How I treat postthrombotic syndrome

Kahn, Susan R.

doi:10.1182/blood-2009-07-199174

Cited by 146 publications

(121 citation statements)

References 82 publications

(76 reference statements)

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“…28 In the general population, PTS develops in approximately 20 to 50% of patients following DVT with significant adverse financial and QOL effects. 29 In fact, 2 years post-DVT, the development of PTS remained the primary determinant of health-related QOL scores. 30 Given this significant risk of PTS in the cancer population and potentially adverse effects, consideration for aggressive treatment should be given to all DVT patients, including those with cancer.…”

Section: Clinical Outcomesmentioning

confidence: 99%

Deep Vein Thrombosis Interventions in Cancer Patients

Charalel

Vedantham

2017

Semin intervent Radiol

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The presence of cancer increases the risk of deep vein thrombosis (DVT), DVT recurrence, and treatment-related bleeding, and therefore offers distinctive clinical considerations when planning treatment. Anticoagulation with a low-molecular-weight heparin is the preferred initial and long-term therapy in cancer patients. Inferior vena cava filters may be used judiciously for patients with cancer-related DVT who have contraindications to anticoagulation or who exhibit breakthrough pulmonary embolism (PE) despite anticoagulation, but should be removed when the PE risk is felt to subside. Because moderate-quality evidence suggests that the use of catheter-directed thrombolysis (CDT) can prevent the postthrombotic syndrome, cancer patients with acute iliofemoral DVT, low expected bleeding risk, and good functional status may reasonably be considered for CDT if DVT-related sequelae are likely to be a dominant contributor to the patient's clinical condition, functional status, and quality of life. In selected patients who have chronic venous symptoms from mass/nodal compression of the pelvic veins, endovascular stent placement may provide symptom relief. As current recommendations are based on very limited data, further studies would be welcome to better delineate the most appropriate use of endovascular therapies in patients with cancer.

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Section: Clinical Outcomesmentioning

confidence: 99%

Deep Vein Thrombosis Interventions in Cancer Patients

Charalel

Vedantham

2017

Semin intervent Radiol

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Section: Editorialmentioning

confidence: 99%

“…More than one-third of patients with DVT will develop PTS, and 5% to 10% of patients will develop severe PTS, which may manifest as venous ulceration [14]. Women, obese patients, patients with proximal DVT and those with varicose veins have an increased risk of PTS [15].…”

Section: Editorialmentioning

confidence: 99%

“…One presumed mechanism of action of this adjunct treatment modality is the increase of shear stress in the microcirculation of the vein wall releasing anti-inflammatory and anti-coagulatory mediators [17]. Daily use of elastic compression stockings for 2 years after proximal DVT appears to reduce the risk as well [14]; however, there is uncertainty about optimal duration of use and compression strength of elastic stockings and the magnitude of their effect.In conclusion, both physicians and physiotherapists should aim to early mobilize patients with acute thromboembolic disease under proper anticoagulation and compression measures. This practice will obviate both early as well as late complications, reducing both morbidity and mortality in this population.…”

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confidence: 99%

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Mobilisation after Lower Limb Deep Vein Thrombosis and Post-Thrombotic Syndrome

