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Semin Vasc Med 2001; 01(1): 071-080
DOI: 10.1055/s-2001-14543
Copyright © 2001 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel.: +1(212) 584-4662

Postthrombotic Syndrome: Incidence, Prevention, and Management

Enrico Bernardi, Paola Bagatella, Michela Frulla, Paolo Simioni, Paolo Prandoni
  • Department of Medical and Surgical Sciences, University of Padua Medical School, Padua, Italy
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Publikationsverlauf

Publikationsdatum:
31. Dezember 2001 (online)

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ABSTRACT

Mild to severe postthrombotic sequelae, including chronic pain, edema, and ulceration, arise in one third of patients short after deep vein thrombosis (DVT).

Recurrent DVT is closely associated with the development of postthrombotic syndrome (PTS), whereas if the extent and location of DVT might be relevant remains unclear. Chronic venous hypertension and abnormal microvessel or lymphatic function also correlates with PTS.

The diagnosis of PTS is based on clinical grounds only if patients report a history of documented DVT; otherwise, objective testing is required.

To abate the prevalence of PTS, the best policy is represented by prevention of recurrent thrombosis and use of stockings. Despite a plenty of surgical options, conservative treatment is preferable because half of the patients improve or remain stable during follow-up, provided they wear elastic stockings.

Clinical presentation has a prognostic value, as patients with initially severe symptoms enjoy a more favorable outcome than those who progressively deteriorate over time.

KEYWORD

Postthrombotic syndrome - standardized clinical evaluation - leg ulceration - compression stockings

