Management of Post-Thrombotic Syndrome Thanainit Chotanaphuti Phramongkutklao College of Medicine Bangkok, Thailand President of CAOS Asia President of Thai Hip & Knee Society President of ASEAN Arthroplasty Association
Introduction The post-thrombotic syndrome (PTS) is a chronic condition that develops in 20-50% of patients after deep vein thrombosis (DVT), it is thus the most common complication of venous thromboembolism (VTE). PTS is a costly and burdensome condition in term of healthcare costs and effect on quality of life and productivity
How Does DVT Lead to PTS When DVT is diagnosed, standard anticoagulant treatment prevents thrombus extension and embolization to the pulmonary arteries, but does not directly lyse the acute thrombus. In most patients, only partial clearance of thrombus occurs and return of normal function of the vein is rare. Even when lysis is achieved, permanent damage to venous valves occurs frequently, leading to valve incompetence (reflux). Residual venous obstruction and valvular reflex lead to increased venous pressure (venous hypertension), which results in reduced calf muscle perfusion, increased tissue permeability and the associated clinical manifestations of PTS. Thrombus
Clinical Presentation of PTS PTS is termed a syndrome because it is associated with groupings of symptoms and clinical signs which may vary from patient to patient. Patients with PTS experience pain, heaviness, swelling, cramps, itching or tingling in the affected limb. Symptoms may be present in various combinations and may be persistent or intermittent. Typically, symptoms are aggravated by standing or walking and improve with resting, leg elevation and lying down. Signs that may be noted on physical examination of the limb include edema, telangiectasias, hyperpigmentation, eczema, varicose veins and, in severe cases, lipodermatosclerosis and ulceration.
Which Patients With DVT Are At Risk of Developing PTS In general, 60% of patients will recover from a leg DVT without any residual symptoms, 30% will have some degree of PTS and 5% will have severe PTS Symptoms of PTS usually occur within the first 6 months, but can occur up to 2 years after DVT. If a patient has done well for 1/2-2 years after DVT it is unlikely that they will develop PTS
Post-Thrombotic Syndrome The most important late complication of acute DVT Venous hypertension resulting from either venous reflux or persistent venous obstruction Mild symptoms, edema or skin hyperpigmentation to ulceration Recurrent thrombotic events have been noted in 45% of patients with PTS in comparison with only 17% of asymptomatic subjects Linder et al, Long term hemodynamic and clinical sequelae of lower extremity deep vein thrombosis. J Vas Surg 1996 Monreal et al, Venographic assessment of deep vein thrombosis and risk of developing PTS:a prospective trial. J Intern Med 1993 Prandoni et al, The long term clinical course of acute deep vein thrombosis. Ann Intern Med 1996
How is PTS Diagnosed? PTS is primarily diagnosed on clinical grounds There is no gold standard laboratory or imaging that establishes the diagnosis In patients with objectively confirmed prior DVT who have typical PTS symptoms and signs, PTS is usually the correct diagnosis In some patients, it may take a few months for the initial pain and swelling associated with acute DVT to resolve, hence a diagnosis of PTS should be deferred until after the acute phase has passed Many DVT patients develop valvular incompetence but do not have symptomatic PTS. Objective evidence of venous valvular incompetence may help to confirm the diagnosis of PTS in symptomatic patients, but PTS should not be diagnosed if clinical symptoms are absent The Villalta PTS scale has been used in clinical studies to diagnose and grade the severity of PTS
Determining PTS Villalta score Clinical measurement of PTS that grades severity from 0 ( absent ) to 3 ( severe ) of five patient-rated symptoms ( pain, cramps, heaviness, pruritus and paresthesia ) and six clinician-rated clinical signs ( edema, redness, skin induration, hyperpigmentation, venous ectasia, and pain on calf compression ) A score of 5 indicates the presence of PTS Mild ( 5-9 ) Moderate ( 10-14 ) Severe ( >14 or ulcer )
Determining PTS Duplex ultrasound
Mild PTS : Swelling, skin change
Moderate PTS : Superficial phlebitis Proximal involvement
Severe PTS : Recurrent VTE or ulcer Both reflex & obstruction
Post-Thrombotic Syndrome After Total Knee Arthroplasty: A 2-year Prospective Study J Med Ass Thailand 2009 We called the patients with unprotected VTE in a prior DVT study back to evaluate PTS
Methods 2002-2004 ; 100 cases of TKA were performed with bilateral postoperative contrast venogram @ Day 6 th -10 th DVT 60 cases Non-DVT 40 cases [ 2005] Post-thrombotic syndrome at minimal 2-year follow up
Diagnosis of PTS Clinical assessment Villalta score Venous valvular incompetence Duplex ultrasound
Clinical Assessment Villalta score Clinical measurement of PTS that grades severity from 0 ( absent ) to 3 ( severe ) of five patient-rated symptoms ( pain, cramps, heaviness, pruritus and paresthesia ) and six clinician-rated clinical signs ( edema, redness, skin induration, hyperpigmentation, venous ectasia, and pain on calf compression ) A score of 5 indicates the presence of PTS Total score: 5-14 mild moderate PTS Mild >14 ( 5-9 severe ) PTS Venous ulcer Moderate / bilateral thrombosis ( 10-14 PTS ) Severe ( >14 or ulcer )
Venous Valvular Incompetence Duplex ultrasound Venous reflux Bilateral Common femoral vein Superficial femoral vein Popliteal vein Posterior tibial vein
Duplex Ultrasound
Grade by Radiologist Grade I Grade II
Report of Post-Thrombotic Syndrome Previous DVT 58% No previous DVT 9.2% Post-thrombotic syndrome 67.2% Caprini JA, Motykie GD, Arcelus JI, Kudrna JC, Cella DF, Reyna JJ. Investigating the prevalence and pathophysiology of the post-thrombotic syndrome after total hip arthroplasty: Presented at the European venous forum 2000. Am Col Phleb 1999;Nov:10-13
Post-Thrombotic Syndrome After TKA Prevalence of post-thrombotic syndrome after TKA in Phramongkutklao Hospital : Diagnosed by clinical assessment (Villalta score) 22 / 76 cases (28.9%) All symptomatic PTS have previous DVT.
Post-Thrombotic Syndrome Patients without previous DVT showed NO symptomatic PTS even in cases of positive reflux by duplex ultrasound. Duplex Ultrasound [44/76 valve reflux]
Conclusion Overall prevalence of post-thrombotic syndrome at 2 years FU after total knee arthroplasty is 28.9% but mostly mild clinical and venous reflux grade I Previous DVT associated with symptomatic post-thrombotic syndrome [22/76 cases] J Med Ass of Thailand 2009
Management Elastic compression stockings reduce edema and may improve PTS symptoms Intermittent pneumatic compression units are effective for severely symptomatic PTS Venoactive agent such as aescin or rutosides may offer short-term improvement of PTS symptoms Compression therapy, skin care and topical dressings are used to treat venous ulcers
Post-Thrombotic Syndrome Best treatment is thromboprophylaxis Geerta et al, 2004
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