Moderate Post-thrombotic Syndrome Research Articles

Percutaneous transluminal angioplasty of femoropopliteal veins for treatment of post-thrombotic syndrome.

Background: Controversy persists concerning the endovascular treatment of the post-thrombotic syndrome (PTS), particularly if femoropopliteal veins are involved. Methods: We screened consecutive patients with PTS who underwent percutaneous transluminal angioplasty (PTA) of femoropopliteal veins using posterior tibial or popliteal vein access who had at least 3-month follow-up. Our assessment included the evaluation of primary and secondary patency of the treated segments by Doppler ultrasound (DUS) and clinical outcomes measured by the change in Villalta score as well as ulcer healing. Results: Among 29 patients, 8 (27.7%) were women and the mean (SD) age was 53.3 (13.6) years. Posterior tibial vein and popliteal access were used in 26 (89.7%) and 3 patients (10.3%), respectively. 13 (44.8%) patients had prior (n = 11, 37.9%) or concomitant (n = 9, 31.0%) endovascular treatment of the iliac or common femoral veins. At a median follow-up of 395 days (Q1: 205-Q3: 756 days), primary patency of femoropopliteal veins was 79.3% (95% CI 64.6-94.1%) and secondary patency was 82.8% (95% CI, 69.0-96.5%). The percentage of patients with moderate or severe PTS according to the Villalta score decreased from baseline to last follow-up from 34.5% to 18.5% and from 31% to 14.8%, respectively (p<0.003). Overall, the mean (SD) Villalta score decreased from 11.5 (1.7) to 8.0 (1.7) (p<0.0001). Postprocedural complete ulcer healing occurred in 4 out of 5 (80%) patients. Two (6.9%) patients developed new ulcers. No major bleeding, pulmonary embolism, stroke, or death occurred. Conclusion: PTA of femoropopliteal veins via posterior tibial or popliteal vein access appears to improve the severity of PTS with acceptable patency rates.

Sequelae and post-thrombotic syndrome after venous thromboembolism in acute lymphoblastic leukemia survivors treated on the NOPHO ALL2008 protocol.

The treatment of acute lymphoblastic leukemia (ALL) is frequently complicated by toxicity, including venous thromboembolism (VTE) affecting roughly 8% of patients. VTE can lead to post-thrombotic syndrome (PTS), a group of signs and symptoms developed as a complication to deep venous thrombosis (DVT), imposing risk of permanent disability and reduced quality of life (QoL). PTS prevalence ranges from 0% to 70%, reflecting very heterogenous cohorts and assessment tools. We aimed to estimate sequelae, including PTS and QoL in children and adults (<45years old) who had a DVT during ALL treatment. PTS and QoL scores were obtained through use of Villalta and Modified Villalta Scale, PedsQL, and Short Form-36 questionnaires. The cohort comprised 20 children (<18years) and seven adults (median age: 12.9years, range: 2-44years) at the time of DVT diagnosis. In total, 25 ALL survivors underwent PTS examination. The examination took place when survivors were 7-48years (median age: 20.3years, median follow-up time 6.8years). QoL was assessed correlating cases with three matching ALL survivors without VTE. Two adults (15.4%) showed mild or moderate PTS. Eight children (66.7%) were diagnosed with mild PTS, while three cases had collaterals as sole symptoms. Pain or symptoms affecting daily life were reported by 16%. No difference in QoL was found (p=.9). This study underscores the need for comprehensive population-based investigations with validation of PTS instruments in ALL survivors.

The background and role of catheter-directed thrombolysis evolving procedures for acute iliofemoral deep venous thrombosis.

Minimal invasive treatment such as early endovenous thrombus removal for iliofemoral deep venous thrombosis (DVT) emerged in the end of last century. The principle is catheter-directed thrombolysis (CDT) using either plasminogen activating agents alone, as ultrasound-assisted CDT, or in combination with mechanical devices as pharmaco-mechanical CDT. The interest for this treatment modality is the high rate of post-thrombotic syndrome (PTS) with anticoagulation (AC) alone, especially after iliofemoral DVT. Recently published randomized controlled trials (RCTs) comparing early thrombus removal with AC alone, as well as non-randomized studies, have demonstrated favorable rates, or at least a decrease of moderate and severe PTS, in favor of these procedures. This article will summarize the background and evolution of the procedures in the last three decades and discuss fundamental criteria for inclusion and exclusion, focusing on the procedures regarding thrombus age and location, technical issues, complications and results including different outcome measures for PTS, for which iliac DVT involvement is a massive risk factor to be prevented.

