Post-Thrombotic Syndrome Prevention and Management. Dr. Ashwini Bennett
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1 Post-Thrombotic Syndrome Prevention and Management Dr. Ashwini Bennett
2 Disclosures No disclosures relevant to this presentation
3 Outline Importance of VTE and PTS Aetiology of PTS PTS risk factors PTS clinical assessment PTS prevention PTS management
4 Outline Importance of VTE and PTS Aetiology of PTS PTS risk factors PTS clinical assessment PTS prevention PTS management
5 Why is this topic relevant to you? VTE is very common VTE can cause PTS Severe PTS may result in venous leg ulcers
6 VTE is very common Australia cases $1.72 billion Annual incidence VTE Perth, WA per 1000 residents (95% CI 0.47 to 0.67) 1: Ho KH et al. The incidence of venous thromboembolism: a prospective, communitybased study in Perth, Western Australia. MJA 2008: 189 (3): : Access Economics 2008 report
7 Access Economics 2008 report VTE is very common
8 VTE can cause PTS PTS occurs in 1/3 symptomatic DVT Can be up to 50%, especially proximal DVT Severe PTS (± ulceration) occurs in 5 to 10% DVTs Kahn S. Blood 2009; 114: Kahn S. Blood Reviews 2002; 16:
9 Severe PTS is a cause of morbidity 1: Arch Intern Med 2005; 165: : J Thromb Haemost 2008; 6: Ulcers Discomfort Decreased mobility Occupational issues Poorer QOL than chronic lung disease, diabetes, arthritis 1, 2 Severe PTS QOL as CCF or cancer 1
10 PTS prevalence VTE cohort study Monash Health and Alfred Health N=235 (July 2011 to Feb 2014) PTS in 17.5% of patients - 68% mild - 23% moderate - 9% severe Aoki et al Abstract for European Haematology Association congress
11 Outline Importance of VTE and PTS Aetiology of PTS PTS risk factors PTS clinical assessment PTS prevention PTS management
12 Kahn S. How I treat post-thrombotic syndrome. Blood 2009; 114: Kahn S & Ginsberg J. The post-thrombotic syndrome: current knowledge, controversies, and directions for future research. Blood Reviews 2002;16: Arumugaswamy, Tran. Post-thrombotic syndrome: a potential cause of venous ulcer. Wound Practice and Research 2014: 22 (2):
13 Outline Importance of VTE and PTS Aetiology of PTS PTS risk factors PTS clinical assessment PTS prevention PTS management
14 PTS risk factors More proximal DVT 1 Incomplete resolution of signs/symptoms by 1 month post-dvt 2 Recurrent ipsilateral DVT 3 BMI 1 Older 1 Possible 4 Female, hormonal therapy, varicose veins, abdominal surgery 1 Kahn S.Blood 2009; 114: Kahn S et al. Ann Intern Med 2008; 149: Kahn S & Ginsberg J. Blood Reviews 2002; 16: Jorgensen M et al.post-phlebitic syndrome and general surgery: an epidemiologic investigation. Angiology 1991; 42:
15 PTS risk factors Probably not at increased risk Family history 1 Thrombophilic states 2 (e.g. antiphospholipid antibodies, factor V Leiden, prothrombin gene mutation, deficiency of protein C/S/ATIII) 1: Kahn S & Ginsberg J. Blood Reviews 2002; 16: : Rabinovich A et al. J Thromb Haemost 2014; 12:14 23.
16 Outline Importance of VTE and PTS Aetiology of PTS PTS risk factors PTS clinical assessment PTS prevention PTS management
17 Clinical assessment Diagnosis mainly clinical E.g. Oedema, pain, hyperpigmentation, pruritus, induration, lipodermatosclerosis Radiologic findings: Supportive but not diagnostic E.g. Valvular incompetence Can mimic DVT Defer diagnosis until 3-6 months after acute episode Remain vigilant for recurrent DVT
18 Clinical scoring systems Villalta: Most commonly used Ginsberg 1, 2 Identifies a more severe subset of PTS (Other) E.g. Brandjes, Widmer, CEAP, Venous Clinical Severity Score 1: Kahn S et al. J Thromb Haemost 2006: 4: : Kahn S et al. Lancet 2014: 383:
19 Villalta Score Mild PTS: 5-9 points Moderate PTS: points Severe PTS: 15 points or venous ulcer Villalta et al. Haemostasis 1994: a.
