Abstract
ImportanceThe post-thrombotic syndrome (PTS) is the most common long-term complication of deep vein thrombosis (DVT), occurring in up to 40–50% of cases. There are limited evidence-based approaches for PTS clinical management.ObjectiveTo provide an expert consensus for PTS diagnosis, prevention, and treatment.Evidence-ReviewMEDLINE, Cochrane Database review, and GOOGLE SCHOLAR were searched with the terms “post-thrombotic syndrome” and “post-phlebitic syndrome” used in titles and abstracts up to September 2020.Filters WereEnglish, Controlled Clinical Trial / Systematic Review / Meta-Analysis / Guideline. The relevant literature regarding PTS diagnosis, prevention and treatment was reviewed and summarized by the evidence synthesis team. On the basis of this review, a panel of 15 practicing angiology/vascular medicine specialists assessed the appropriateness of several items regarding PTS management on a Likert-9 point scale, according to the RAND/UCLA method, with a two-round modified Delphi method.FindingsThe panelists rated the following as appropriate for diagnosis: 1-the Villalta scale; 2- pre-existing venous insufficiency evaluation; 3-assessment 3–6 months after diagnosis of iliofemoral or femoro-popliteal DVT, and afterwards periodically, according to a personalized schedule depending on the presence or absence of clinically relevant PTS. The items rated as appropriate for symptom relief and prevention were: 1- graduated compression stockings (GCS) or elastic bandages for symptomatic relief in acute DVT, either iliofemoral, popliteal or calf; 2-thigh-length GCS (30–40 mmHg at the ankle) after ilio-femoral DVT; 3- knee-length GCS (30–40 mmHg at the ankle) after popliteal DVT; 4-GCS for different length of times according to the severity of periodically assessed PTS; 5-catheter-directed thrombolysis, with or without mechanical thrombectomy, in patients with iliofemoral obstruction, severe symptoms, and low risk of bleeding. The items rated as appropriate for treatment were: 1- thigh-length GCS (30–40 mmHg at the ankle) after iliofemoral DVT; 2-compression therapy for ulcer treatment; 3- exercise training. The role of endovascular treatment (angioplasty and/or stenting) was rated as uncertain, but it could be considered for severe PTS only in case of stenosis or occlusion above the inguinal ligament, followed by oral anticoagulation.Conclusions and RelevanceThis position paper can help practicing clinicians in PTS management.
Highlights
Post-thrombotic syndrome (PTS) is the most common longterm complication of deep vein thrombosis (DVT) occurring in up to 40–50% of patients, primarily due to impaired thrombus resolution with persistent venous outflow obstruction and secondary valvular incompetence [1]
PTS Diagnosis and Surveillance 1- The Villata Scale (VS) is appropriate for the diagnosis and classification of PTS severity. 2- It is appropriate to assess pre-existing venous insufficiency for classifying PTS severity after DVT. 3- It is appropriate to assess PTS at least 3–6 months after the diagnosis of iliofemoral or femoro-popliteal DVT, and afterwards according to a personalized schedule depending on the presence or absence of clinically relevant PTS at these time-points
There is no specific recommended time limit to diagnose PTS and studies have followed up patients for two 2 years or longer
Summary
Post-thrombotic syndrome (PTS) is the most common longterm complication of deep vein thrombosis (DVT) occurring in up to 40–50% of patients, primarily due to impaired thrombus resolution with persistent venous outflow obstruction and secondary valvular incompetence [1]. PTS has not been routinely considered as an outcome of the large number of randomized clinical trials which have investigated pharmacological strategies for the prevention and treatment of venous thromboembolism (VTE), which includes DVT and PE in the last 30 years [2,3,4] and only secondary post-hoc analyses are available [5]. The limited evidence available and the many areas of uncertainty imply a wide spectrum of variations and heterogeneity in PTS clinical management across different countries. This prompted VAS-European Independent Foundation in Angiology/Vascular Medicine to launch a project for a position paper on the appropriateness of interventions for PTS involving practicing expert clinicians from many different countries. An appropriate procedure is one in which “the expected health benefit (e.g., increased life expectancy, relief of pain, reduction in anxiety, improved functional capacity) exceeds the expected negative consequences (e.g., mortality, morbidity, anxiety, pain, time lost from work) by a sufficiently wide margin that the procedure is worth doing, exclusive of cost” [6]
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