Epidemiology and Diagnosis of Post-Thrombotic Syndrome: Qualitative Synthesis with a Systematic Review.

Background: Post-thrombotic syndrome (PTS) is a common and debilitating sequela of lower limb deep vein thrombosis (DVT). There is significant heterogeneity in reported PTS incidence due to lack of standardised diagnostic criteria. This review aimed to develop diagnostic criteria for PTS and subsequently refine the reported incidence and severity. Methods: PRISMA principles were followed; however, the review was not registered. The Cochrane CENTRAL database, MEDLINE, Embase, the NHS NICE Healthcare Databases Advanced Search interface, and trial registers including isrctn.com and clinicaltrials.gov were searched for studies addressing areas of interest (PTS definition, epidemiology, assessment). An experienced Clinical Librarian undertook the systematic searches, and two independent reviewers agreed on the relevance of the papers. Conflicts were resolved through panel review. Evidence quality was assessed using a modified Coleman scoring system and weighted according to their relevance to the aforementioned areas of interest. Results: A total of 339 abstracts were retrieved. A total of 33 full-text papers were included in this review. Following qualitative analysis, four criteria were proposed to define PTS: (1) a proven thrombotic event on radiological assessment; (2) a minimum 24-month follow-up period after an index DVT; (3) assessment with a validated score; and (4) evidence of progression of venous insufficiency from baseline. Four papers conformed to our PTS definition criteria, and the incidence of mild to moderate PTS ranged from 7 to 36%. On reviewing the studies which utilised the recommended Villalta scale, PTS incidence narrowed further to 23-36%. Incidence and severity reached a plateau at 24 months. Conclusions: Four diagnostic criteria were developed from qualitative synthesis. When these criteria were applied to the literature, the range of reported PTS incidence narrowed. These four criteria may standardise PTS diagnosis in future studies, facilitating the pooling of data for meta-analysis and synthesis of higher levels of evidence.

Cost Effectiveness of Early Endovenous Thrombus Removal for Acute Iliofemoral Deep Vein Thrombosis in the United Kingdom

Early clot removal using endovascular intervention aims to reduce post-thrombotic syndrome (PTS) following iliofemoral deep venous thrombosis (DVT). This may reduce long term morbidity but incurs a higher initial cost. This study examined the cost effectiveness of catheter-directed thrombolysis (CDT) and pharmacochemical thrombectomy (PMT) compared with oral anticoagulation (OAC) alone for treatment of acute iliofemoral DVT in the United Kingdom. A combined decision tree (acute DVT complications) and Markov model [long term complications (PTS)] was used decision analytic modelling with five states: no PTS, mild PTS, moderate PTS, severe PTS, and dead. All patients started with acute DVT. Patients who survived acute complications transitioned into the Markov model. Cycle time was 6 months. A healthcare payer perspective and lifetime horizon was used, adjusting for excess mortality due to history of thrombosis. Data for probabilities, transition probabilities, mortality, and utilities were obtained from published literature. Cost data were obtained from UK NHS tariffs and published literature. Outcomes were mean lifetime cost, quality-adjusted life years (QALYs), and cost effectiveness. Over a patient's lifetime, OAC was more costly (£37 206) than CDT (£32 043) and PMT (£36 288). Mean lifetime QALYs for OAC (12.9) were lower than CDT (13.5) and PMT (13.3). Therefore, in the incremental cost effectiveness analysis, both CDT and PMT were dominant: CDT was less costly (- £5 163) and more effective (+0.6 QALYs) than OAC, and PMT was also less costly (-£917) and more effective (+0.3 QALYs) than OAC. Results were robust to univariate sensitivity analyses, but probabilistic sensitivity analyses suggested considerable parameter uncertainty. Early interventional treatment of iliofemoral DVT is cost effective in the UK. Future clinical and epidemiological studies are needed to characterise parameter uncertainty. Further analysis of modern practice, alternative treatments, and optimised care models is warranted.

