Post thrombotic syndrome

Post-thrombotic syndrome an important complication from having had a blood clot or deep venous thrombosis (DVT) in your legs ¹. Post-thrombotic syndrome develops in about 20% to 50% of patients who develop DVT in their legs, even when appropriate anticoagulant therapy is used to treat the DVT and it is the most common DVT complication ². Post-thrombotic syndrome is a frequent complication of DVT and develops within 2 years of DVT diagnosis and is severe in 5% to 10% of cases ³. Hence on average, about 6 of 10 patients can expect to recover from DVT without any residual symptoms, 3 of 10 will have some degree of post-thrombotic syndrome, and 1 in 10 to 1 in 20 will have severe post-thrombotic syndrome, which can include leg ulcers.

Manifestations of post-thrombotic syndrome vary from mild clinical symptoms or signs to more severe manifestations such as chronic leg pain that limits activity and the ability to work, intractable edema, and leg ulcers ³. Post-thrombotic syndrome adversely affects quality of life and productivity and is costly as measured by health resource utilization, direct costs, and indirect costs ⁴.

What is DVT?

Deep vein thrombosis, commonly referred to as DVT, occurs when a blood clot, or thrombus, develops in the large veins of the legs or pelvic area. Some DVTs may cause no pain, but others can be quite painful. If DVTs are identified and treated early, very few are life-threatening.

Post thrombotic syndrome causes

Post-thrombotic syndrome is thought to develop after DVT as a result of venous hypertension (ie, increased venous pressures). Venous hypertension reduces calf muscle perfusion, increases tissue permeability, and promotes the associated clinical manifestations of post-thrombotic syndrome. Two pathologic mechanisms contribute to venous hypertension: persistent (acute, then residual) venous obstruction and valvular reflux caused by damage to vein valves.6 Standard anticoagulant treatment of DVT prevents thrombus extension and embolization to the pulmonary arteries but does not directly lyse the acute thrombus, and in many cases only partial clearance of thrombus occurs. Inflammation may play a role in promoting the development of post-thrombotic syndrome by delaying thrombus resolution and by inducing vein wall fibrosis, which promotes valvular reflux ⁵. There may also be a genetic predisposition to post-thrombotic syndrome from gene polymorphisms associated with vein wall remodeling ⁶.

Risk factors for post-thrombotic syndrome

Although it is not yet possible to precisely predict the absolute risk of post-thrombotic syndrome in an individual patient with DVT, research done over the last 5 to 10 years has provided new information on various risk factors for post-thrombotic syndrome, which has been detailed in 2 recent reviews ⁷. This information is summarized next, grouped according to the time points at which patients with DVT are assessed in clinical practice.

Risk factors apparent at time of DVT diagnosis

• DVT location: Risk of post-thrombotic syndrome is higher (two- to threefold) after proximal (especially with involvement of the iliac or common femoral vein) than distal (calf) DVT.
• Previous ipsilateral DVT.
• Preexisting primary venous insufficiency: up to twofold increased risk of post-thrombotic syndrome.
• Elevated body mass index (BMI): obesity (BMI >30) more than doubles the risk of post-thrombotic syndrome.
• Older age increases the risk of post-thrombotic syndrome; reported increased risk from 30% to threefold.

The following factors appear to have little or no effect on the risk of developing post-thrombotic syndrome: sex, whether DVT was provoked vs unprovoked, and biological thrombophilia.

Risk factors related to treatment of acute DVT

• Quality of oral anticoagulation: post-thrombotic syndrome risk increases twofold if the level of anticoagulation is inadequate (eg, subtherapeutic international normalized ratio [INR] >50% time) during the first 3 months of treatment with vitamin K antagonists.
• Choice of anticoagulant to treat DVT: It is not known whether use of the new direct oral anticoagulants to treat DVT influences the risk of post-thrombotic syndrome, compared with treatment with low-molecular-weight heparin (LMWH) or vitamin K antagonists. A meta-analysis of available data suggested that use of LMWH monotherapy to treat DVT may lead to lower rates of post-thrombotic syndrome than treatment with LMWH for 5 to 7 days followed by vitamin K antagonists ⁸. Large multicenter trials that use validated criteria to diagnose post-thrombotic syndrome are needed to confirm the effectiveness of extended LMWH in patients at high risk for post-thrombotic syndrome, and also to assess the effectiveness of new direct oral anticoagulants in preventing post-thrombotic syndrome.
• The potential role of thrombolysis in reducing the risk of post-thrombotic syndrome is discussed in the next section.