REFERENCES

  • 1 Bergqvist D, Jendteg S, Johansen L, Persson U, Ödegaard K. Cost of long term complications of deep venous thrombosis of the lower extremities: an analysis of a defined patient population in Sweden.  Ann Intern Med . 1997;  126 454-457
    CrossrefPubMedGoogle Scholar
  • 2 Kahn S R, Solymoss S, Lamping D L, Abenhaim L. Long-term outcomes after deep-vein thrombosis: postphlebitic syndrome and quality of life.  J Gen Intern Med . 2000;  15 425-429
    CrossrefPubMedGoogle Scholar
  • 3 Bauer G. Roentgenological and clinical study of the sequelae of thrombosis.  Acta Chir Scand . 1942;  1-110 (1-110)
    PubMedGoogle Scholar
  • 4 Gjores J E. The incidence of venous thrombosis and its sequelae in certain districts of Sweden.  Acta Chir Scand . 1956;  1-88 (1-88)
    PubMedGoogle Scholar
  • 5 O'Donnell T F, Browse N L, Burnand K G, Lea Thomas M. The socioeconomic effects of an ilio-femoral venous thrombosis.  J Surg Res . 1977;  22 483-488
    CrossrefPubMedGoogle Scholar
  • 6 Shull K C, Nicolaides A N, Fernandes J F. Significance of popliteal reflux in relation to ambulatory venous pressure and ulceration.  Arch Surg . 1979;  114 1304-1306
    CrossrefPubMedGoogle Scholar
  • 7 Strandness D E, Langlois Y, Cramer M, Randlett A, Thiele B L. Long-term sequelae of acute venous thrombosis.  JAMA . 1983;  250 1289-1292
    CrossrefPubMedGoogle Scholar
  • 8 Widmer L K, Zemp E, Widmer T. Late results in deep vein thrombosis of the lower extremity.  Vasa . 1985;  14 264-268
    PubMedGoogle Scholar
  • 9 Lindner D J, Edwards J M, Phinney E S, Taylor L M, Porter J M. Long-term hemodynamic and clinical sequelae of lower extremity deep vein thrombosis.  J Vasc Surg . 1986;  4 436-442
    CrossrefPubMedGoogle Scholar
  • 10 Heldal M, Seem E, Snadset P M, Abildgaard U. Deep vein thrombosis: a 7-year follow-up study.  J Intern Med . 1993;  234 71-75
    PubMedGoogle Scholar
  • 11 Lagerstedt C, Olsson C G, Fagher B, Norgren L, Tengborn L. Recurrence and late sequelae after first-time deep vein thrombosis. Relationship to initial signs.  Phlebology . 1993;  8 62-67
    PubMedGoogle Scholar
  • 12 Monreal M, Martorell A, Callejas J M. Venographic assessment of deep vein thrombosis and risk of developing post-thrombotic syndrome: a prospective study.  J Intern Med . 1993;  233 854-859
    PubMedGoogle Scholar
  • 13 Eichlisberger R, Frauchiger B, Widmer M T, Widmer L K, Jager K. Late sequelae of deep venous thrombosis: a 13-year follow-up of 223 patients.  Vasa . 1994;  23 234-243
    PubMedGoogle Scholar
  • 14 Beyth R J, Cohen A M, Landefeld C S. Long-term outcomes of deep-vein thrombosis.  Arch Intern Med . 1995;  155 1031-1037
    CrossrefPubMedGoogle Scholar
  • 15 Johnson B F, Manzo R A, Bergelin R O, Strandness D E. Relationship between changes in the deep venous system and the development of the postthrombotic syndrome after an acute episode of lower limb deep vein thrombosis: a one- to six-year follow-up.  J Vasc Surg . 1995;  21 307-313
    PubMedGoogle Scholar
  • 16 Saarinen J, Sisto T, Laurikka J, Salenius J P, Tarkka M. Late sequelae of acute deep venous thrombosis: evaluation five and ten years after.  Phlebology . 1995;  10 106-109
    PubMedGoogle Scholar
  • 17 Franzeck U K, Schalch I, Jäger K A, Schneider E, Grimm J, Bollinger A. Prospective 12-year follow-up study of clinical and haemodinamic sequelae after deep vein thrombosis in low-risk patients (Zürich study).  Circulation . 1996;  93 74-79
    PubMedGoogle Scholar
  • 18 Prandoni P, Lensing A WA, Cogo A. The long-term clinical course of acute deep venous thrombosis.  Ann Intern Med . 1996;  125 1-7
    CrossrefPubMedGoogle Scholar