Is it necessary to wear compression stockings and how long should they be worn for preventing post thrombotic syndrome? A meta-analysis of randomized controlled trials

BackgroundPost thrombotic syndrome (PTS) is a serious complication of deep venous thrombosis (DVT). There were always debates on the efficacy of elastic compression stockings (ECS) in prevention for post thrombotic syndrome. ObjectiveTo assess effects of elastic compression stockings and ECS's wearing time on post thrombotic syndrome after diagnosis of deep venous thrombosis. MethodsPubMed, Cochrane Library, Embase, Web of Science were last searched on 23 November 2022 for studies assessing effects of elastic compression stockings or theirs wearing time on post thrombotic syndrome after diagnosis of deep venous thrombosis. Results9 randomized controlled trials were included. Wearing elastic compression stockings was associated with a statistically reduction in the overall post thrombotic syndrome rate (RR 0.73, 95 % CI 0.53 to 1.00; P = 0.05; I2 = 82 %). No significant difference in severe post thrombotic syndrome rate, recurrent deep venous thrombosis rate, and death rate was seen whether wearing elastic compression stockings or not. The pooled effect of studies comparing different wearing time of elastic compression stockings showed no significant difference in post thrombotic syndrome rate, severe and moderate post thrombotic syndrome rate, recurrent deep venous thrombosis syndrome rate and death rate. ConclusionsWearing ECS can reduce the risk of developing PTS after DVT and a wearing time of less than or equal to 1 year is comparable to 2 years wearing. The results support ECS's role as a foundation therapy for preventing PTS.

The effects of pharmacomechanical thrombolysis treatment administered to patients with iliofemoral deep vein thrombus

Aim: In this study, the mid-term results of the pharmacomechanical thrombolysis treatment administered in patients with iliofemoral acute-subacute (patients with symptoms less than 21 days old whose DVT was diagnosed with physical examination and duplex ultrasonography) deep vein thrombus (DVT) were investigated. The cases were evaluated in terms of disease-related quality of life, and the presence of post-thrombotic syndrome (PTS) which occurred in patients after previous DVT and treatment, and if present, its severity was determined. Material and Methods: Disease-related status of 40 patients (24 males, 16 females; mean age 44; age interval 20-80 years) treated due to iliofemoral acute-subacute DVT with interventional method between July 2013 and January 2017 were retrospectively analyzed two years after the interventional treatment. These patients were considered as mid-term patients. The patients were evaluated with VEINES-QOL/Sym quality of life scale and the Villalta scale. The occurrence and severity of PTS, the presence of venous ulcer, and the diameter difference between legs were evaluated. Results: No venous ulcer was present in our cases. In the evaluation made with Villalta scale, PTS was not observed in 20 out of 40 cases, mild PTS was found in 15, moderate PTS in 4, and severe PTS was observed in 1 case. Conclusion: We have concluded that pharmacomechanical thrombolysis treatment administered in well-selected patients reduced the severity of PTS and increased the quality of life associated with disease in DVT treatment.

Early outcomes of mantis pharmacomechanical thrombectomy system combined with catheter-directed thrombolysis for treatment of acute iliofemoral deep vein thrombosis

Aim: The purpose of this research was to investigate the early outcomes of pharmacomechanical thrombectomy (PMT) with the Mantis device and adjunctive catheter-directed thrombolysis (CDT) for the treatment of acute iliofemoral deep vein thrombosis (IFDVT). Material and Methods: Twenty patients with symptomatic acute IFDVT were successfully treated with the Mantis rotational thrombectomy device and CDT, between August 2020 and March 2021. Patients' demographical, clinical and follow-up data were obtained and analysed retrospectively. Villalta and Pain Severity scores were utilized to assess the patients for the occurrence of post-thrombotic syndrome (PTS). Results: The procedural success rate was 100%. All cases presented early clinical improvement. No device related complications were encountered. Reocclusion was observed in 3 (15%) patients. Pre-procedural median pain score was 7 (range: 6–8) and 1 (range: 0–7) at 12-month following thrombectomy (P &lt; .001). Pre-procedural median Villalta score was 7 (range: 3–11) and 1 (range: 0–13) at 12-month following thrombectomy (P&lt;.001). At 12-month follow-up, no PTS was reported in 15 (75%) patients, mild PTS was reported in 2 (10%) patients, moderate PTS was reported in 2 (10%) patients and no severe PTS was observed. Conclusion: The Mantis PMT system with CDT seems to be an efficient treatment approach for acute IFDVT with encouraging early results.