Risk factors apparent during follow-up after DVT

• Ipsilateral DVT recurrence: Increases risk of post-thrombotic syndrome four- to sixfold, presumably by damaging compromised venous valves or aggravating venous outflow obstruction.
• Persistent venous symptoms and signs 1 month after acute DVT: Increases risk of subsequent post-thrombotic syndrome ⁹.
• Residual thrombosis on ultrasound (eg, 3-6 months after acute DVT): Modest (1.5- to twofold) increased risk of post-thrombotic syndrome.
• Persistent elevation of d-dimer: Elevated levels of d-dimer in the weeks to months after DVT may be a modest risk factor for post-thrombotic syndrome ¹⁰.

Post thrombotic syndrome prevention

Preventing first and recurrent DVT

Preventing the first occurrence of DVT by improving the systematic use of thromboprophylaxis in high-risk hospitalized patients as recommended in evidence-based consensus guidelines will prevent some cases of post-thrombotic syndrome ¹¹. Because ipsilateral DVT recurrence is a strong risk factor for post-thrombotic syndrome, reducing the risk of recurrent DVT by providing optimal anticoagulation of appropriate intensity and duration to treat the initial DVT is an important clinical goal ¹². In patients treated with vitamin K antagonists, frequent, regular INR monitoring to avoid subtherapeutic INRs in the first months after DVT may also reduce the risk of post-thrombotic syndrome ¹³. Data are insufficient to make specific recommendations regarding choice of anticoagulant to treat DVT, namely a vitamin K antagonist vs a direct, target-specific oral anticoagulant versus low-molecular-weight heparin (LMWH) monotherapy, on the outcome of developing post-thrombotic syndrome.

Use of elastic compression stockings

Elastic compression stockings, by reducing leg swelling and venous hypertension, could plausibly play a role in preventing post-thrombotic syndrome. However, there are conflicting data on the long-term effectiveness of elastic compression stockings to prevent post-thrombotic syndrome. In the past, evidence-based consensus guidelines recommended the use of elastic compression stockings for at least 2 years after DVT to prevent post-thrombotic syndrome, based on results of 2 previous small open-label trials that reported that wearing 30- to 40-mm Hg knee-high elastic compression stockings for at least 2 years after proximal DVT was effective in preventing post-thrombotic syndrome ¹⁴. However, a recent multicenter, randomized, placebo-controlled trial in 803 patients with proximal DVT (SOX Trial) showed no evidence of benefit of active compression stockings, worn for 2 years, to prevent post-thrombotic syndrome, to reduce the risk of recurrent venous thromboembolism, or to improve quality of life ¹⁵. A recent meta-analysis that incorporated data from the SOX Trial reported a pooled hazard ratio for post-thrombotic syndrome with elastic compression stockings of 0.69. However, the authors caution that there is very low confidence in this pooled estimate because of heterogeneity and inclusion of unblinded studies at high risk of bias, and that the recent, highest-quality evidence available suggests no effect of elastic compression stockings on post-thrombotic syndrome ¹⁶. Based on these new data, the latest guideline statements do not advocate the routine use of elastic compression stockings to prevent post-thrombotic syndrome ¹².

Although elastic compression stockings are unlikely to cause harm, they can be difficult to apply, uncomfortable, expensive, and require replacement every few months. In light of the current state of evidence, Dr. Kahn do not routinely prescribe elastic compression stockings to all her patients with DVT. Dr. Kahn ² clinical approach is to prescribe a trial of 20- to 30-mm Hg or 30- to 40-mm Hg below-knee elastic compression stockings to patients with residual leg swelling or discomfort after proximal or distal DVT, and to continue wearing them for as long as the patient derives symptomatic benefit or is able to tolerate them.

