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CLINICAL UPDATE
Post thrombotic syndrome and non-thrombotic vein obstruction By Dr Patrik Tosenovsky, Vascular Surgeon, Joondalup Post-thrombotic syndrome (PTS) is a combination of signs and symptoms that include any of the following: swelling, pain, skin colour changes or leg ulcer. It is a complication of lower limb DVT. Similar signs and symptoms can be observed on a leg of patients who have never had DVT, and this is sometimes called venous stasis syndrome (VSS). In both situations, reflux or obstruction (often both) play a crucial pathophysiological role. This will lead to a venous hypertension. Primary obstruction causing haemodynamic changes is usually seen in the deep axial veins (IVC, iliac, femoral or popliteal veins). The incidence of PTS is cited as between 10% and 50%, and its severity varies from mild ankle swelling or chronic ache with no other signs or symptoms of chronic
Key messages PTS and VSS have similar signs and symptoms Both need venography rather than simply advising stockings Treatment is mini-invasive venous disease to recurrent cellulitis, skin hyperpigmentation and a tissue loss. VSS patients present with similar complaints. It is not difficult to make a clinical diagnosis in PTS cases since there is usually a symptomatic DVT in the history, but it is harder in VSS cases. Imaging is critical and a venous ultrasound is a good non-invasive start. Evaluate the lower limb venous system including abdominal and pelvic veins. Sensitivity of duplex ultrasound in detection of
venous obstruction is unfortunately poor, therefore recent European and North American guidelines suggest more invasive imaging for all symptomatic patients. Treatment is mini-invasive, and it can be offered as a one session day-case surgery. Even during the initial venography, where an obstruction is verified by using Intra Vascular Ultrasound (IVUS), outflow obstructions can be successfully treated with venoplasty and stent. During the same setting, the incompetent superficial axial veins can be closed using either laser catheter or a cyanoacrylate glue. The results of vein stenting are encouraging and it is recommended to all symptomatic patients because the associated morbidity and complication rates are low. – References available on request
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APRIL 2020 | 31
