Post-thrombotic Syndrome

What is Post-Thrombotic Syndrome (PTS)? Post-thrombotic syndrome (PTS) is a long-term complication of DVT, manifesting as swelling, pain, edema, venous ectasia, and skin induration of the affected limb.

Post-Thrombotic Syndrome Symptoms Less dramatic than PE Greater degree of chronic socioeconomic morbidity Disabling in severe states Consists of Pain Edema Hyperpigmentation Ulceration Approximately 60% of patients with iliofemoral DVT will develop PTS Symptoms usually appear within the first 5 years Johnson et al. J Vasc Surgery. 1998

The one-way valves in deep veins prevent blood from flowing backward, and the muscles surrounding the deep veins compress them, helping force the blood toward the heart, just as squeezing a toothpaste tube ejects toothpaste.

We are still failing DVT patients today Post-Thrombotic Syndrome (PTS) is also referred to as Post-Phlebtic Syndrome or Venous Stress Disorder. It affects anywhere from 23-60% of patients in the initial two years following DVT of the leg. Of these, approximately 10% go on to develop severe PTS, which can include venous ulcers. Kahn SR, Shrier I, Julian JA, et al. Determinants and time course of the post-thrombotic syndrome after acute deep venous thrombosis. Ann Intern Med 2008; 149: 698–707

Femoral-Popliteal DVT Iliofemoral DVT Calf DVT Femoral-Popliteal DVT Iliofemoral DVT Low Risk High Risk Patients with iliofemoral DVT location may have higher risk for: Recurrent venous thromboembolism Post-thrombotic syndrome Pulmonary embolism Douketis JD, et al. Am J Med. 2001;110(7):515–519 Watson L, Broderick C, Armon MP. Cochrane Database Syst Rev. 2014 Jan 23;1:CD002783. oi:10.1002/14651858.CD002783.pub3

The Economic Burden of Post-Thrombotic Syndrome (PTS) PTS results in lost productivity and income by patients, psychological stress, and discomfort. The annual cost per patient has been estimated at $3,800 in the first year, and the annual health-related costs of PTS in the US has been estimated to be $200 million.

DVT Treatment Options Anticoagulation & Compression Stockings only Catheter Directed Throbolysis (CDT) & Enhanced CDT (eg, ultrasound) Mechanical Thrombectomy Pharmacomechanical Thrombectomy

Anticoagulant Therapy Prevents clot propagation Reduces risk of pulmonary embolism May provide moderate symptomatic relief Advantages Easily administered without specialized skills Low cost of medications / appliances Accepted as standard of care Anticoagulation does NOT: Resolve clot Rapidly resolve symptoms Reduce risk of venous valvular damage Prevent venous hypertension Prevent or reduce severity of (PTS) ~1/3 of patients mess up anticoagulation regimes1 1 J Gen Intern Med. 2007 September; 22(9): 1254–1259 https://ash.confex.com/ash/2012/webprogram/Paper46479.html

Endovascular DVT Treatment Prevent embolization Prevent extension Quickly restore patency & alleviate symptoms Preserve valve function Prevent loss of limbs due to venous gangrene Prevent severe post-thrombotic syndrome With Current Treatment patterns the CDC states: “Nearly one-third of people who have a DVT will have long-term complications caused by the damage the clot does to the valves in the vein called post-thrombotic syndrome (PTS). People with PTS have symptoms such as swelling, pain, discoloration, and in severe cases, scaling or ulcers in the affected part of the body. In some cases, the symptoms can be so severe that a person becomes disabled.” Centers for Disease Control and Prevention. Venous Thromboembolism (Blood Clots). Diagnosis & Treatment. https://www.cdc.gov/ncbddd/dvt/facts.html. Accessed October 12, 2017.

Considerations for endovascular intervention Age of Thrombus / extent of the clot Acute ≤ 14 days (fresh thrombus, early formation easier to remove) Sub-acute ≤ 6 months (fibrin-bound, more stable clot increases difficulty) Chronic ≥ 6 months (organized thrombus, fibrin-rich stable and difficult to remove) Mixed morphology (e.g. recurrent DVT) Symptoms Pain, leg swelling, difficulty walking Life-style limiting Anatomy Common femoral or higher Iliofemoral DVT are typically most symptomatic

A New Option For Venous Thrombus Removal New options exist for minimally invasive treatment to remove the venous clot Infusion of clot busting medication to assist in removal Followed by thrombus removal using a mechanical device to remove the clot from the vessel and body 12

Why treat DVT? PTS is a debilitating disease for patients and for society. Because the signs and symptoms of venous insufficiency manifest in many variations, PTS is not always recognized. For years, the standard of care has been compression to control edema and pain. The treatment of chronic vascular disease is palliative – a bandage, not a cure. With DVT, however, the sequela of edema and pain do not develop if the thrombus is autolysed or removed early, before damage is permanent. We are challenged to treat obstructive DVT early with safe and affordable therapy to prevent the endovascular injury that leads to PTS. When patients present with PTS, long after the initial event, we can significantly decrease disability and improve QOL with endovascular reconstruction. Endovascular Today;Oct2007

What can you do as a first-line provider? Diagnose deep vein thrombosis (DVT) based on medical history, a physical exam, and test results Evaluate medical history and risks (Wells Score) Physical exam - check legs for signs of DVT, swelling or redness Diagnostic testing – completing a D-Dimer test Complete an Ultrasound, CT or MRI If positive for proximal DVT, symptomatic DVT, and PTS you should consider a consult with a venous specialist to evaluate all treatment options