Thrombolysis of acute DVT to prevent post-thrombotic syndrome

Up-front thrombolytic therapy in conjunction with heparin to treat acute DVT leads to higher rates of vein patency and better preservation of valve function than the use of heparin alone ¹⁷.

Catheter-directed thrombolysis or pharmacomechanical catheter-directed thrombolysis (catheter-directed thrombolysis plus mechanical disruption of thrombus) are likely to be safer and more effective than systemic thrombolytic therapy and could prove to be promising techniques as a means of preventing post-thrombotic syndrome, primarily after proximal DVT ¹⁸. In a recent multicenter randomized controlled trial of modest size (n = 189), the use of additional catheter-directed thrombolysis in anticoagulated patients with acute DVT involving the iliac and/or upper femoral vein was associated with a statistically significant (P = .047) 26% relative reduction in risk of post-thrombotic syndrome at 2 years, at the cost of an additional 3% rate of major bleeding ¹⁹. However, post-thrombotic syndrome still developed in 41% of catheter-directed thrombolysis patients, indicating that catheter-directed thrombolysis does not eliminate the risk of post-thrombotic syndrome, and catheter-directed thrombolysis did not result in improved quality of life at 2 years’ ²⁰ or 5 years’ follow-up ²¹, suggesting that additional endovascular thrombolytic approaches should be investigated. Larger multicenter trials of pharmacomechanical catheter-directed thrombolysis plus standard anticoagulation versus standard anticoagulation alone to prevent post-thrombotic syndrome are ongoing ²², with results expected within 1 to 2 years. Dr. Kahn carefully consider patients for these techniques on a case-by-case basis: namely, those with extensive (eg, iliofemoral) thrombosis with recent onset (ie, ≤14 days) of symptoms, a low risk of bleeding, and a life expectancy of at least 1 year, who are seen at hospital centers experienced in performing these techniques.

Post thrombotic syndrome symptoms

The clinical manifestations of post-thrombotic syndrome are similar to those of primary venous insufficiency and comprise a constellation of symptoms and signs that vary from patient to patient ².

Typical post-thrombotic syndrome symptoms include ²:

• leg pain
• sensations of leg heaviness, pulling, or fatigue; and
• limb swelling.

Symptoms can be present in various combinations, may be persistent or intermittent, and are usually aggravated by standing or walking and tend to improve with rest and leg elevation.

Typical post-thrombotic syndrome signs may include ²:

• leg edema, redness, dusky cyanosis when the leg is in a dependent position,
• perimalleolar or more extensive telangiectasiae,
• new varicose veins,
• stasis hyperpigmentation,
• thickening of the skin and subcutaneous tissues of the lower limb known as lipodermatosclerosis, and
• in severe cases, leg ulcers, which may be precipitated by minor trauma.

These are characteristically chronic, painful, and slow to heal; require close medical attention; and often recur. The intensity of symptoms and signs of post-thrombotic syndrome tends to increase over the course of the day. Their severity ranges from minimal discomfort and cosmetic concerns to severe clinical manifestations such as chronic pain, intractable edema, and leg ulceration.

Post thrombotic syndrome diagnosis

There exists no gold standard biomarker, imaging, or physiologic test that establishes the diagnosis of post-thrombotic syndrome ². Post-thrombotic syndrome is primarily diagnosed on clinical grounds, based on the presence of typical symptoms and signs in a patient with previous DVT. In some patients, it can take a few months for the initial pain and swelling associated with acute DVT to resolve, hence a diagnosis of post-thrombotic syndrome should be deferred until after the acute phase (ie, 3-6 months) has passed ²³. Symptoms of post-thrombotic syndrome usually manifest within 3 to 6 months after DVT, but can occur up to 2 years or longer after DVT ²⁴.