Venous Stenting for Postthrombotic Iliocaval Venous Obstructive Disease: Clinical Efficacy and Mid-term Outcomes.

Postthrombotic syndrome (PTS) can cause both venous outflow obstruction and deep venous reflux, and results in severe symptoms of chronic venous disease. Venous stenting in the chronic iliocaval venous obstruction has been shown to be a safe and efficacious procedure. The long-term studies have shown the high patency rate, the good symptom relief, and the low recurrence rate of healed venous ulcerations. Although venous stenting has become a widely accepted treatment option in PTS with chronic venous occlusion or severe stenosis, it is not yet covered by insurance in Japan, and is being performed at limited facilities using off-label arterial stents. In this study, we performed venous stenting in 30 patients with the moderate and severe PTS. All patients showed significant improvement in their venous scores postoperatively, the Villalta score changed from a median of 16 before treatment to a median of 7 after treatment. Likewise, the Venous Clinical Severity Score and the Venous Disability Score dropped from a median of 13, 2.4 before treatment to 6, 1.2 after treatment, respectively. The primary patency and the secondary patency at 40 months were 93% and 96%, respectively. We report the excellent results and discuss current issues and future perspective in Japan. (This is secondary publication from J Jpn Coll Angiol 2021; 61: 99-105.).

A Clinical Trial of Venous Stent Placement for Post-thrombotic Syndrome: Current Status and Pandemic-related Changes.

Patients with post-thrombotic syndrome (PTS) and iliac vein obstruction have lower extremity symptoms, activity limitation and impairment of health-related quality of life. Preliminary studies suggest that iliac vein stent placement, which eliminates venous outflow obstruction, may reduce the clinical severity of PTS. However, stent placement is associated with patient risk, inconvenience and cost. Therefore, the Chronic Venous Thrombosis - Relief with Adjunctive Catheter-directed Therapy (C-TRACT) trial was launched to rigorously assess the risk-benefit ratio of stent placement for the treatment of moderate or severe PTS. In the trial, patients in both treatment groups receive a high quality of multimodality PTS care that includes medical, compressive, and ulcer therapies. Due to the COVID-19 pandemic, the trial protocol and practices were modified to enhance the study feasibility while preserving its ability to answer its primary question. This review summarises the current status of the trial and the potential impact of the pandemic-related adaptations to future venous clinical practice and research.

Stenting in the common femoral vein does not increase posthrombotic syndrome or rethrombosis

