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Open Access 01-01-2016

Guidance for the prevention and treatment of the post-thrombotic syndrome

Authors: Susan R. Kahn, Jean-Philippe Galanaud, Suresh Vedantham, Jeffrey S. Ginsberg

Published in: Journal of Thrombosis and Thrombolysis | Issue 1/2016

Abstract

The post-thrombotic syndrome (PTS) is a frequent, potentially disabling complication of deep vein thrombosis (DVT) that reduces quality of life and is costly. Clinical manifestations include symptoms and signs such as leg pain and heaviness, edema, redness, telangiectasia, new varicose veins, hyperpigmentation, skin thickening and in severe cases, leg ulcers. The best way to prevent PTS is to prevent DVT with pharmacologic or mechanical thromboprophylaxis used in high risk patients and settings. In patients whose DVT is treated with a vitamin K antagonist, subtherapeutic INRs should be avoided. We do not suggest routine use of elastic compression stockings (ECS) after DVT to prevent PTS, but in patients with acute DVT-related leg swelling that is bothersome, a trial of ECS is reasonable. We suggest that selecting patients for catheter-directed thrombolytic techniques be done on a case-by-case basis, with a focus on patients with extensive thrombosis, recent symptoms onset, and low bleeding risk, who are seen at experienced hospital centers. For patients with established PTS, we suggest prescribing 20–30 mm Hg knee-length ECS to be worn daily. If ineffective, a stronger pressure stocking can be tried. We suggest that intermittent compression devices or pneumatic compression sleeve units be tried in patients with moderate-to-severe PTS whose symptoms are inadequately controlled with ECS alone. We suggest that a supervised exercise training program for 6 months or more is reasonable for PTS patients who can tolerate it. We suggest that management of post-thrombotic ulcers should involve a multidisciplinary approach. We briefly discuss upper extremity PTS and PTS in children.

Kahn SR (2009) How I treat postthrombotic syndrome. Blood 114(21):4624–4631PubMedCrossRef

Kahn SR, Partsch H, Vedantham S, Prandoni P, Kearon C (2009) Definition of post-thrombotic syndrome of the leg for use in clinical investigations: a recommendation for standardization. J Thromb Haemost 7:879–883PubMedCrossRef

Kahn SR, Comerota AJ, Cushman M et al (2014) The post-thrombotic syndrome: evidence-based prevention, diagnosis, and treatment strategies a scientific statement from the American Heart Association. Circulation 130(18):1636–1661PubMedCrossRef

Prandoni P, Lensing AWA, Cogo A et al (1996) The long-term clinical course of acute deep venous thrombosis. Ann Intern Med 125(1):1–7PubMedCrossRef

Kahn SR, Shrier I, Julian JA et al (2008) Determinants and time course of the post-thrombotic syndrome after acute deep venous thrombosis. Ann Intern Med 149(10):698–707PubMedCrossRef

Spencer FA, Emery C, Joffe SW et al (2009) Incidence rates, clinical profile, and outcomes of patients with venous thromboembolism: The Worcester VTE study. J Thromb 28(4):401–409CrossRef

Tagalakis V, Patenaude V, Kahn SR, Suissa S (2013) Incidence of and mortality from venous thromboembolism in a real-world population: the Q-VTE study cohort. Am J Med 126(9):832.e813-821CrossRef

Naess IA, Christiansen SC, Romundstad P, Cannegieter SC, Rosendaal FR, Hammerstrom J (2007) Incidence and mortality of venous thrombosis: a population-based study. J Thromb Haemost 5(4):692–699PubMedCrossRef

Guanella R, Ducruet T, Johri M et al (2011) Economic burden and cost determinants of deep vein thrombosis during 2 years following diagnosis: a prospective evaluation. J Thromb Haemost 9(12):2397–2405PubMedCrossRef

10.

MacDougall DA, Feliu AL, Boccuzzi SJ, Lin J (2006) Economic burden of deep-vein thrombosis, pulmonary embolism, and post-thrombotic syndrome. Am J Health Syst Pharm 63(20):S5–S15PubMedCrossRef

11.

Caprini JA, Botteman MF, Stephens JM et al (2003) Economic burden of long-term complications of deep vein thrombosis after total hip replacement surgery in the United States. Value Health 6(1):59–74PubMedCrossRef

12.

Bergan JJ, Schmid-Schonbein GW, Smith PD, Nicolaides AN, Boisseau MR, Eklof B (2006) Chronic venous disease. N Engl J Med 355(5):488–498PubMedCrossRef

13.

van Korlaar I, Vossen C, Rosendaal F, Cameron L, Bovill E, Kaptein A (2003) Quality of life in venous disease. Thromb Haemost 90(1):27–35PubMed

14.