The Villalta scale (sometimes called the Villalta-Prandoni scale) ²⁵ has been adopted by the International Society on Thrombosis and Hemostasis as a standard to diagnose and grade the severity of post-thrombotic syndrome in clinical studies ²³. The Villalta scale’s components (5 patient-reported symptoms and 6 clinician-assessed signs) are each rated on a 4-point severity scale (from 0 to 3), and the points are summed to produce a total score; a score >4 or the presence of an ulcer denotes post-thrombotic syndrome (Table 1). The Villalta scale has been shown to be valid, reproducible, and responsive to clinical change and is easy to administer. The Villalta scale has been used to diagnose post-thrombotic syndrome in a number of recent multicenter randomized trials of interventions to prevent and treat post-thrombotic syndrome ¹⁵.

Recently, a fully patient-reported version of the Villalta scale was developed and validated ²⁶. In this version, the patient completes all questions on symptoms and signs, using a visual guide for assistance with ratings of clinical signs severity. By reducing the need for in-person study visits, use of this tool may increase the efficiency and reduce resource needs in future clinical studies of post-thrombotic syndrome.

Additional diagnostic or classification scales have been used to assess post-thrombotic syndrome, including the CEAP classification, Ginsberg measure, and Venous Clinical Severity Score (VCSS) ³.

Table 1. Villalta post-thrombotic syndrome scale

Assessment of:
• 5 symptoms (pain, cramps, heaviness, pruritus, paresthesia) by patient self-report
• 6 signs (edema, skin induration, hyperpigmentation, venous ectasia, redness, pain during calf compression) by clinician assessment
Severity of each symptom and sign is rated as 0 (absent), 1 (mild), 2 (moderate) or 3 (severe). In addition, ulcer is noted as present or absent.
Points are summed to yield the total Villalta score:
0-4:	No post thrombotic syndrome
5-9:	Mild post thrombotic syndrome
10-14:	Moderate post thrombotic syndrome
≥15, or presence of ulcer	Severe post thrombotic syndrome

Post thrombotic syndrome treatment

Current approaches to treating post thrombotic syndrome.

Table 2. Suggested approaches to prevent and treat post thrombotic syndrome

Prevention
Prevent the occurrence of DVT with the use of thromboprophylaxis in high-risk patients and settings as recommended in evidence-based consensus guidelines.
Prevent recurrent ipsilateral DVT by providing anticoagulation of appropriate intensity and duration for the initial DVT and by targeted use of appropriate thromboprophylaxis if long-term anticoagulation is discontinued.
In patients whose DVT is treated with a vitamin K antagonist, frequent, regular INR monitoring should be performed to avoid subtherapeutic INRs, especially in the first 3 months of treatment.
Do not routinely prescribe elastic compression stockings (ECS) for 2 years to all DVT patients. However, it is reasonable to prescribe a trial of 20-30–mm Hg or 30-40–mm Hg below-knee elastic compression stockings to patients who have residual leg swelling or discomfort after DVT, and to continue wearing them for as long as the patient derives symptomatic benefit or is able to tolerate them.
The role of thrombolysis for the prevention of post thrombotic syndrome is not yet established. Pharmacomechanical catheter-directed thrombolysis is currently undergoing evaluation in large, well-designed trials. At present, selection of patients for these techniques should be done on an individual patient basis, and mainly considered for those with extensive thrombosis, recent symptom onset, low risk of bleeding, and long life expectancy, seen at experienced centers.
Treatment
Use elastic compression stockings to reduce edema and improve post thrombotic syndrome symptoms such as leg pain and heaviness. If 20-30–mm Hg stockings do not adequately control post thrombotic syndrome symptoms, a stronger pressure stocking (30-40 mm Hg; or 40-50 mm Hg) can be tried.
Consider a trial of intermittent pneumatic compression units in patients with moderate to severe post thrombotic syndrome.
Consider prescribing a supervised exercise training program with leg strengthening and aerobic components for ≥6 months to patients with post thrombotic syndrome who can tolerate it.
Until more safety and effectiveness data are available, do not use venoactive drugs to treat post thrombotic syndrome.
A multidisciplinary approach should be used for venous ulcer management, which typically consists of compression therapy, skin care, and topical dressings.
In patients with symptoms of upper extremity post thrombotic syndrome, a 20-30–mm Hg or 30-40–mm Hg compression sleeve should be tried.
Providing patient support and ongoing follow-up is an important component of post thrombotic syndrome management.