20 Kahn SOX trial
21 Outline Importance of VTE and PTS Aetiology of PTS PTS risk factors PTS clinical assessment PTS prevention PTS management
22 PTS prevention (Prevent initial DVT) Adequate treatment of initial DVT E.g. INR in therapeutic range 1 Thrombolysis CaVenT study 2 : Ileofemoral DVT. PTS at 24 months: CDT arm: 37/101 (41.1%) p= 0.04 Control: 55/108 (55.6%) ARR= 14.4%, NNT=7 ATTRACT study ongoing 1: Van Dongen. J Thromb Haemost 2005: 3: : Enden. Lancet 2012: 379 (9810):
23 Outline Importance of VTE and PTS Aetiology of PTS PTS risk factors PTS clinical assessment PTS prevention PTS management
24 ECS: Entering the lions den Daniel in the lion s den: Rubens
25 Elastic compression stockings Graduated elastic compression stockings Not TEDS Class II: mm Hg at ankle Class III: mm Hg at ankle
26 ECS in PTS Earlier studies suggested up to 50% reduction in PTS incidence with appropriate use of ECS Author Year N PTS in control arm Other studies with different design have found no effect E.g. Ginsberg Arch Intern Med 2001 PTS in ECS arm Brandjes (70%) 30 (31%) Prandoni (49.1%) 23 (24.5%)
27 SOX trial SOX Trial Double-blind RCT, First proximal DVT 2 year follow-up 30-40mm Hg graduated ECS Randomised to or Placebo stocking (<5mmHg) Kahn. Lancet 2014; 383:
28 SOX trial Primary efficacy outcome PTS diagnosed using Ginsberg criteria at 6 months ECS arm: 44/409 (14.2%) HR 1.13 (95%CI ) Placebo arm: 37/394 (12.7%) p=0.58 Secondary efficacy outcome PTS diagnosed using Villalta criteria at at 6 months ECS arm: 176/409 (52.6%) HR 1.00 (95%CI ) Placebo arm: 168/394 (52.3%) p=0.96
29 SOX trial No major adverse events in either arm Minor adverse events equal in both groups E.g. Rash, itching
30 N= year followup 2 scoring systems Strengths of SOX trial Prospect -ive RCT Doubleblinded Multicentre
31 Scoring systems subjective Compliance High rate loss to follow-up Limitations of SOX Really blinded? (yes) Advice on how to apply stockings Delay in starting stocking use? Correspondence to Lancet editor in response to publication of SOX trial results
32 ECS: A pragmatic approach Ipsilateral class II compression stocking all patients with proximal DVT Use during waking hours Remove before bed-time Ideally for 2 years Correctly fitted by orthotic supplier If not tolerated/too expensive/too inconvenient: Patient may consider ceasing 1 pair class II stockings $110 below knee, $150 thigh-high. Last for 6 months.
33 PTS management: Other options Early physical activity May PTS rate compared to bed rest Venous ulcer management Specialist management
34 PTS management: Not routine Intermittent pneumatic compression Portable venous return assist devices E.g. Venowave 1 Venoactive medications Aescin (horse chestnut seed): May symptoms of CVI 2 Hydroxyethylrutosides: May PTS symptoms 3 1: O Donnell Thromb Haemost 2008; 99: : Pittler. Cochrane review : Prandoni. Throm Haemost 2005; 93:
35 Take home messages PTS is common and under-appreciated Ongoing monitoring for PTS required Severe PTS can Venous ulcers Villalta score Compression stockings may be useful
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