This is a syndrome that occurs following blood clot in the vein (DVT). It could occur weeks or months afterDVT resulting in pain, swelling, redness and shiny skin. An ulcer can form months after DVT has been present for a long period of time. It is also called post-thrombotic syndrome (PTS) and Chronic Venous Insufficiency (CVI).
PTS affects 23-60% of the patients within two years of DVT. 10% may go on to developing severe PTS and venous ulcers. It is estimated that about 2-5% of the entire population suffers from CVI. The peak incidence in women is 40-49 years while in men it is 70-79 years.
How do you know you have it?
The swelling in the affected leg is increased after standing or sitting for long period of time. One must differentiate between postphlebitic syndrome and the formation of fresh clot in the leg. This is done by colour Doppler study.
In normal legs when we walk the calf muscles reduce the venous pressure by 70% which returns to normal within 30 seconds of resting. However in diseased veins the reduction of pressure when we walk is only 20% and takes minutes to return to normal when resting.
The exact cause is not known though it is considered that inflammation cause due to the clot destroys the valves causing incompetence. Various theories have been postulated. Venous hypertension along with venous obstruction leads to increased venous and capillary pressure causing subcutaneous haemorrhage and increased tissue permeability leading to oedema, pain, discolouration and ulcers.
The blood clot in the vein interferes with the blood flow from the site of blockage to the heart. It causes injury to the vein lining and to the valves causing permanent damage. The pooling of the blood is responsible for the swelling and the pain in the leg. The larger the clot and the longer it is present before treatment, the more severe the post-phlebitic syndrome.
The clinical presentation includes:
The risk factors include:
Though post-phlebitic syndrome may be difficult to treat, in time the swelling could be brought to near normal. Patient has to wear graded elastic stockings before getting out of bed in the morning and removed before sleeping at night. If the job involves much standing then elevate legs at scheduled times as often as possible. If the job involves sitting for long then elevate the leg which will reduce the swelling.
Besides this there are electro-stimulation devices and care of the wound ulcers. The electro-stimulation devices are veinoplus which stimulates the calf muscles promoting venous return, preventing reflux and thus reducing oedema.
This begins with preventing the initial and recurrent DVT.
For high risk hospitalized patients ambulation, stockings, leg elevation, electrostimulation devices and/or anticoagulation.
For those who have already had DVT the best way to prevent second DVT is by appropriate anticoagulation therapy.
Weight loss for the obese is a way of prevention of DVT
Some data suggest that post-DVT compression stockings for 2 years prevents PTS.
The signs and symptoms for DVT and PTS are quite similar so we wait for 3-6 months after DVT before an appropriate diagnosis of PTS is made.
Upper limb –PTS
This is also present but incidence is lower than the leg (15 – 25%). There is no established treatment except compression sleeve for persistent symptoms.
Areas of Future Research
The exact pathophysiology has not been defined as yet – including role of inflammation and residual thrombus even after anticoagulation therapy.Role of thrombolysis in PTS preventionDefining the true efficacy of compression stockings in PTS and if effective what is the compression strength necessary, when to wear stockings and for how long.Does PTS need more unidentified methods for treatment than those for DVT.
Why do we get PTS?
The exact cause is unknown though there are various theories:
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