[Source ² ]

Compression therapy

Compression-based therapies, usually elastic compression stockings, are the cornerstones of managing established post thrombotic syndrome. Their use is intended to reduce post thrombotic syndrome symptoms (especially leg swelling, sensation of heaviness, and discomfort) and improve daily functioning. Patients should be educated on how to apply and use elastic compression stockings and on the importance of compliance to maximize their benefit. Because few controlled studies of their effectiveness in post thrombotic syndrome have been performed, their use in clinical practice is based primarily on extrapolation from patients with primary venous insufficiency, the low risk of harm, and the possibility of benefit to at least some patients with post thrombotic syndrome. The principal contraindication to using elastic compression stockings is symptomatic peripheral arterial disease, because claudication can worsen when stockings are worn. Dr. Kahn approach is to prescribe the daily use of 20- to 30-mm Hg elastic compression stockings to patients with post thrombotic syndrome-related leg heaviness or swelling, and advise the patient to apply their stockings in the morning and to remove them at bedtime or in the early evening. Dr. Kahn prescribe knee-length elastic compression stockings, which have similar physiologic effects to thigh-length elastic compression stockings and are easier to apply, more comfortable, and less costly ²⁷. If 20- to 30-mm Hg elastic compression stockings does not adequately control post thrombotic syndrome symptoms, a stronger pressure stocking (30-40 mm Hg; or 40-50 mm Hg) can be tried.

In patients with moderate to severe post thrombotic syndrome whose symptoms are not adequately controlled with elastic compression stockings alone, the portable, battery-powered Venowave intermittent compression device can be tried. In a randomized crossover trial in 32 patients with severe post thrombotic syndrome, wearing the device on the affected leg alone or in combination with elastic compression stockings was associated with improvement in quality of life and reduced severity of post thrombotic syndrome ²⁸. For patients with severe, intractable post thrombotic syndrome symptoms or severe edema, intermittent pneumatic compression sleeve units (eg, used for 20-30 minutes at a time, 2-3 times per day) can be used to provide symptom relief ²⁹; however, patients may find these units to be cumbersome and expensive.

How can I get compression stockings?

There are different types of compression stockings, and each type is used for different reasons. To prevent or treat post thrombotic syndrome, your health care provider will prescribe a prescription strength stocking. You should take the prescription to a pharmacy or medical supply store that sells the stockings. Ask someone to at the store or pharmacy to measure your leg for the correct size stocking. It is best to visit the medical supply store in the morning, when your leg is least swollen, to get the most accurate measurement.

Caution: If you experience poor blood flow in your leg arteries (different from your leg veins) compression stockings may not be the right choice for you. Talk to your health care provider before purchasing compression stockings.

What kind of compression stockings should I get?

The level of tightness in compression stockings is measured in millimeters of mercury (mm Hg). To prevent or treat post thrombotic syndrome, you will need a stocking that provides a compression strength of 30-40 mm Hg. Your health care provider will indicate this on your prescription. If you are unable to wear this strength of stocking, your health care provider may prescribe a lower strength for you.

Compression stockings come in different styles: knee-high, thigh-high, or full-length. They are available in more fashionable fabrics than in the past. You can wear knee-high stockings even if your blood clot is above the knee. Most people think the knee-high stockings are more comfortable and easier to put on than the longer styles, and you will have the same relief in post thrombotic syndrome symptoms with the knee-high style.