Abstract Background In lower limbs deep venous thrombosis (DVT) scenario there is evidence that favours catheter guided invasive treatment. The treatment with stenting in the common femoral vein could be related with a diminished permeability in the inflow of the deep femoral vein. There is scarce data of the clinical follow up of this treatment. Purpose To analize and compare clinical and procedural outcomes in endovenous interventions that required stent placement in the common femoral vein because of residual lesion vs interventions that did no require such treatment. Methods From May 2010 to December 2020, 122 endovenous interventions were performed, within these 74 were DVT compromising the iliofemoral territory. Two groups were defined: Group A 28 (38%) that required stent placement in the common femoral vein and Group B 46 (62%) that did not required such treatment. Results Baseline characteristics were Group A vs Group B n (%) respectively: Median age 41.1±16.7 vs 40.5±18.8; female 23 (82) vs 27 (58); smoking 7 (25) vs 14 (30); cancer 1 (4) vs 7 (15); prior prolonged rest 7 (25) vs 14 (30); concomitant diagnosis of pulmonary embolism 7 (25) vs 17 (37). Within the female population 2 (7) vs 1 (2) were in puerperium; 6 (21) vs 6 (13) were under contraceptive therapy. Regarding the diagnosis of DVT 21 (75) vs 37 (80) were acute; 7 (25) vs 9 (19) were chronic. Compromised vessels were primitive iliac vein 21 (75) vs 38 (82); external iliac vein 6 (21) vs 18 (39); superficial femoral vein 11 (39) vs 8 (17); May-Thurner syndrome 14 (50) vs 20 (43). As regards the aspects of the intervention 15 (53) vs 34 (74) had a filter implanted in the inferior vena cava; thrombolytics were infused in 20 (71) vs 32 (70); manual thrombectomy was performed in 8 (27) vs 17 (37); mechanical thrombectomy 11 (39) vs 19 (41); pre dilation with balloon was performed in 22 (79) vs 39 (85); dedicated venous stents were implanted in 22 (78) vs 39 (85); not dedicated venous stents in 13 (46) vs 11 (24). Technique success was achieved in 28 (100) vs 45 (98) p=1; major bleeding occurred 0 vs 2 (4) p=0.5; rethrombosis 3 (10) vs 9 (20) p=0.25; intrahospital death 1 (4) vs 2 (4) p=1; early reintervention was needed 1 (4) vs 2 (4) p=1, radiation dose (min) 35.4±20.2 vs 30.1±17.0 p=0.2; Contrast (ml) 216.5±76.8 vs 217.3±90.8 p=0.9. During follow up (34.1±31.5 vs 22.3±16.4) image control was performed in 27 (96) vs 39 (85) p=0.23 with either doppler or chest computed tomography angiography. Post thrombotic syndrome (PTS) symptoms were classified with Villalta Score assuming that 0–4 points had no PTS, 5–9 points presented mild PTS, 10–14 points moderate PTS, &amp;gt;14 points severe PTS, in Group A 1 (4) presented mild PTS vs Group B 2 (4) mild PTS p=1, 1 (2) moderate PTS. Conclusions Endovenous treatment with stent placement in the common femoral vein did not required more reinterventions nor had more complications nor had more PTS that the interventions without stent placement. Funding Acknowledgement Type of funding sources: None. Table 1. Basal CharacteristicsTable 2. Outcomes

Our Treatment Outcomes in Patients with Acute Deep Vein Thrombosis Associated with Congenital Inferior Vena Cava Agenesis

Introduction: In this study, we present the treatment outcomes of patients with acute deep venous thrombosis (DVT) associated with congenital agenesis of the inferior vena cava (IVCA). Patients and Methods: In this retrospective study, the clinical findings and follow-up data of patients who were scheduled for an interventional procedure due to acute DVT in 2019-2021 and who were found to have IVCA in venography were analyzed retrospectively. Results: A total of 11 patients with acute DVT associated with IVCA were identified during the study period. Eight of the patients (72.7%) were male. The mean age of the patients was 25.5 ± 6.5 years (16-36 years). Five of the patients were followed up with conservative medical treatment. Endovascular procedure was performed in six patients. At the end of the first year, moderate post-thrombotic syndrome was found in 1 patient and mild post-thrombotic syndrome was detected in 2 patients. Patients who received only medical treatment had a significantly higher Villalta score at the end of the first year than patients who received endovascular treatment (6.6 ± 4.1 and 2.1 ± 1.9, p= 0.04). Conclusion: Congenital IVCA is a rare diagnosis that should be kept in mind in young patients with deep venous thrombosis. In these patients, endovascular approach may be effective to prevent postthrombotic syndrome.

PNS90 Estimation of Markov Chain Transition Probabilities and Rates for Use As Inputs to Multistate Models

Post-thrombotic syndrome (PTS) is a chronic venous disease that can occur after deep-vein thrombosis and substantially impacts on quality of life. This paper develops and extends Markov Chain Monte Carlo (MCMC) methods (Welton 2005) to estimate the rates of transition between PTS health states using published summary data. A clinical study reported aggregate baseline and follow-up outcomes for 97 PTS patients, of whom 46(47%) were severe and 39(40%) moderate PTS (Black 2018). After 2 years, 7 were severe, 6 moderate, 22 mild and 18 had no PTS, with 44 missing data. A MCMC model was constructed in Winbugs to estimate the underlying rates of transition between severe PTS to moderate (r1), moderate to mild (r2) and mild to no PTS (r3), taking account that transitions are unobserved and assuming missing data were missing completely at random. The set of Kolmogorov forward equations required to map between transition rates and probabilities were calculated algebraically using matrix decomposition (Jones 2017). The MCMC model estimated mean (standard error) rates of r1=0.52(0.23), r2=2.16(0.50), and r3=0.83(0.21). These rates make predictions that fit reasonably well with the observed data at 2 years, predicting with the same baseline patients, 7 severe, 5 moderate, 23 mild and 18 no PTS at 2 years. The MCMC model made estimates that fit well with observed data to be used as baseline rates in a state-transition decision model. The advantage of estimating rates using MCMC rather than other methods for obtaining transition probabilities (e.g. assuming a multivariate Dirichlet distribution) is that rates can be directly multiplied by relative treatment effects obtained from literature review of randomized controlled trials, and permit more straightforward extrapolation beyond the time horizon of the original study.

