The Postthrombotic Syndrome: Evidence-Based Prevention, Diagnosis, and Treatment Strategies: A Scientific Statement From the American Heart Association
This American Heart Association Scientific Statement summarizes the evidence for prevention, diagnosis, and treatment of the post-thrombotic syndrome (PTS). The following are 10 key points from the scientific statement:
1. PTS manifests as a spectrum of signs and symptoms of chronic venous insufficiency in patients with prior deep venous thrombosis (DVT). These can range from minor leg swelling to chronic, debilitating lower-limb pain, intractable edema, and ulcerations, which may require intensive nursing and medical care.
2. In patients with a history of DVT, 20-50% will develop signs and/or symptoms of PTS. Most cases develop within a few moths, but they can occur up to 10-20 years after the index DVT has occurred. In about 5-10% of DVT patients, severe PTS can develop. This has enormous economic impact, ranging from increased health care utilization to lost worker productivity.
3. The central pathophysiologic mechanism for the development of PTS is venous hypertension. This can occur from obstructed venous outflow and venous reflux from vessel wall damage and incomitant venous valves.
4. PTS is diagnosed based on clinical assessment in a patient with known prior DVT. The Villalta scale can be used to assess signs and symptoms consistent with PTS. The Villalta scale has been shown to correlate well with quality-of-life (QOL) assessments. However, it is relatively nonspecific and fairly nondescript regarding more advanced PTS complication, including venous ulcer characteristics. The Ginsberg measure has been used in recently published randomized trials, but lacks the ability to assess for severity of PTS symptoms. However, it also correlates well with QOL assessments.
5. The CEAP (Clinical-Etiology-Anatomy-Pathophysiology) classification and Venous Clinical Severity Score are descriptive systems to systematically document the extent and severity of PTS for an individual patient. However, both of these scales have poor correlation with the Villalta scale.
6. Risk factors for developing PTS include elevated body mass index and obesity, older age, and smoking status. Similarly, extensive thrombus in the common femoral or iliac veins increased the risk of PTS development, as does persistent vein occlusion despite initial DVT therapy.
7. The key preventive intervention for development of PTS is the prevention of DVT itself, often with appropriate prophylaxis. Similarly, appropriate, high-quality initial anticoagulation of DVT is important to prevent the development of PTS.
8. Based on conflicting results between older and more recent studies in patients with acute DVT, there is uncertain benefit in the use of compression stockings to prevent development of PTS. However, there may be benefit for the use of catheter-directed thrombolysis (CDT) and/or pharmacomechanical CDT.
9. Once PTS has occurred, treatment is focused on use of compression stockings in patients without a known contraindication (e.g., severe peripheral artery disease). Similarly, use of leg strengthening training and aerobic activity may be of benefit.
10. Surgical intervention is reserved for patients with severe symptoms despite medical therapy.
Keywords: Stockings, Compression, Varicose Ulcer, Postthrombotic Syndrome, Peripheral Arterial Disease, American Heart Association, Edema, Femoral Vein, Risk Factors, Pain, Smoking, Body Mass Index, Iliac Vein, Venous Valves, Venous Thrombosis, Obesity, Hypertension
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