Kahn SR, Ducruet T, Lamping DL et al (2005) Prospective evaluation of health-related quality of life in patients with deep venous thrombosis. Arch Intern Med 165(10):1173–1178PubMedCrossRef

15.

Broholm R, Sillesen H, Damsgaard MT et al (2011) Postthrombotic syndrome and quality of life in patients with iliofemoral venous thrombosis treated with catheter-directed thrombolysis. J Vasc Surg 54(6 Suppl):18S–25SPubMedCrossRef

16.

Kahn SR, Shbaklo H, Lamping DL et al (2008) Determinants of health-related quality of life during the 2 years following deep vein thrombosis. J Thromb Haemost 6(7):1105–1112PubMedCrossRef

17.

Kahn SR, Hirsch A, Shrier I (2002) Effect of post-thrombotic syndrome on health-related quality of life after deep venous thrombosis. Arch Intern Med 162:1144–1148PubMedCrossRef

18.

Kahn SR, Ginsberg JS (2004) Relationship between deep venous thrombosis and the postthrombotic syndrome. Arch Int Med 164:17–26CrossRef

19.

Prandoni P, Kahn SR (2009) Post-thrombotic syndrome: prevalence, prognostication and need for progress. Br J Haematol 145(3):286–295PubMedCrossRef

20.

Kolbach DN, Neumann HA, Prins MH (2005) Definition of the post-thrombotic syndrome, differences between existing classifications. Eur J Vasc Endovasc Surg 30(4):404–414PubMedCrossRef

21.

Vedantham S (2009) Valvular dysfunction and venous obstruction in the post-thrombotic syndrome. Thromb Res 123(4 Suppl):S62–S65PubMedCrossRef

22.

Deatrick KB, Elfline M, Baker N et al (2011) Postthrombotic vein wall remodeling: preliminary observations. J Vasc Surg 53(1):139–146PubMedPubMedCentralCrossRef

23.

Henke PK, Varma MR, Moaveni DK et al (2007) Fibrotic injury after experimental deep vein thrombosis is determined by the mechanism of thrombogenesis. Thromb Haemost 98(5):1045–1055PubMed

24.

Bharath V, Kahn SR, Lazo-Langner A (2014) Genetic polymorphisms of vein wall remodeling in chronic venous disease: a narrative and systematic review. Blood 124(8):1242–1250PubMedCrossRef

25.

Roumen-Klappe EM, den Heijer M, Janssen MC, van der Vleuten C, Thien T, Wollersheim H (2005) The post-thrombotic syndrome: incidence and prognostic value of non-invasive venous examinations in a six-year follow-up study. Thromb Haemost 94(4):825–830PubMed

26.

Villalta S, Bagatella P, Piccioli A, Lensing AWA, Prins MH, Prandoni P (1994) Assessment of validity and reproducibility of a clinical scale for the post-thrombotic syndrome. Haemostasis 24(1 Suppl):158a

27.

Kahn SR (2009) Measurement properties of the Villalta scale to define and classify the severity of the post-thrombotic syndrome. J Thromb Haemost 7:884–888PubMedCrossRef

28.

O’Donnell MJ, McRae S, Kahn SR et al (2008) Evaluation of a venous-return assist device to treat severe post-thrombotic syndrome (VENOPTS)—a randomized controlled trial. Thromb Haemost 99(3):623–629PubMed

29.

Prandoni P, Lensing AWA, Prins MH et al (2004) Below-knee elastic compression stockings to prevent the post-thrombotic syndrome: a randomized, controlled trial. Ann Intern Med 141(4):249–256PubMedCrossRef

30.

Enden T, Haig Y, Kløw NE et al (2012) Long-term outcome after additional catheter-directed thrombolysis versus standard treatment for acute iliofemoral deep vein thrombosis (the CaVenT study): a randomised controlled trial. Lancet 379(9810):31–38PubMedCrossRef

31.

Kahn SR, Shapiro S, Wells PS et al (2014) Compression stockings to prevent post-thrombotic syndrome: a randomised placebo-controlled trial. Lancet 383(9920):880–888PubMedCrossRef

32.

Holmes CE, Bambace NM, Lewis P, Callas PW, Cushman M (2014) Efficacy of a short course of complex lymphedema therapy or graduated compression stocking therapy in the treatment of post-thrombotic syndrome. Vasc Med 19(1):42–48PubMedCrossRef

33.

Rabinovich A, Kahn SR (2014) How to predict and diagnose postthrombotic syndrome. Pol Arch Med Wewn 124(7–8):410–416PubMed

34.

Galanaud JP, Holcroft CA, Rodger MA et al (2013) Predictors of post-thrombotic syndrome in a population with a first deep vein thrombosis and no primary venous insufficiency. J Thromb Haemost 11(3):474–480PubMedCrossRef

35.