  • 19 Brandijes D PM, Büller H R, Heijboer H, Huisman M V, de Rijk M, Jagt H. Randomised trial of effect of compression stockings in patients with symptomatic proximal-vein thrombosis.  Lancet . 1997;  349 759-762
    CrossrefPubMedGoogle Scholar
  • 20 Biguzzi E, Mozzi E, Alatri A, Taioli E, Moia M, Mannucci P M. The post-thrombotic syndrome in young women: retrospective evaluation of prognostic factors.  Thromb Haemost . 1998;  80 575-577
    PubMedGoogle Scholar
  • 21 Masuda E M, Kessler D M, Kistner R L, Eklof B, Sato D T. The natural history of calf vein thrombosis: lysis of thrombi and development of reflux.  J Vasc Surg . 1998;  28 67-74
    PubMedGoogle Scholar
  • 22 McLafferty R B, Moneta G L, Passmann M A, Brant B M, Taylor L M, Porter J M. Late clinical and hemodynamic sequelae of isolated calf vein thrombosis.  J Vasc Surg . 1998;  27 50-57
    PubMedGoogle Scholar
  • 23 Haenen J H, Janssen M CH, van Langen H. The post-thrombotic syndrome in relation to venous haemodynamics, as measured by means of duplex scanning and strain-gauge plethysmography.  J Vasc Surg . 1999;  29 1071-1076
    PubMedGoogle Scholar
  • 24 Holmström M, Åberg W, Lockner C, Paul C. Long term clinical follow-up in 256 patients with deep-vein thrombosis initially treated with either unfractionated heparin or dalteparin: a retrospective analysis.  Thromb Haemost . 1999;  82 1222-1226
    PubMedGoogle Scholar
  • 25 Saarinen J, Kallio T, Lehto M, Hiltunen S, Sisto T. The occurrence of the post-thrombotic changes after an acute deep venous thrombosis. A prospective two-year follow-up study.  J Cardiovasc Surg . 2000;  41 441-446
    PubMedGoogle Scholar
  • 26 Villalta S, Bagatella P, Piccioli A, Lensing A WA, Prins M H, Prandoni P. Assessment of validity and reproducibility of a clinical scale for the post-thrombotic syndrome.  Haemostasis . 1994;  157a (157a)
    PubMedGoogle Scholar
  • 27 Prandoni P, Villalta S, Bagatella P. The clinical course of deep-vein thrombosis. Prospective long-term follow-up of 528 symptomatic patients.  Haematologica . 1997;  82 423-428
    PubMedGoogle Scholar
  • 28 McColl M D, Ellison J, Greer I A, Tait R C, Walker I D. Prevalence of the post-thrombotic syndrome in young women with previous venous thromboembolism.  Br J Haematol . 2000;  108 272-274
    CrossrefPubMedGoogle Scholar
  • 29 Immelman E J, Jeffrey P C. The postphlebitic syndrome. Pathophysiology, prevention and management.  Clin Chest Med . 1984;  5 537-550
    PubMedGoogle Scholar
  • 30 Carter C J. Incidence of post-phlebitic syndrome after streptokinase therapy for deep vein thrombosis.  Am J Med . 1990;  89 697-698
    PubMedGoogle Scholar
  • 31 Shami S K, Shields D A, Scurr J H, Coleridge Smith D P. Leg ulceration in venous disease.  Postgrad Med J . 1992;  68 779-785
    PubMedGoogle Scholar
  • 32 Salzman E W, Hirsh J. The epidemiology, pathogenesis, and natural history of venous thrombosis. In: Colman EW, Hirsh J, Marder VJ, Salzman EW, eds. Hemostasis and Thrombosis Philadelphia: JB Lippincott 1993: 1275-1296
    Google Scholar
  • 33 Rutherford R B. Pathogenesis and pathophysiology of the post-thrombotic syndrome: clinical implications.  Semin Vasc Surg . 1996;  9 21-25
    PubMedGoogle Scholar
  • 34 Franzeck U K, Schalch I, Bollinger A. On the relationship between changes in the deep veins evaluated by Duplex sonography and the postthrombotic syndrome 12 years after deep vein thrombosis.  Thromb Haemost . 1997;  77 1109-1112
    PubMedGoogle Scholar
  • 35 Hirsh J, Hoak J. Management of deep vein thrombosis and pulmonary embolism. A statement for health care professionals.  Circulation . 1996;  93 2212-2245
    CrossrefPubMedGoogle Scholar
  • 36 Prandoni P, ten Cate W J. Epidemiology, risk factors, and natural history of venous thromboembolism. In: Oudkerk M, van Beek EJR, ten Cate JW, eds. Pulmonary Embolism Berlin: Blackwell Science 1999: 2-33
