is possible to accurately assess the severity and extent of post-thrombotic lesions, identify the site of stenosis and obstruction and assess the degree of recanalisation.

CT venography: (1) post-thrombotic lesions in the inferior vena cava drain (2) reconstructed 3D collateral circulation in a patient with left iliac drain obstruction (3) fixed post-thrombotic lesions in the right external iliac vein drain.

Computed tomography venography (English. computed tomography venography, CTV) in post-thrombotic syndrome is also a valuable diagnostic tool providing a detailed evaluation of the venous system. The examination is performed after intravenous administration of a contrast agent, using specific scanning protocols adapted to the vein imaging and clinical situation. It is less suitable than MR venography for assessing changes in the lumen of the vessels. However, it allows an accurate assessment of vascular anatomy and the detection of obstructions and obvious stenosis. Particularly valuable is the possibility of three-dimensional image reconstruction, which is crucial when planning endovascular procedures. The method also makes it possible to assess the tissues surrounding the vessels and identify any external pathologies compressing the venous trunks.

Other advantages of CT venography are undoubtedly the short examination time once high spatial resolution. The disadvantages are the exposure to ionising radiation and the need to administer larger amounts of contrast agent than in MRV.

Digital phlebography with the administration of iodine contrast medium is a second-line examination, performed mainly during endovascular treatment planned on the basis of previously performed examinations: Doppler ultrasound and MR venography (or CT). Phlebography allows a precise evaluation of the stenosis from the vascular access side and visualisation of the collateral circulation pathways. It can be used in conjunction with intravascular ultrasound (intravascular ultrasonography, IVUS). However, IVUS is not an essential tool in patients treated for obstruction or palliation in post-thrombotic syndrome.

In summary, properly planned and performed imaging diagnostics is crucial not only for confirming the diagnosis of PTS and the extent of its lesions, but above all for selecting the optimal treatment method and monitoring its effects. This has a direct impact on the effectiveness of treatment and the patients' quality of life.

dr n. med. Cezary Szary - phlebologist, radiologist

Phlebology, Radiology and Imaging Diagnostics

Dr Dominika Plucińska - phlebologist, radiologist

radiology and diagnostic imaging, phlebology

Tomasz Grzela, MD - phlebologist, surgeon

General surgery, phlebology

dr n. med. Jerzy Leszczyński - vascular surgeon

General surgery, vascular surgery

dr n. med. Justyna Wilczko – flebolog, internista

Phlebology, internal medicine, radiology and diagnostic imaging

Dr Krzysztof Celejewski - phlebologist, surgeon

general surgery, phlebology

dr n. med. Łodyga Małgorzata - phlebologist, cardiologist

cardiology, phlebology, Doppler ultrasonography

Dr Marcin Napierała - phlebologist, surgeon

general surgery, phlebology

Treatment methods for post-thrombotic syndrome

Post-thrombotic syndrome this is serious complication of deep vein thrombosiswhich significantly impairs patients' quality of life. Correct and early recognition of post-thrombotic syndrome is crucial for the implementation of appropriate therapeutic management. How effective it will be is already decided at the stage of diagnosis venous thrombosis. Its prompt recognition and implementation of effective treatment reduces the risk of developing post-thrombotic syndrome. Comprehensive treatment of developed post-thrombotic syndrome requires a multidirectional approach, including both conservative methods and, in selected cases, surgical interventions. Effective therapy not only relieves symptoms and improves patients' quality of life, but also prevents the development of complications and progression of the disease.

Principles of treatment of post-thrombotic syndrome

Compression therapy:

knee-length socks or compression stockings (CCL2 or CCL3)
multilayer bandages
non-elastic compression systems (e.g. CircAid) - an alternative to bandages
pneumatic compression device

Pharmacotherapy:

anticoagulants (long-term anticoagulant treatment is recommended to prevent recurrent venous thrombosis and further damage to the veins)
venereal drugs (limited evidence of efficacy)

Lifestyle modification:

weight reduction combined with regular physical activity
limb elevation
avoidance of prolonged standing/sitting

Intervention treatment (in selected clinical cases):

balloon angioplasty and venous stenting
venous valve surgery
surgical reconstruction of the venous system

Prevention:

early incorporation of compression therapy in the treatment of venous thrombosis
appropriate control of anticoagulant treatment
regular medical check-ups (phlebology)
early mobilisation after an episode of deep vein thrombosis