Bouman AC, Smits JJ, Ten Cate H, Ten Cate-Hoek AJ (2012) Markers of coagulation, fibrinolysis and inflammation in relation to post-thrombotic syndrome. J Thromb Haemost 10(8):1532–1538PubMedCrossRef

36.

Rabinovich A, Cohen JM, Prandoni P, Kahn SR (2014) Association between thrombophilia and the post-thrombotic syndrome: a systematic review and meta-analysis. J Thromb Haemost 12(1):14–23PubMedCrossRef

37.

van Dongen CJ, Prandoni P, Frulla M, Marchiori A, Prins MH, Hutten BA (2005) Relation between quality of anticoagulant treatment and the development of the postthrombotic syndrome. J Thromb Haemost 3(5):939–942PubMedCrossRef

38.

Chitsike RS, Rodger MA, Kovacs MJ et al (2012) Risk of post-thrombotic syndrome after subtherapeutic warfarin anticoagulation for a first unprovoked deep vein thrombosis: results from the REVERSE study. J Thromb Haemost 10(10):2039–2044PubMedCrossRef

39.

Roberts LN, Patel RK, Chitongo PB, Bonner L, Arya R (2013) Presenting D-dimer and early symptom severity are independent predictors for post-thrombotic syndrome following a first deep vein thrombosis. Br J Haematol 160(6):817–824PubMedCrossRef

40.

Prandoni P, Frulla M, Sartor D, Concolato A, Girolami A (2005) Vein abnormalities and the post-thrombotic syndrome. J Thromb Haemost 3(2):401–402PubMedCrossRef

41.

Rabinovich A, Cohen JM, Kahn SR (2014) The predictive value of markers of fibrinolysis and endothelial dysfunction in the post thrombotic syndrome. A systematic review. Thromb Haemost 111(6):1031–1040PubMedCrossRef

42.

Baglin T (2012) Prevention of post-thrombotic syndrome: a case for new oral anticoagulant drugs or for heparins? J Thromb Haemost 10(8):1702–1703PubMedCrossRef

43.

Hull RD, Liang J, Townshend G (2011) Long-term low-molecular-weight heparin and the post-thrombotic syndrome: a systematic review. Am J Med 124(8):756–765PubMedCrossRef

44.

Gould MK, Garcia DA, Wren SM et al (2012) Prevention of VTE in nonorthopedic surgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 141(2 Suppl):e227S–e277SPubMedPubMedCentral

45.

Falck-Ytter Y, Francis CW, Johanson NA et al (2012) Prevention of VTE in orthopedic surgery patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 141(2 Suppl):e278S–e325SPubMedPubMedCentral

46.

Kahn SR, Lim W, Dunn AS et al (2012) Prevention of VTE in Nonsurgical Patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 141(2 Suppl):e195S–e226SPubMedPubMedCentral

47.

Kearon C, Akl EA, Comerota AJ et al (2012) Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 141(2 Suppl):e419S–e494SPubMedPubMedCentral

48.

Brandjes DPM, Buller HR, Heijboer H, Hulsman MV, de Rijk M, Jagt H (1997) Randomised trial of effect of compression stockings in patients with symptomatic proximal-vein thrombosis. Lancet 349:759–762PubMedCrossRef

49.

Kearon C, Kahn SR, Agnelli G, Goldhaber S, Raskob GE, Comerota AJ (2008) Antithrombotic therapy for venous thromboembolic disease: ACCP evidence-based clinical practice guidelines (8th edition). Chest 133(6 Suppl):454S–545SPubMedCrossRef

50.

Kahn SR, Shapiro S, Ducruet T et al (2014) Graduated compression stockings to treat acute leg pain associated with proximal DVT: A randomised controlled trial. Thromb Haemost 112(6):1137–1141PubMedCrossRef

51.

Comerota AJ, Grewal N, Martinez JT et al (2012) Postthrombotic morbidity correlates with residual thrombus following catheter-directed thrombolysis for iliofemoral deep vein thrombosis. J Vasc Surg 55(3):768–773PubMedCrossRef

52.

Watson L, Broderick C, Armon MP (2014) Thrombolysis for acute deep vein thrombosis. Cochrane Database Syst Rev 1:CD002783PubMed

53.

Vedantham S, Goldhaber S, Kahn S et al (2013) Rationale and Design of the ATTRACT Study—a multicenter randomized trial to evaluate pharmacomechanical catheter-directed thrombolysis for the prevention of post-thrombotic syndrome in patients with proximal deep vein thrombosis. Am Heart J 165(4):523–530PubMedPubMedCentralCrossRef

54.

DUTCH CAVA-trial: CAtheter Versus Anticoagulation Alone for Acute Primary (Ilio)Femoral DVT. Clinicaltrials.gov identifier NCT00970619. Accessed 3 Sept 2014

55.