How to put on elastic compression stockings

Compression tights or elastic compression stockings are designed to fit tightly. It may take time and practice to get used to putting on these items correctly. Here are some tricks you can use to put on your stocking:

1. Put your stocking on first thing in the morning when your leg is less painful and swollen.
2. Gently pull the compression stocking up your leg, smoothing the extra material as you pull. Make sure the heel is in the correct position and the seams are straight. If you are putting on a thigh high or longer stocking, stand up to continue pulling it over your knee, hips and waist.
3. Compression stockings should be smooth, especially at the ankle or behind the knee. Do not roll knee-high or thigh-high compression stockings at the top. Do not fold the stocking down if it seems too long.
4. Try wearing rubber gloves, like those sold for household cleaning, or buy special gloves made by the compression apparel companies. The rubber gloves make it easier to grip the material firmly and smooth out wrinkles. The rubber gloves also protect the compression clothing from tears caused by your fingernails or jewelry. If you get a tear or run, then the stocking does not give you the necessary compression.
5. Apply talcum powder to your leg to make the stocking go on more smoothly. If you use a lotion of any kind, be sure it is dry before putting your stockings on.
6. Purchase a “stocking aid” at a medical supply store. This is a plastic or metal frame that you place in the stocking, and then slide it out as you slide your foot in.
7. Have a friend or family member help you with putting on the stockings and taking them off.

If you don’t wear your compression stockings for a day or two, it may be too difficult to put them on. If your limb swells too much and you cannot get the stockings on because they are too tight, you may need to wrap the limb as instructed by your health care provider.

When do I wear the stockings?

• If you have leg pain and swelling for several weeks after your blood clot was found, you should begin wearing the stockings as soon as possible.
• Stockings are sold in pairs, but you only need to wear a stocking on the leg with the blood clot.
• You should begin by putting your stocking on first thing in the morning when your leg is least swollen.
• You may take the stocking off at bedtime. If you are able to elevate your leg while sitting or lying down in the evening, you can remove the stocking at that time as well.

How long do I have to wear the stockings?

You should wear the stockings daily as long as they continue to make your leg feel better. Some research shows that you should wear compression stockings for as long as two years after your blood clot to prevent post thrombotic syndrome.

Caring for compression stockings

Wash the stocking every other day with a mild soap. Do not use Woolite™ detergent. Use warm water and wash by hand or in the gentle cycle in the washing machine. After rinsing the compression stocking completely, remove excess water by rolling it in a towel.

You can either air-dry or dry it in the dryer on the delicate cycle at a cool temperature. It may be convenient to have two compression stockings so you have one to wear while the other is being washed or dried. Order the second stocking after you are sure that the fit of your first one is correct.

The most important things about compression stockings are to wear them consistently and replace them regularly. Over time, any compression clothing will lose its elasticity and its effectiveness. Compression stockings last for about 4-6 months with proper care. A prescription for compression therapy is good for one year. You may need to be remeasured every year, especially if you have gained or lost more than 15 pounds. If you have further questions about your compression apparel, be sure to contact your health care provider.

Medications

As summarized in a recent systematic review and meta-analysis ³⁰, 4 randomized trials have evaluated the effectiveness of “venoactive” drugs for post thrombotic syndrome: 3 parallel trials and 1 crossover study. The drugs evaluated were rutosides (thought to reduce capillary filtration and microvascular permeability), defibrotide (downregulates plasminogen activator inhibitor-1 release and upregulates prostacyclin, prostaglandin E2, and thrombomodulin), and hidrosmin (mechanism of action unknown). Overall, there is low-quality evidence to support the use of venoactive drugs to treat post thrombotic syndrome because studies were limited by a high degree of inconsistency and imprecision. Also, drug treatment was usually of short duration (eg, 8 weeks to a few months), and potential long-term side effects are unknown. More rigorous studies using validated measures of clinically important outcomes, including quality of life, are needed to assess the safety, effectiveness, and sustainability of pharmacologic treatments for post thrombotic syndrome. At present, Dr. Kahn do not suggest the use of venoactive drugs to treat post thrombotic syndrome. Further, there is no evidence that use of diuretics is effective for the treatment of post thrombotic syndrome-related edema.