Outcomes of Aspirex®S thrombectomy system combined with catheter-directed thrombolysis for treating bilateral lower extremity deep venous thrombosis

BackgroundPharmacomechanical catheter-directed thrombolysis (PCDT) is rarely reported in treating bilateral lower extremity deep venous thrombosis (LEDVT). This study was aimed to investigate the safety, patency, and mid-term outcomes of the Aspirex®S thrombectomy system combined with catheter-directed thrombolysis (CDT) in treating symptomatic bilateral LEDVT. Patients and MethodsThe clinical data of 45 consecutive patients with acute or subacute bilateral LEDVT (60.00% male; mean age, 53.8 ± 16.5 years) who received endovascular treatment with PCDT between January 2015 and June 2019 were retrospectively analyzed in this study. The clinical efficacy of thrombolysis (≥50% thrombolysis), complications, primary patency, valvular function, and cumulative prevalence of post-thrombotic syndrome (PTS) were retrospectively analyzed. ResultsPCDT was performed in all 45 patients successfully. No serious procedure-related complication or death was observed. The average urokinase dosage was 4.1 ± 1.5 million IU, and the average thrombolysis time was 5.3 ± 1.3 days. The mean length of hospital stay was 9.9 ± 2.5 days. The primary patency was 100% after lysis. The clinical efficacy of thrombolysis was 86.7% (39/45). Deep venous thrombosis recurrence was observed in six (13.3%) patients within 12 months after discharge. The primary patency at 1-, 3-, 6-, 9-, and 12-month follow-up was 97.8%, 93.3%, 88.9%, 82.2%, and 73.3%, respectively. The cumulative prevalence of PTS was 24.4% (11/45) throughout the follow-up period, whereas the prevalence of moderate and severe PTS was only 6.7% (3/45). ConclusionsPCDT for treating bilateral LEDVT is feasible, effective, and safe.

The Burden of Post-Thrombotic Syndrome in a Long-Term Retrospective Cohort in Northern Portugal.

Post-thrombotic syndrome is a frequent and disabling complication of deep venous thrombosis. Its incidence is not described in the Portuguese population. The objective of this study is to report the incidence and severity of post-thrombotic syndrome after the initial episode of deep venous thrombosis. This is an observational, unicentric, retrospective cohort of patients who had a first episode of deep venous thrombosis in the lower limb, documented with duplex ultrasound (n = 101). The modified Villalta score was applied by phone interview for the diagnosis and staging of post-thrombotic syndrome. The quality of life of patients was measured with the modified CIVIQ 14 classification. Median follow-up time was six years (interquartile range 1). Severe post-thrombotic syndrome was present in 27% of patients and moderate in 33%. Performing physical activity at the time of the interview was associated with lower incidence of post-thrombotic syndrome (relative risk 0.489; 95% confidence interval = 0.320 - 0.748). Body weight gain after deep venous thrombosis (relative risk 2.188; 95% confidence interval 1.137 - 4.210) and lower education levels (relative risk 2.005; 95% confidence interval 1.297 - 3.098) were associated positively with post-thrombotic syndrome. Quality of life was 90 ± 17 vs 64 ± 18 vs 43 ± 15 in patients without postthrombotic syndrome, with moderate post-thrombotic syndrome and with severe post-thrombotic syndrome, respectively (p < 0.001). The long-term incidence of post-thrombotic syndrome in a cohort of patients from Northern Portugal is higher than in other studies and correlates with worse adjusted CIVIQ-14 scores. Large studies of prospective nature could provide more definitive evidence.

Incidence and severity of postthrombotic syndrome after iliofemoral thrombosis - results of the Iliaca-PTS - Registry.

