D

eep vein thrombosis (DVT) requires prompt treatment to prevent its most feared complications. Physicians have numerous guidelines and a wide armamentarium to address this condition acutely. However, long after patients have been discharged and completed their anticoagulation course, some will continue to have symptoms that interfere with their quality of life. It is estimated that 20-50% of patients will develop post-thrombotic syndrome (PTS) in the first two years after DVT,1,2 and this can result in debilitation and increased healthcare cost, to the tune of $7000 over their lifetime.3

Post-thrombotic syndrome is a direct result of the acute thrombus from DVT. Local inflammation caused by the thrombus damages the venous valves and causes fibrous scarring within the vein, leading to both reflux and obstruction, respectively. Over time, collaterals form around the obstruction and venous hypertension occurs in the affected limb.

As a result, PTS can present itself in a wide variety of symptoms similar to other forms of chronic venous insufficiency. Extremity edema and pain are common and tend to be worse at the end of the day or after prolonged standing. Patients describe the sensation as an achiness or heaviness in their leg, which can be severe enough to limit activity. This can be associated with telangiectasia, varicose veins and lower leg hyperpigmentation. Approximately 5-10% of patients will develop venous ulceration.1

Despite the prevalence of DVT, there are no strong guidelines for PTS treatment. Compression therapy and leg elevation are the main strategies for reducing symptoms from not only PTS, but all forms of chronic venous insufficiency. In cases of patients who lack the dexterity or grip strength to apply compression stockings, there are alternatives including Velcro and zippered stockings, as well as application assistants which can be purchased at pharmacies or through large retailers. Certain advanced centers provide endovascular recanalization of chronic venous lesions for select patients, although this is still a relatively new therapy. Similarly, prevention of PTS remains an area of uncertainty. Research suggests patients with proximal (iliac and femoral) DVT, obesity, subtherapeutic anticoagulation, and persistent leg symptoms one month after DVT are at higher risk for developing PTS.2 Multiple studies have shown that there is benefit to use of elastic compression stockings after proximal DVT, although the duration of treatment and full extent of benefits are unknown. Notably, catheterdirected thrombolysis of acute DVT has been shown to have some benefit in reducing PTS.4 However, this therapy is only applicable for certain patients, given the increase in bleeding risk compared to anticoagulation alone. The likely candidate for this procedure is a young, otherwise healthy person who ambulates without difficulty.

The priority when treating DVT is managing the acute phase and reducing the risk of immediate complications. During follow-up, it is important to reassess the patient’s symptoms to detect and treat PTS as it develops. The ultimate goal is reducing the impact of PTS on both patient’s quality of life and economics.

References

1. Kahn, S.R. The Post-thrombotic Syndrome: The Forgotten Morbidity of Deep Venous Thrombosis. J Thromb Thrombolysis 21, 41–48 (2006). https://doi.org/10.1007/s11239-006-5574-9

2. Anat Rabinovich, Susan R. Kahn; How I treat the postthrombotic syndrome. Blood 2018; 131 (20): 2215–2222. doi: https://doi.org/10.1182/blood-2018-01-785956

3. Caprini JA, Botteman MF, Stephens JM, Nadipelli V, Ewing MM, Brandt S, Pashos CL, Cohen AT. Economic burden of long-term complications of deep vein thrombosis after total hip replacement surgery in the United States. Value Health. 2003 Jan-Feb;6(1):5974. doi: 10.1046/j.1524-4733.2003.00204.x. PMID: 12535239.

4. Broderick C, Watson L, Armon MP. Thrombolytic strategies versus standard anticoagulation for acute deep vein thrombosis of the lower limb. Cochrane Database of Systematic Reviews 2021, Issue 1. Art. No.: CD002783. DOI: 10.1002/14651858.CD002783.pub5

Ashton Lee, MD is a vascular surgeon with special interests in dialysis access, limb salvage and preoperative risk assessment. She is also a member of Bexar County Medical Society (BCMS)