    Google Scholar
  • 37 Ernst E. Rheology of the post-thrombotic syndrome.  J Mal Vasc . 1992;  93-96 (93-96)
    PubMedGoogle Scholar
  • 38 Coleridge Smith D P, Thomas P, Scurr J H, Dormandy J A. Causes of venous ulceration: a new hypothesis.  Br Med J . 1988;  296 1726-1727
    CrossrefPubMedGoogle Scholar
  • 39 Lindhagen A, Bergqvist D, Hallböök T, Efsing H O. Venous function five to eight years after clinically suspected deep venous thrombosis.  Acta Med Scand . 1985;  217 389-395
    PubMedGoogle Scholar
  • 40 Johnson B F, Manzo R A, Bergelin R O, Strandness D E. Relationship between changes in the deep venous system and the development of the postthrombotic syndrome after an acute episode of lower limb deep vein thrombosis. A one- to six-year follow-up.  J Vasc Surg . 1995;  21 307-313
    PubMedGoogle Scholar
  • 41 Markel A, Manzo R A, Bergelin R O, Strandness D E. Valvular reflux after deep vein thrombosis: incidence and time of occurrence.  J Vasc Surg . 1992;  15 377-384
    CrossrefPubMedGoogle Scholar
  • 42 Johnson B F, Manzo R A, Bergelin R O, Strandness D E. The site of residual abnormalities in the leg veins in long-term follow-up after deep vein thrombosis and their relationship to the development of the post-thrombotic syndrome.  Int Angiol . 1996;  15 14-19
    PubMedGoogle Scholar
  • 43 van Ramshorst B, van Bemmelen S P, Hoeneveld H, Eikelboom B C. The development of valvular incompetence after deep vein thrombosis: a follow-up study with Duplex scanning.  J Vasc Surg . 1994;  20 1059-1066
    PubMedGoogle Scholar
  • 44 Labropoulos N, Leon N, Nicolaides A N. Venous reflux in patients with previous deep venous thrombosis: correlation with ulceration and other symptoms.  J Vasc Surg . 1994;  20 20-26
    PubMedGoogle Scholar
  • 45 Milne A A, Stonebridge P A, Bradbury A W, Ruckley C V. Venous function and clinical outcome following deep vein thrombosis.  Br J Surg . 1994;  81 847-849
    PubMedGoogle Scholar
  • 46 Janssen M C, Haenen J H, van Asten N W. Clinical and hemodynamic sequelae of deep venous thrombosis: retrospective evaluation after 7-13 years.  Clin Sci Colch . 1997;  93 7-12
    PubMedGoogle Scholar
  • 47 Raju S. Venous insufficiency of the lower limbs and stasis ulceration.  Ann Surg . 1983;  197 688-697
    PubMedGoogle Scholar
  • 48 Scott T E, LaMorte W W, Gorin D R, Menzoian J O. Risk factors for chronic venous insufficency: a dual case-control study.  J Vasc Surg . 1995;  22 622-628
    PubMedGoogle Scholar
  • 49 Browse N L, Clemenson G, Lea Thomas M. Is the postphlebitic leg always postphlebitic?.  <~>Relation between phlebographic appearances of deep-vein thrombosis and late sequelae. Br Med J . 1980;  281 1167-1170
    PubMedGoogle Scholar
  • 50 Porter J M, Moneta G L. International consensus committee on chronic venous disease.  J Vasc Surg . 1995;  21 635-645
    CrossrefPubMedGoogle Scholar
  • 51 Bettmann M A, Paulin S. Leg phlebography: the incidence, nature, and modification of undesirable side effects.  Radiology . 1977;  122 101-104
    PubMedGoogle Scholar
  • 52 Ruehm S G, Wiesner W, Debatin J F. Pelvic and lower extremity veins: contrast-enhanced three-dimensional MR venography with a dedicated vascular coil-initial experience.  Radiology . 2000;  215 421-427
    CrossrefPubMedGoogle Scholar
  • 53 Villalta S, Prandoni P, Cogo A. The utility of non-invasive tests for detection of previous proximal-vein thrombosis.  Thromb Haemost . 1995;  73 592-596
    PubMedGoogle Scholar
  • 54 Prandoni P, Cogo A, Bernardi E. A simple ultrasound approach for detection of recurrent proximal-vein thrombosis.  Circulation . 1993;  88 1730-1735