**Proper compression fitting is crucial to the effectiveness of post-thrombotic syndrome treatment.**

Mostly
questions asked

It is important to realise that high temperatures can greatly exacerbate the symptoms of post-thrombotic syndrome. Hot baths and the sauna dilate the venous vessels (including the smallest ones), which can exacerbate swelling and the feeling of heaviness in the legs. For these people, we therefore do not recommend prolonged sauna sessions (up to 5-10 min max.), and we encourage them to forgo hot baths in favour of lukewarm or cool baths. Swimming as a sporting activity is advisable, especially when the water temperature is up to 26-28°C. Movement in which the body is not loaded by gravity has an excellent effect on the venous system.
Regular physical activity is highly recommended in patients with post-thrombotic syndrome. Particularly recommended are daily walks, swimming, not too intensive cycling (also stationary) or exercise in water. Contact sports and exercises with heavy loads should be avoided. Physical activity improves blood circulation, strengthens the calf muscle pump and reduces swelling in the lower legs. Start with short sessions and gradually increase activity time. Reduce the intensity of the exercises or stop them if pain or significant discomfort develops.
Post-thrombotic syndrome is not an absolute contraindication to pregnancy. However, patients who have undergone deep vein thrombosis and have developed post-thrombotic syndrome require special management during pregnancy. We recommend:
- consultation with a haematologist or phlebologist before the planned pregnancy
- establishment of an individual thromboprophylaxis plan
- regular phlebological check-ups during pregnancy (preferably at the end of the first trimester and at the beginning of the third)
- selection of appropriate compression therapy for pregnancy and the postpartum period
- cure pelvic venous insufficiency before pregnancy, if possible and it causes a large venous stasis (prothrombotic state).
During long air journeys (lasting more than 4-6h), patients with PTS are at particular risk of recurrent deep vein thrombosis. In such cases, we recommend:
- wearing knee-length socks or compression stockings (type of product and compression class should be selected by a phlebologist) during the entire flight
- regular (every 1-2 hours) walks on board the aircraft
- performing foot and calf exercises while sitting (preferably several repetitions per hour)
- adequate hydration (minimum 250 ml of water every 2 hours)
- for long flights (over 4 hours), it is worth consulting a phlebologist and asking about the need for a prophylactic dose of low molecular weight heparin or other oral anticoagulant.
Post-thrombotic syndrome (PTS) is a chronic condition resulting from damage to the veins, usually the deep system. Its symptoms may persist even throughout life. It is estimated that post-thrombotic syndrome develops in up to 20-50% patients who have undergone deep vein thrombosis. Its development usually occurs within the first 2 years. Symptoms of post-thrombotic syndrome may worsen over time, especially if anticoagulant, phlebotropic treatment is not used and the patient does not conscientiously use compression therapy.

The scientific activities of the team at the Department of Phlebology make a significant contribution to the development of modern phlebology. Our scientific research and publications confirm the effectiveness of innovative and proprietary treatment methods, setting new standards in the treatment of venous diseases.

Venous embolisation. An important step in the sequential causal treatment of venous insufficiency.

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Do patients with recurrent venous disease benefit more from sequential treatment than patients without previous venous interventions?

The doctors of the Phlebology Clinic have pioneered the causal treatment of venous disease worldwide. Our proprietary treatment methods, validated by scientific research and prestigious publications, have opened up new possibilities for all phlebology patients.

Pregnant woman with ultrasound result. Varicose veins of the intimate area.

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Can the number of pregnancies be a predictor of venous disease progression and influence the effectiveness of treatment?

The introduction of a proprietary haemodynamic and radiological classification used in the assessment of ovarian venous insufficiency has facilitated treatment planning for patients with pelvic venous insufficiency. This proprietary method allows for a precise assessment of blood flow abnormalities, enabling clinicians to select the optimal therapeutic strategy.

Venous embolisation. Vascular laboratory of the Department of Phlebology. Cezary Szary

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Radiological-hemodynamic classification of ovarian venous insufficiency

The doctors of the Phlebology Clinic were pioneers in the use of the varicose vein bonding method in Poland. We were the first to introduce this innovative, minimally invasive technique into clinical practice in our country. We encourage you to read the results of a study comparing the effectiveness of adhesive and intravenous laser ablation in the treatment of venous insufficiency of the lower limbs.

Adhesive of varicose veins. Glue. Clinic of Phlebology.

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A 2-year follow-up study evaluating treatment of limbic venous insufficiency using cyanoacrylate glue and intravenous laser ablation

Venous thrombosis - what are the symptoms?

Early detection of venous thrombosis is the key to successful treatment! ✅ In this video we show you what to look out for and what symptoms should worry you. Don't underestimate the signals your body is sending you! 👂

How long do I have to take anticoagulants after a deep vein thrombosis that occurred after skiing?
The duration of anticoagulant treatment after deep vein thrombosis is usually at least three months. In the case of thrombosis caused by factors such as trauma or immobilisation (e.g. after skiing), the doctor may recommend a longer treatment period, especially if there are additional risk factors for recurrence.

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Vascular spider veins

Pajączki naczyniowe to drobne, czerwone lub sine rozszerzenia naczyń krwionośnych pod skórą, przypominające swoim wyglądem pajęczynę.

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Varicose veins of the lower limbs

Varicose veins are permanent dilations of the superficial veins of the legs, visible through the skin, resulting from venous valve insufficiency.

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Venous edema of the shin

Venous oedema of the shin is a visible enlargement of tissue volume in the lower leg area, caused by venous blood stasis and increased vascular permeability.

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Pelvic venous insufficiency

Pelvic venous insufficiency manifests as chronic pelvic pain and discomfort, resulting from stagnation of venous blood in the venous plexuses of the reproductive organs.

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Venous compression syndromes

Venous compression syndromes arise from obstruction of venous blood outflow through large vascular trunks in the pelvis and abdominal cavity.

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Venous disease in pregnancy

Venous disease in pregnancy develops under the influence of hormonal and mechanical changes associated with the developing pregnancy, leading to venous stasis and varicose vein formation.

Perineal and groin pain. Varicose veins of the seminal vagina.

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Varicose veins of the spermatic cord

Vestibular varices are the most common symptom of a condition called male pelvic venous insufficiency.

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Venous thrombosis

Venous thrombosis is a serious condition of the venous system in which a thrombus (clot) forms inside an altered venous vessel.

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Venous embolisation. Vascular laboratory. Phlebology Clinic.

Modern vein treatment

We offer treatment both on an outpatient basis and in day ward admissions. The stay is of short duration. The patient spends between 1 and 5 hours in the Clinic.

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