Background: Deep venous thrombosis (DVT) and in particular, iliofemoral thrombosis (IFT) can lead to recurrent thrombosis and postthrombotic syndrome (PTS). Data on the prevalence, predictors and outcome of IFT are scarce. Patients and methods: We retrospectively searched our database of outpatients who had presented with DVT and IFT including the iliac veins from 2014 until 2017. In addition, we performed a prospective registry in a subgroup of patients with IFT. These patients received duplex ultrasound, magnetic resonance venography and measurement of symptom-free walking distance using a standardized treadmill ergometry. The severity of PTS was analyzed using the Villalta-Scale (VS) and quality of life was assessed using the VEINES-QOL/Sym Questionnaire. Results: 847 patients were retrospectively identified with DVT and 19.7% (167/847) of these presented with IFT. 50.9% (85/167) of the IFT-patients agreed to participate in the prospective registry. The majority of these patients (76.5%: 65/85) presented with left-sided IFT. In 53.8% (35/65) May-Thurner syndrome was suspected. 27.1% (23/85) underwent invasive therapy. Moderate or severe PTS (VS≥10) occurred in 10.6% (9/85). The severity of PTS is correlated with a reduced quality of life (ρ (CI 95%)=-0.63 (-0.76; -0.46); p<0.01). None of the patients presented with a venous ulcer at any time. A high body mass index was a significant predictor (OR (CI 95%)=1.18 (1.05; 1.33), p=0.007) for the development of clinically relevant PTS (VS≥10) and venous claudication. Conclusions: Every fifth patient with DVT presented with an IFT. The majority developed left sided IFT. Every 10th patient developed moderate or severe PTS (VS≥10). A high body mass index was predictive for the development of PTS and venous claudication.

Surgical thrombectomy for iliofemoral deep vein thrombosis: Patient outcomes at 8.5 years.

IntroductionDeep vein thrombosis (DVT) is a frequent burden and a post-thrombotic syndrome (PTS) can be a serious long-term consequence. Iliofemoral DVT should be associated with severe forms of PTS. Therefore an early thrombus removal has been recommended in specific conditions. The aim of this study was to find out both, the long-term results after surgical thrombectomy of iliofemoral DVT in respect of the development of PTS as well as the venous hemodynamics after surgery concerning venous reflux and venous obstruction.MethodsSixty-seven patients who underwent surgical thrombectomy between the years 2000 and 2014 were included in this study; iliofemoral DVT was present in 52 of these patients. 35 patients could be reinvestigated after a mean follow-up of 8.5 years. CEAP (Clinical-Etiological-Anatomical-Pathophysiological) and Villalta scores were recorded in order to describe and assess PTS. Follow-up examinations included a detailed duplex mapping. Venous hemodynamics were measured by digital photoplethysmography and venous occlusion plethysmography.ResultsThe primary patency rate of the iliofemoral segment was 88% after 8.5 years. 48% of all patients showed reflux in deep vein segments. Mild or moderate PTS occurred in 57% of all patients. Notably, there was no patient with an active ulcer or severe PTS. The mean venous outflow volume of all patients in the treated legs was 66.1 ml/100ml/min and significantly less than in the controlled contralateral non-treated legs (p<0.05). The mean venous refilling time was 16.3 seconds, while the mean value of the non-treated contralateral legs was 25.6 seconds and therefore significantly higher (p<0.05).ConclusionEven though venous hemodynamics are significantly inferior in the treated legs, this study demonstrates excellent patency rates and good clinical outcome after surgical thrombectomy of iliofemoral veins.

Long-Term Outcome of Catheter-Directed Thrombolysis in Pregnancy-Related Venous Thrombosis.