    CrossrefPubMedGoogle Scholar
  • 55 Neglen P, Raju S. A comparison between descending phlebography and duplex Doppler investigation in the evaluation of reflux in chronic venous insufficiency: a challenge to phlebography as the ``gold standard''.  J Vasc Surg . 1992;  16 687-693
    PubMedGoogle Scholar
  • 56 Cronan J J. Venous thromboembolic disease: the role of US.  Radiology . 1993;  186 619-630
    PubMedGoogle Scholar
  • 57 Evers E J, Wuppermann T. Ultrasound diagnosis in post-thrombotic syndrome. Comparative study with color duplex, cw-Doppler and B-image ultrasound.  Ultraschall Med . 1995;  16 259-263
    PubMedGoogle Scholar
  • 58 Belcaro G. Evaluation of recurrent deep venous thrombosis using colour duplex scanning-comparison with venography.  Vasa . 1992;  21 22-26
    PubMedGoogle Scholar
  • 59 Bartolo M, Antignani P L, Nicosia P M, Raffi S. Clinical-instrumental relationships in post-phlebitic syndrome.  Angiology . 1985;  36 53-60
    PubMedGoogle Scholar
  • 60 Hafner J, Bounameaux H, Burg G, Brunner U. Management of venous leg ulcers.  Vasa . 1996;  25 161-167
    PubMedGoogle Scholar
  • 61 Evers E J, Wuppermann T. Effect of different compression therapies on the reflux in deep veins with a post-thrombotic syndrome.  Vasa . 1999;  28 19-23
    PubMedGoogle Scholar
  • 62 Erickson C A, Lanza D J, Karp D L. Healing of venous ulcers in an ambulatory care program: the roles of chronic venous insufficiency and patients compliance.  J Vasc Surg . 1995;  22 629-636
    PubMedGoogle Scholar
  • 63 Milne A A, Ruckley C V. The clinical course of patients following extensive deep venous thrombosis.  Eur J Vasc Surg . 1994;  8 56-59
    PubMedGoogle Scholar
  • 64 Prandoni P, Lensing A WA, Prins M H, Bagatella P, Scudeller A, Girolami A. Which is the outcome of the post-thrombotic syndrome?.  Thromb Haemost . 1999;  82 1196-1197
    PubMedGoogle Scholar
  • 65 Colgan M P, Dormandy J A, Jones P W, Schraibman I G, Shanik D G, Young R A. Oxpentifylline treatment of venous ulcers of the leg.  BMJ . 1990;  300 972-975
    PubMedGoogle Scholar
  • 66 Layton A M, Ibbotson S H, Davies J A, Goodfield M J. Randomized trial of oral aspirin for chronic venous leg ulcer.  Lancet . 1994;  344 164-165
    CrossrefPubMedGoogle Scholar
  • 67 Rudofsky G. Intravenous prostaglandin E1 in the treatment of venous ulcers-a double-blind, placebo-controlled trial.  Vasa . 1989;  39-43 (39-43)
    PubMedGoogle Scholar
  • 68 Salim A S. Role of sulphydril-containing agents in the management of venous (varicose) ulceration. A new approach.  Clin Exp Dermatol . 1992;  17 427-432
    PubMedGoogle Scholar
  • 69 Salim A S. The role of oxygen-derived free radicals in the management of venous (varicose) ulceration. A new approach.  World J Surg . 1991;  15 264-269
    CrossrefPubMedGoogle Scholar
  • 70 Holzinger C, Zuckermann A, Kopp C. Treatment of non-healing skin ulcers with autologous activated mononuclear cells.  Eur J Vasc Surg . 1994;  8 351-356
    PubMedGoogle Scholar
  • 71 Baste J C, Midy F. Surgery for post-thrombotic syndrome of the lower limbs.  Rev Prat . 1994;  44 781-785
    PubMedGoogle Scholar
  • 72 Gloviczki P, Bergan J J, Rhodes J M, Canton L G, Harmsen S, Ilstrup D M. Mid-term results of endoscopic perforator vein interruption for chronic venous insufficiency: lessons learned from the North American subfascial endoscopic perforator surgery registry. The North American study group.  J Vasc Surg . 1999;  29 489-502
    PubMedGoogle Scholar
  • 73 Perrin M, Hiltbrand B, Bayon J M. Results of valvuloplasty in patients presenting deep venous insufficiency and recurring ulceration.  Ann Vasc Surg . 1999;  13 524-532
    CrossrefPubMedGoogle Scholar
