Post-Thrombotic Syndrome

Aka: Post-Thrombotic Syndrome, Postthrombotic Syndrome, Post-Phlebitic Syndrome, Postphlebitic Syndrome

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II. Definitions

  1. Post-Thrombotic Syndrome (Post-Phlebitic Syndrome)
    1. Complication of Deep Vein Thrombosis (DVT) resulting in severe symptomatic Venous Insufficiency
    2. Symptoms include edema, pain, myalgias and may be further complicated by Venous Stasis Ulcers

III. Epidemiology

  1. Postthrombotic Syndrome is seen in 20 to 50% of patients with history of DVT
  2. Severe Postthrombotic Syndrome (e.g. Venous Stasis Ulcers) occurs in 5 to 10% of patients after DVT

IV. Pathophysiology

  1. Persistent venous Occlusion and valvular reflux result in increased venous pressures (venous Hypertension)
    1. Residual venous thrombus typically remains following DVT Anticoagulation
  2. Venous Hypertension results in Muscle hypoperfusion, decreased tissue integrity and increased permeability
    1. Leads to chronic inflammation-mediated edema

V. Risk Factors

  1. Anatomically extensive Deep Vein Thrombosis
  2. Recurrent Deep Vein Thrombosis on the same side
  3. Persistent extremity symptoms one month after the acute Deep Vein Thrombosis
  4. Older age (up to 3 fold increased risk)
  5. Obesity (BMI>30 doubles risk)

VI. Symptoms

  1. Characteristics
    1. Limb Pain
    2. Limb heaviness of Fatigue
    3. Limb swelling
  2. Provocative
    1. Standing
    2. Walking
  3. Palliative
    1. Rest
    2. Limb elevation

VII. Signs

  1. See Venous Insufficiency
  2. Acute Venous Insufficiency findings
    1. Limb Edema
    2. Limb Redness
    3. Limb dusky Cyanosis
  3. Chronic Venous Insufficiency findings
    1. Telangiectasias (esp. peri-malleolar)
    2. New Varicose Veins
    3. Stasis Hyperpigmentation
    4. Lipodermatosclerosis (skin and subcutaneous tissue thickening)
    5. Venous Stasis Ulcers

VIII. Grading: Severity

  1. See Villalta Post-Thrombotic Syndrome Scale (Villalta-Prandoni Scale)

IX. Management

  1. Bothersome Leg Edema is reduced with below knee graded Compression Stockings
    1. Prandoni (2004) Ann Intern Med 141:249-56 [PubMed]
  2. Encourage 30 minute walk per day
    1. Kahn (2011) CMAJ 183(1):37-44 +PMID:21098066 [PubMed]

X. Prevention

  1. See Deep Vein Thrombosis Prevention
  2. Prevent the first DVT
  3. Prevent subsequent DVT
    1. Maximize compliance with Anticoagulation after DVT
    2. Avoid subtherapeutic INR with Warfarin (esp. in the first month after DVT diagnosis)
  4. Elastic Compression Socks (30-40 mmHg knee high) following lower extremity DVT
    1. May prevent Postthrombotic Syndrome with 30-40 mmHg knee high socks
    2. However mixed study results
    3. Berntsen (2016) Am J Med 129(4): 447 [PubMed]
    4. Kahn (2014) Lancet 383(9920): 880-8 [PubMed]
  5. Acute catheter directed Thrombolysis with or without thrombectomy
    1. Consider in acute proximal DVT (e.g. iliac vein or upper femoral vein)
    2. Lowers, but does eliminate risk of Post-Thrombotic Syndrome
    3. Enden (2012) Lancet 379(9810): 31-8 [PubMed]
    4. Watson (2014) Cochrane Database Syst Rev 1(1): CD002783 [PubMed]

XI. References

  1. Baldwin (2013) J Thromb Haemost 11(5):795-805 +PMID: 23433231 [PubMed]
  2. Kahn (2016) Hematology 2016(1):413-8 +PMID: 27913509 [PubMed]

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