BackgroundVenous thromboembolism (VT) is a leading cause of maternal mortality and morbidity worldwide. Catheter-directed thrombolysis (CDT) is an effective and safe treatment modality for VT patients. However, the long-term outcome of CDT in pregnancy-related venous thrombosis are unclear. The aim of this study was to assess long-term results of pregnancy-related VT patients.Material/MethodsWe reviewed 41 pregnancy-related deep venous thrombosis (DVT) patients who underwent CDT from February 2008 to May 2015. Clinical data, including demographic variables, disease location, vascular risk factors, treatment regimen, interventional procedure and complications, were collected retrospectively. Clinical and color-duplex ultrasonography were performed to monitor venous patency during follow-up. Post-thrombotic syndrome (PTS) was assessed with the Villalta scale and quality of life (QOL) was evaluated by the VEINES-QOL/Sym questionnaire.ResultsTwenty-three patients underwent spontaneous abortion or induced abortion within 3 months before DVT, and 18 patients had DVT during the first 3 months after delivery. Technical success was achieved in all patients. Grade III (complete) lysis was obtained in 15 patients and grade II (partial) lysis was obtained in 21 patients. The follow-up period was 3 years. Twenty-eight patients had venous patency at 3-year follow-up; 36.6% of patients developed mild or moderate PTS (Villalta score 5–14) and 4.8% with severe PTS (Villalta score ≥15). VEINES-QOL/Sym scores were 55.24±7.35 and 53.25±6.65, respectively.ConclusionsCatheter-directed thrombolysis is a reliable and safe treatment modality for postnatal or abortion patients with DVT. CDT can reduce the incidence rate of PTS and increase the quality of life.

Characterization of Post-Thrombotic Syndrome in Children with Cardiac Disease

To assess the validity of existing clinical scales assessing the presence of physical and functional abnormalities for diagnosing post-thrombotic syndrome (PTS) in children, including specific evaluation of use in children with congenital heart disease (CHD). One hundred children aged >2 years (average age, 6 years), including 33 with CHD and previously proven extremity deep vein thrombosis (DVT), 37 with CHD and no previous DVT, and 30 healthy siblings, were blindly assessed for PTS using the modified Villalta Scale (MVS). All patients aged <6 years underwent neurodevelopmental testing and an age-appropriate quality of life assessment. The MVS identified mild PTS in 20 children and moderate PTS in 1 child (including 14 of 33 [42%] in the CHD/DVT group, 5 of 37 [14%] in the CHD/no DVT group, and 2 of 30 controls [7%]). The diagnosis of PTS was confirmed clinically in 14 patients, all of whom had previous thrombosis and 1 of whom was MVS-negative. MVS had an accuracy of 91% and performed reasonably well as a screening tool but poorly as a diagnostic tool. MVS reliability was acceptable. Children with PTS had similar quality of life as those without PTS but had higher rates of neurodevelopmental delays in gross motor skills (70% vs 24%; P = .02) and problem-solving indicators (60% vs 15%; P = .008). Using the MVS scale for PTS screening in children with CHD is feasible and reliable, and the scale has good correlation with a clinical diagnosis of PTS despite a high prevalence of false-positive findings. Further research is needed to determine the clinical relevance of PTS in this population.

Treatment-Related Outcomes in Paget–Schroetter Syndrome—A Cross-Sectional Investigation

To investigate treatment-related outcomes, namely radiological clot resolution, post-thrombotic syndrome (PTS), and health related quality-of-life (HRQoL) scores, in children with Paget-Schroetter syndrome (PSS) undergoing multidisciplinary management, including anticoagulation and decompressive rib-resection surgery, with or without thrombolytic therapy. We identified all patients treated for PSS at our institution between the years 2010 and 2017. Baseline clinical and radiologic data were abstracted from medical records. Two validated survey instruments to quantify PTS and HRQoL were mailed to eligible patients. Standard statistical methods were used to summarize these measures. In total, 22 eligible patients were identified; 10 were treated with thrombolysis followed by anticoagulation and rib resection, and 12 were treated with anticoagulation and rib resection alone. Nineteen patients responded to the survey instruments. Median age at deep vein thrombosis diagnosis and survey completion were 16.3 and 20.4 years, respectively. Nineteen of 22 patients had thrombus resolution on radiologic follow-up. Fourteen of 19 survey respondents reported signs/symptoms of PTS of which the majority (12/14) reported mild PTS. Aggregate total, physical, and psychosocial HRQoL scores reported were 90.6, 96.7, and 93.3, respectively. Thrombolytic therapy was not associated with a significant improvement in radiologic, clinical or HRQoL outcomes. Most patients with PSS had complete thrombus resolution on imaging. Only 11% of survey respondents reported moderate PTS. The entire cohort reported excellent HRQoL scores. The role for thrombolytic therapy in the management of childhood PSS remains incompletely elucidated.