Ginsberg JS, Magier D, MacKinnon B, Gent M, Hirsh J (1999) Intermittent compression units for severe post-phlebitic syndrome: a randomized crossover study. CMAJ 160:1303–1306PubMedPubMedCentral

56.

de Jongste AB, Jonker JJ, Huisman MV, ten Cate JW, Azar AJ (1989) A double blind three center clinical trial on the short-term efficacy of 0-(beta-hydroxyethyl)-rutosides in patients with post-thrombotic syndrome. Thromb Haemost 62(3):826–829PubMed

57.

Coccheri S, Andreozzi GM, D’Addato M, Gensini GF (2004) Effects of defibrotide in patients with chronic deep insufficiency. The PROVEDIS study. Int Angiol 23(2):100–107PubMed

58.

Frulla M, Marchiori A, Sartor D et al (2005) Elastic stockings, hydroxyethylrutosides or both for the treatment of post-thrombotic syndrome. Thromb Haemost 93(1):183–185

59.

Monreal M, Callejas JM, Martorell A, Lisbona C, Lerma R (1994) A prospective study of the long-term efficacy of two different venoactive drugs in patients with post-thrombotic syndrome. Phlebology 9(1):37–40

60.

Cohen JM, Akl EA, Kahn SR (2012) Pharmacologic and compression therapies for postthrombotic syndrome: a systematic review of randomized controlled trials. Chest 141(2):308–320PubMedCrossRef

61.

Padberg JR, Johnston MV, Sisto SA (2004) Structured exercise improves calf muscle pump function in chronic venous insufficiency: a randomized trial. J Vasc Surg 39(1):79–87PubMedCrossRef

62.

Kahn SR, Shrier I, Shapiro S et al (2011) Six-month exercise training program to treat post-thrombotic syndrome: a randomized controlled two-centre trial. CMAJ 183(1):37–44PubMedPubMedCentralCrossRef

63.

O’Meara S, Cullum N, Nelson EA, Dumville JC (2012) Compression for venous leg ulcers. Cochrane database of systematic reviews 11:CD000265PubMed

64.

Jull AB, Arroll B, Parag V, Waters J (2012) Pentoxifylline for treating venous leg ulcers. Cochrane database of systematic reviews 12:CD001733PubMed

65.

Neglen P, Hollis KC, Raju S (2006) Combined saphenous ablation and iliac stent placement for complex severe chronic venous disease. J Vasc Surg 44(4):828–833PubMedCrossRef

66.

Nayak L, Hildebolt CF, Vedantham S (2012) Postthrombotic syndrome: feasibility of a strategy of imaging-guided endovascular intervention. J Vasc Interv Radiol 23(9):1165–1173PubMedCrossRef

67.

Elman ER, Kahn SR (2006) The post-thrombotic syndrome after upper extremity deep venous thrombosis: a systematic review. Thromb Res 117(6):609–614PubMedCrossRef

68.

Prandoni P, Bernardi E, Marchiori A et al (2004) The long term clinical course of acute deep vein thrombosis of the arm: prospective cohort study. BMJ 329(7464):484–485PubMedPubMedCentralCrossRef

69.

Kahn SR, Elman EA, Bornais C, Blostein M, Wells PS (2005) Post-thrombotic syndrome, functional disability and quality of life after upper extremity deep venous thrombosis in adults. Thromb Haemost 93(3):499–502PubMed

70.

Czihal M, Paul S, Rademacher A, Bernau C, Hoffmann U (2012) Impact of the postthrombotic syndrome on quality of life after primary upper extremity deep venous thrombosis. VASA. Zeitschrift fur Gefasskrankheiten 41(3):200–204PubMedCrossRef

71.

Goldenberg NA, Donadini MP, Kahn SR et al (2010) Post-thrombotic syndrome in children: a systematic review of frequency of occurrence, validity of outcome measures, and prognostic factors. Haematologica 95(11):1952–1959PubMedPubMedCentralCrossRef

72.

Monagle P, Chan AK, Goldenberg NA et al (2012) Antithrombotic therapy in neonates and children: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 141(2 Suppl):e737S–e801SPubMedPubMedCentralCrossRef

Title: Guidance for the prevention and treatment of the post-thrombotic syndrome
Authors: Susan R. Kahn
Jean-Philippe Galanaud
Suresh Vedantham
Jeffrey S. Ginsberg
Publication date: 01-01-2016
Publisher: Springer US
Published in: Journal of Thrombosis and Thrombolysis / Issue 1/2016
Print ISSN: 0929-5305
Electronic ISSN: 1573-742X
DOI: https://doi.org/10.1007/s11239-015-1312-5

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