Post Thrombotic Syndrome

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What is Post Thrombotic Syndrome?

Post thrombotic syndrome is the worse condition of Deep vein thrombosis. Anatomically, tiny valves are present in deep veins located at legs and assisting in controlling the blood flow direction. Any clot formation in a deep vein of the leg can cause swelling and obstruct blood circulation.

The resultant of this leads to damage of the valves. The damaging of valves causes leakage and fluid accumulated around the ankle. Delay curing or not properly healed clot can also cause blood circulation obstruction in the leg. Pain, inflammation, redness in the leg gradually turns to ulcer formation in the affected leg at the advanced stage of post-thrombotic syndrome and that become difficult to treat^1,2,3.

Symptoms

Post Thrombotic Syndrome (PTS) symptoms arise on the legs and clinical presentation include chronic leg aching, inflammation, leg muscles become frequently fatigue, feeling of heaviness, skin patches in the legs due to hyperpigmentation, edema and subcutaneous fibrosis in the affected lower extremity.

If the condition becomes severe then venous claudication and venous leg ulcers can progress. Both these conditions can significantly restrict movement of the affected individual and limit the working capability, which ultimately hampers the quality of life of the patients. Evidence also supported that the degree of reduced quality of life in chronic Post Thrombotic Syndrome can be comparable with other chronic ailments such as chronic obstructive pulmonary disease and arthritis^4,5.

The symptoms of Post Thrombotic Syndrome can be divided into two stages, initial stage, and advanced stage. In the initial stage, the symptoms are similar as Deep Vein Thrombosis.

Initial symptoms

Cramping of leg
Itching of leg
Prolonged standing or walking leads leg aching, pain and inflammation in a higher degree. Rest and lifting up of leg provide relieve from these symptoms.
Dryness of leg skin
Unspecific uneasiness of the affected lower extremity

Advanced symptoms

Chronic inflammation of the affected leg
Chronic leg pain
Skin become shiny on the affected lower extremity
Tiredness, heaviness and cramping of leg
Diffuse aching
Tingling sensation
Capability of leg become diminished
Post-thrombotic pigmentation leads to pigmented dark patches in the leg skin
Toes or foot of the affected leg develops bluish discoloration
Eczema
Skin of the leg become harden
Varicose veins formation
Ulcer formation in the skin of the leg

It is always advisable that if any symptom arises, then better to discuss with the doctor, who can diagnose the possibility of Post Thrombotic Syndrome development by symptomatic analysis³.

Risk Factors

Study findings supported that 20 to 50% of patients have a post-thrombotic syndrome (PTS) after the development of an initial episode of lower limb deep vein thrombosis (DVT)⁷. Some individuals have higher possibility of developing post-thrombotic syndrome (PTS) with following conditions

Clot formation over the knee, clinically this condition is termed as proximal deep vein thrombosis.
Repeated multiple blood clot formation in the same leg
Symptoms of blood clot continue for more than one month
Obese individuals
Blood-thinner medication unable to control blood thinner levels after continuing the medication for 3 months³.

Diagnosis

There is no special diagnosis testing for PTS. The primary diagnostic tool to diagnose the Post-Thrombotic Syndrome is anatomical and/or physiological findings.

Anatomical/Physiological Findings

Detail medical history with symptomatic analysis and/or physical findings are primary investigative tools of post-thrombotic syndrome. All these findings are directing that duplex ultrasound requires performing for spotting iliac vein blockage and/or superficial valvular deficit in the great saphenous vein (GSV) and/or small saphenous vein (SSV).

Symptomatic analysis usually indicates the following symptoms to identify the iliac vein blockage

Inflammation and pain in the thigh and calf of the affected limb and gradually spread to the entire limb, which is a characteristic feature of the early DVT occurrence
Simultaneously these symptoms continue regularly and indicative of PTS symptoms. Physical examination provides the detail symptoms of PTS
Preeminence of venous claudication
A prior incidence with imaging recorded result showed thrombosis formation in the common femoral vein and/or iliac vein
An ultrasound examination provided the evidence of incomplete compressible common femoral vein
Lack of phasicity in common femoral vein Doppler waveform in comparison with the contralateral common femoral vein⁵

Laboratory Test

Ultrasound Evaluation

Ultrasound evaluation of the femoral vein and profunda femoral vein is conducted before performing stent placement⁵.

Treatment

There are different treatment approaches for patients having the post-thrombotic syndrome. Following are some

Pharmacological agents

Traditionally anticoagulant therapy is prescribed for DVT and the initial stage of PTS. But currently, anticoagulant therapy is not frequently prescribed as PTS is reoccurred frequently.

Patients with venous leg ulceration usually treat with nonselective phosphodiesterase inhibitor (pentoxifylline) and platelet aggregation inhibitors (rutosides). Alternatively, sulodexide can also prescribe in alteration with rutosides. To local wound care, sulodexide is administered intramuscularly at the beginning of therapy and then orally.

Compressive Therapies

Elastic compressive stockings can control mild to moderate symptoms of PTS and also reduce the risk of progression of PTS, but may not be effective to treat severe PTS related symptoms.

Intermittent pneumatic compression (IPC) is a newer approach to compressive therapy to treat the PTS affected patients with elevated venous pressure. IPC can effective to control severe leg edema and/or venous leg ulcers. But IPC is expensive than other compressive therapies like wearing stockings and it also causes inconvenience, as the therapy requires to pump for more than a few hours in a day.

Another novel compressive approach is battery-powered, boot-like compression device i.e. VenoWave. This device is lightweight and portable. The application of this device provides a good prognosis.

Exercise Therapy

Mild to moderately affected patients suffering from PTS may get benefits from exercise therapy.

Wound Care

Different medical products are available to treat venous leg ulcers, such as topical antibiotics, exfoliants, ointments, compression wraps, and growth factors. Depending upon the patient condition and nature of symptoms doctor prescribe these products⁵.

References

Ashrani AA, Heit JA. Incidence and cost burden of post-thrombotic syndrome. J Thromb Thrombolysis. 2009; 28: 465–476.
Kahn SR. How I treat postthrombotic syndrome. Blood. 2009; 114: 4624–4631.
Sara R. Vazquez, Susan R. Kahn; Postthrombotic Syndrome; DOI https://doi.org/10.1161/CIRCULATIONAHA.109.925651; Circulation. 2010;121:e217-e219; Originally published March 1, 2010; Online available at http://circ.ahajournals.org/content/121/8/e217
Kahn S R. The post thrombotic syndrome. Thromb Res. 2011;127 03:S89–S92
Lina Nayak, Suresh Vedantham, Multifaceted Management of the Postthrombotic Syndrome; Semin Intervent Radiol. 2012 Mar; 29(1): 16–22.; DOI: 10.1055/s-0032-1302447; Online available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3348767/
Postthrombotic Syndrome; National Blood Clot alliance; Online available at https://www.stoptheclot.org/postthrombotic-syndrome.htm
Kahn S R, Shrier I, Julian J A. et al. Determinants and time course of the postthrombotic syndrome after acute deep venous thrombosis. Ann Intern Med. 2008;149(10):698–707