  • 74 Ginsberg J S, Magier D, Mackinnon B, Gent M, Hirsh J. Intermittent compression units for severe post-phlebitic syndrome: a randomised crossover study.  CMAJ . 1999;  160 1303-1306
    PubMedGoogle Scholar
  • 75 Burnand K, Clemenson G, Morland M, Jarret P E, Browse N L. Venous lipodermatosclerosis: treatment by fibrinolytic enhancement and elastic compression.  Br Med J . 1980;  280 7-11
    PubMedGoogle Scholar
  • 76 de Jongste B A, Jonker J JC, Huisman M V, ten Cate W J, Azar A J. A double-blind three-center clinical trial on the short-term efficacy of O-(β-hydroxyethyl)-rutosides in patients with post-thrombotic syndrome.  Thromb Haemost . 1989;  62 826-829
    PubMedGoogle Scholar
  • 77 Tsouderos Y. Venous tone: are the phlebotonic properties predictive of a therapeutic benefit?.  <~>A comprehensive view of our experience with Daflon 500 mg. Z Kardiol . 1991;  95-101 (95-101)
    PubMedGoogle Scholar
  • 78 Goldhaber S Z, Buring J E, Lipnick R J, Hennekens C H. Pooled analyses of randomized trials of streptokinase and heparin in phlebographically documented acute deep venous thrombosis.  Am J Med . 1984;  76 393-397
    CrossrefPubMedGoogle Scholar
  • 79 Rogers L Q, Lutcher C L. Streptokinase therapy for deep vein thrombosis: a comprehensive review of the English literature.  Am J Med . 1990;  88 389-395
    CrossrefPubMedGoogle Scholar
  • 80 Juhan C M, Alimi Y S, Barthelemy P J, Fabre D F, Riviere C S. Late results of iliofemoral venous thrombectomy.  J Vasc Surg . 1997;  25 417-422
    CrossrefPubMedGoogle Scholar
  • 81 Plate G, Eklof B, Norgren L, Olhin P, Dahlstrom J A. Venous thrombectomy for ilofemoral vein thrombosis: 10-year results of a prospective randomised study.  Eur J Vasc Endovasc Surg . 1997;  14 367-374
    CrossrefPubMedGoogle Scholar
  • 82 Kakkar V V, Lawrence D. Hemodynamic and clinical assessment after therapy for acute deep vein thrombosis.  Am J Surg . 1985;  150 54-63
    PubMedGoogle Scholar
  • 83 Lensing A WA, Hirsh J. Rationale and results of thombolytic therapy for deep-vein thrombosis. In: Bernstein EF, ed. Vascular Diagnosis St. Louis: Mosby 1993: 875-879
    Google Scholar
  • 84 Sidorov J. Streptokinase vs heparin for deep venous thrombosis. Can lytic therapy be justified?.  Arch Intern Med . 1989;  149 1841-1845
    CrossrefPubMedGoogle Scholar
  • 85 Schweizer J, Elix H, Altmann E, Hellner G, Forkmann L. Comparative results of thrombolysis treatment with r-tPA and urokinase: a pilot study.  Vasa . 1998;  27 167-171
    PubMedGoogle Scholar
  • 86 Gould M K, Dembitzer A D, Doyle R L, Hastie T J, Garber A M. Low-molecular-weight heparins compared with unfractionated heparin for treatment of acute deep vein thrombosis. A meta-analysis of randomized controlled trials.  Ann Intern Med . 1999;  130 800-809
    CrossrefPubMedGoogle Scholar
  • 87 Kearon C, Gent M, Hirsh J. A comparison of three months of anticoagulation with extended anticoagulation for a first episode of idiopathic venous thromboembolism.  N Engl J Med . 1999;  340 901-907
    PubMedGoogle Scholar
  • 88 Shulman S, Rhedin A, Linmarker P. A comparison of six weeks with six months of oral anticoagulant therapy after a first episode of venous thromboembolism.  N Engl J Med . 1995;  332 1661-1665
    CrossrefPubMedGoogle Scholar
  • 89 AbuRahma A F, Stickler D L, Robinson P A. A prospective controlled study of the efficacy of short-term anticoagulation therapy in patients with deep vein thrombosis of the lower extremity.  J Vasc Surg . 1998;  28 630-637
    PubMedGoogle Scholar
  • 90 Ginsberg J S, Gent M, Turkstra F, Buller H R, MacKinnon B, Magier D, Hirsh J. Postthrombotic syndrome after hip or knee arthroplasty. A cross-sectional study.  Arch Intern Med . 2000;  160 669-672
    CrossrefPubMedGoogle Scholar