Post thrombotic syndrome exercise

Two small trials have assessed the effectiveness of exercise to treat post thrombotic syndrome. In a study of 30 patients with chronic venous insufficiency (half had prior DVT), a 6-month leg-strengthening exercise program led to improved calf muscle function and calf muscle strength ³¹. In a 2-center Canadian pilot study, a 6-month exercise training program designed to increase leg strength, leg flexibility, and overall cardiovascular fitness improved post thrombotic syndrome severity and quality of life, with no adverse events ³². Although not definitive, the available data suggest that exercise may benefit patients with post thrombotic syndrome. Dr. Kahn recommend her patients with post thrombotic syndrome to undertake a supervised (at least initially) exercise training program consisting of leg strengthening and aerobic activity for 6 months or more, if they can tolerate it.

Additional common sense lifestyle advice that is relevant to all patients with chronic venous insufficiency includes reducing venous stasis by keeping active and avoiding a sedentary lifestyle; raising the legs on a footrest when seated or elevating the legs on a firm pillow when lying down; avoiding prolonged exposure to heat, which can aggravate symptoms of leg heaviness and swelling; maintaining a healthy, nonobese body weight; and using a moisturizing lotion to avoid skin dryness and breakdown.

Venous ulcer management

DVT in 5% to 10% of patients will progress to severe post thrombotic syndrome, which can include venous leg ulcers. Patients with post-thrombotic ulcers should be treated using a multidisciplinary team approach that ideally includes an internist, dermatologist, vascular surgeon, and wound care nurse. Post-thrombotic venous ulcers are treated with compression therapy, including multicomponent compression bandages, leg elevation, topical dressings, and sometimes hemorheologic agents like pentoxifylline, and may require weeks to months to heal. Ulcers can be refractory to therapy, and they often recur. Surgery or endovascular procedures to treat a major refluxing vein may be advocated in select patients when conservative treatment fails. For more detailed discussion of venous ulcer management, please refer to recent published reviews and consensus guidelines ³, ³³.

Post thrombotic syndrome surgery

Surgical or endovascular procedures such as venous valve repair, venous bypass, and venous stents to treat appropriately selected patients with post thrombotic syndrome may have potential to decrease post-thrombotic manifestations that are attributable to deep vein obstruction or valvular reflux. However, well-designed studies have not been performed to date, experience with these procedures varies significantly among practitioners, and complications and failure rates are uncertain. Hence, these interventions should not be routinely used in unselected post thrombotic syndrome populations. However, for selected patients with moderate-to-severe post thrombotic syndrome who have substantial disability and daily life limitations, it may be appropriate to consult with an endovascular specialist who has experience with assessing and managing complex venous disease. For more detailed discussion of surgical and endovascular treatments for post thrombotic syndrome, please refer to a recently published American Heart Association consensus guideline ³ and a White Paper on endovascular therapy for post thrombotic syndrome management ³⁴.

Upper limb post thrombotic syndrome

After upper extremity DVT, post thrombotic syndrome will develop in 15% to 25% of patients ³⁵. Upper extremity post thrombotic syndrome can reduce quality of life and limb function ³⁶. Symptoms include arm swelling, heaviness, and exertional fatigue. Dilation of the superficial veins of the upper arm and chest wall and dependent cyanosis of the arm may be noted. Not surprisingly, dominant-arm post thrombotic syndrome is associated with worse quality of life and disability than non–dominant-arm post thrombotic syndrome ³⁷. Data to guide the management of upper extremity post thrombotic syndrome are lacking. There have been no trials of compression sleeves or bandages to prevent or treat upper extremity post thrombotic syndrome, and it is not known whether endovascular or surgical treatment of upper extremity DVT leads to lower rates of post thrombotic syndrome than standard anticoagulation alone. Anecdotal experience suggests that patients with persistent arm swelling and pain after upper extremity DVT may derive symptomatic relief from elastic bandages or compression sleeves. Because of the potential for benefit and low potential for harm, Dr. Kahn prescribe a trial of a 20- to 30-mm Hg or 30- to 40-mm Hg compression sleeve in patients with symptoms of upper extremity post thrombotic syndrome.

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