Galyfos¹

2015

J Nov Physiother

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EditorialDeep vein thrombosis (DVT) is one of the commonest cardiovascular diseases, ranking third behind coronary artery disease and stroke [1]. Furthermore, it is one of the major causes for inhospital morbidity and mortality, leading to severe complications such as pulmonary embolism (PE), post-thrombotic syndrome (PTS) and even death [2]. Local damage to venous intima, venous stasis and hypercoagulability are major predisposing factors, and it is thought that two of these factors must be present for a DVT to develop [3].Physiotherapists frequently handle in-patients diagnosed with a DVT, and management of such patients has been controversial. For decades, conservative management of DVTs using strict immobilization was based on the theoretical assumption that early ambulation and active range of motion would cause the thrombus to dislodge proximally, migrating to the pulmonary circulation and causing a PE, possibly leading even to death [4]. However, this assumption has never been tested empirically. Moreover, such a conservative treatment approach of bed rest can lead to secondary complications and can thus be detrimental for patients [4].Concerning proper management, immediate initiation of anticoagulation, and especially low molecular weight heparins (LMWH), has been proved to be the most important first-line treatment, and therefore, is recommended for acute DVT by the latest Guidelines (Level 2B) [5]. Anticoagulants also decrease the risk for subsequent PE and the incidence of thrombi propagation [6]. However, the same Guidelines underline also the importance of early ambulation over initial bed rest (Grade 2C), as well as the preference of treatment at home instead of in-hospital treatment (Grade 1B) [5]. Additionally, many systematic reviews conclude that there is no evidence proving that ambulation by anticoagulated DVT patients in the home setting increases the risk of PE development [4,7]. Aissaoui et al. showed in their recent meta-analysis that early ambulation in patients with DVT with or without PE was not associated with increased risk for DVT progression, new PE or even death [8]. Hence, experimental data also show that even exercise does not increase the risk for new PE, regardless of thrombus status [9]. Therefore, clinicians should be confident in prescribing ambulation in this population.Fear of PE is the main rationale for bed rest, while pain and swelling are expected to resolve faster during leg elevation. However, the rate of resolution of pain and swelling is significantly faster when the patient ambulates with compression [10]. Immediate multilayer compression bandaging in the acute phase of DVT seems to be effective in reducing edema and complaints in the first week, although it has no effect on thrombus regression or valve incompetence within the following year [11]. Regarding the initiation time of ambulation after setting the diagnosis, there are controversial results in literature. Kiser et al. underline that the patient should stay immobilized for at least 48 to 72 hours whi...

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“…The management of patients with venous insufficiency as a result of PTS is similar to that of other patients with venous insufficiency. Up to half of patients with proximal DVT can develop variable degrees of PTS, despite optimal anticoagulant therapy [1]. PTS significantly impacts upon quality of life and has major healtheconomic implications.…”

Section: Introductionmentioning

confidence: 99%

Optimal and Individualized Pneumatic Calf Compression Pressure using Vekroosan to Improve Femoral Venous Flow Velocity in Patients with Severe Post Thrombotic Syndrome: Case Reports and Literature Review

R¹,

Alexander²

2017

J Thrombo Cir

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Post thrombotic syndrome (PTS) symptoms usually occur after deep venous thrombosis (DVT) and eventually affects up to 50% of patients who have had a symptomatic DVT. Symptoms can include lower leg oedema, pain, changes in skin pigmentation, and venous ulcers. Severe PTS has a significant negative effect on quality of life. Thrombolytic therapy for acute DVT may decrease the risk of PTS, but carries its own risks. In patients with symptomatic proximal DVT, the use of knee-high compression stockings capable of exerting a pressure of at least 30 to 40 mmHg at the ankle and less at the knee has been found to be useful. There are practical difficulties in using these stockings and hence Intermittent Pneumatic Calf compression (IPC) devices are recommended. However not all devices have the capability to meet the requirements of mobile patients with severe PTS features. One such device was trialled on these patients to assess peak femoral flow velocity (PFV) and clinical benefits. There was mean 1.8 cm improvement in calf circumference measurements, post therapy and significant individual variations in achieving optimal femoral flow velocity. At a calf compression pressure of 40 mmHg, lower and upper chambers resulted in greater PFV in some patients and at 80 mmHg, middle and upper chambers achieved greater PFV in others. There was a significant variability noted in the PFV, although there was a uniform significant clinical benefit, hence the recommendation of individualising the calf compression pressures to meet the needs of these patients. This device appears to have addressed the needs of some of these patients.

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How I treat postthrombotic syndrome

Cited by 146 publications

References 82 publications

Deep Vein Thrombosis Interventions in Cancer Patients

Deep Vein Thrombosis Interventions in Cancer Patients

Mobilisation after Lower Limb Deep Vein Thrombosis and Post-Thrombotic Syndrome

Optimal and Individualized Pneumatic Calf Compression Pressure using Vekroosan to Improve Femoral Venous Flow Velocity in Patients with Severe Post Thrombotic Syndrome: Case Reports and Literature Review

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