The Post-Thrombotic Syndrome: A 2012 Therapeutic Update

A systematic review and meta-analysis of risk prediction models for post-thrombotic syndrome in patients with deep vein thrombosis

Objective

This systematic review and meta-analysis aimed to systematically evaluate the prediction models for the risk of post-thrombotic syndrome (PTS) in deep vein thrombosis (DVT) patients.

Methods

This systematic review and meta-analysis was guided by the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA). A systematic search on the following electronic database: PubMed/MEDLINE, EMBASE, and Cochrane Library, and Chinese databases such as WANFANG and CNKI was conducted to look for relevant articles based on the research question. The risk of bias for each studies included was carried out based on Prediction Model Risk of Bias Assessment Tool (PROBAST).

Results

We identified 10 studies that developed a total of 13 clinical prediction models for PTS risk in DVT patients, 3 models were externally validated, 2 models were temporally validated. The top 5 predictors were: BMI (N = 9), Varicose vein (N = 6), Baseline Villalta Score (N = 6), Iliofemoral thrombosis (N = 5), and Age (N = 4). The high risk of bias was from the analysis domain, which the number of participants and selection of predictors often did not meet the requirements of PROBAST. A random-effects meta-analysis of C-statistics was conducted, the pooled discrimination was C-statistic 0.75, 95%CI (0.69, 0.81).

Conclusion

Among the 13 PTS risk prediction models reported in this study, no prediction model has been applied to clinical practice due to the lack of external validation. In the development of prediction models, most models were not standardized in data analysis. It is recommended that future studies on the design and implementation of prediction models refer to Transparent reporting of a multivariable prediction model for individual prognosis or diagnosis (TRIPOD) and PROBAST.

Efficacy of rivaroxaban in prevention of post-thrombotic syndrome: a systematic review and meta-analysis

OBJECTIVE

Direct oral anticoagulants (DOACs) have been recommended for the treatment of deep vein thrombosis (DVT). However, the benefits are uncertain for the prevention of post-thrombotic syndrome (PTS). We performed a systematic review and meta-analysis of reported studies to assess the efficacy of DOACs vs vitamin K antagonists for the risk reduction of PTS in patients with DVT.

METHODS

We searched PubMed, Medline, the Cochrane Library, Embase, and the Web of Science for studies reporting on the development of PTS after acute DVT. The outcomes were the risk reduction of PTS, PTS severity, the presence of residual vein thrombosis, and the incidence of recurrent venous thromboembolic (VTE) events.

RESULTS

A total of 59,199 patients from six retrospective and two randomized controlled studies had received DOAC treatment and were followed up for the development of PTS. In all studies, rivaroxaban had been compared with initial low-molecular-weight heparin followed by warfarin. Of the 59,199 patients, 19,840 (33.5%) had received rivaroxaban and 39,377 (66.5%), warfarin. The rivaroxaban group had a significant reduction in PTS development compared with the warfarin group (odds ratio [OR], 0.52; 95% confidence interval [CI], 0.43-0.63; P < .001). Severe PTS was less common in the rivaroxaban group than in the warfarin group (3.7% vs 6.4%; OR, 0.55; 95% CI, 0.36-0.85; P = .024). Additionally, rivaroxaban was associated with a significant reduction in VTE recurrence (OR, 0.83; 95% CI, 0.59-1.18; P = .03) and low rates of residual vein thrombosis compared with warfarin (36.5% vs 51.8%; P = .037).

CONCLUSIONS

Rivaroxaban after acute DVT was associated with a reduced risk of PTS compared with warfarin. Patients treated with rivaroxaban more rarely developed severe PTS and recurrent VTE events compared with patients treated with warfarin.

Gastrointestinal Malignancies and Venous Thromboembolic Disease: Clinical Significance and Endovascular Interventions

Gastrointestinal malignancy encompasses a wide range of disease processes. Its incidence and mortality rate rank among the highest of all cancers. Venous thromboembolic disease is a common complication of gastrointestinal malignancy. Anticoagulation remains the first-line therapy. However, for patients who cannot tolerate or have failed anticoagulation, inferior vena cava (IVC) filter placement may be an option. Furthermore, to improve symptom resolution and reduce the severity of postthrombotic syndrome, catheter-directed thrombolysis (CDT) may be an option. Recent randomized trials including the ATTRACT (Acute Venous Thrombosis: Thrombus Removal with Adjunctive Catheter-Directed Thrombolysis) trial have shed new light on the efficacy and safety of CDT and related methods. Overall, the decision to proceed with IVC filter placement or CDT must be individualized.

Management of vascular Behçet's disease

Behçet's disease (BD) is a chronic, multisystemic, inflammatory disease characterized by recurrent attacks of mucocutaneous, ocular, musculoskeletal, vascular, central nervous system and gastrointestinal manifestations. Treatment of BD changes according to organ involvement, gender and age of the patient with no golden standard therapeutic regimen. Vascular involvement is observed in up to 40% of the patients with BD, especially in young males and is one of the major causes of mortality and morbidity. Glucocorticoids, azathioprine and cyclophosphamide are still recommended as the first-line treatments in vascular BD. However, increasing data with the tumor necrosis factor inhibitors suggest that these agents may also be acceptable options for the management of refractory vascular BD in daily practice. Anticoagulant usage for vascular BD is also still controversial with limited data coming from retrospective studies. There is a clear need for randomized, controlled studies for the management of VBD.

The recalcitrant venous leg ulcer – a never ending story?

Introduction: In general, four particular causes of recalcitrant venous leg ulcers may be distinguished. These are foot pump insufficiency, chronic venous compartment syndrome and non-re-canalized popliteal vein thrombosis. The fourth cause of recalcitrant venous leg ulcers is lipodermatosclerosis as a symptom of severe chronic venous insufficiency.

Methods: We reviewed the literature and based on this we describe four main causes of recalcitrant venous leg ulcers and their specific treatment.

Results: Foot pump insufficiency arises when the plantar foot veins are not able to empty. Treatment should consist of physical therapy, a mechanical foot pump device and an insole. Lipodermatosclerosis may be treated by excision and split-thickness skin grafting (Vigoni procedure). Chronic venous compartment syndrome is usually caused by post-thrombotic syndrome and treatment consists of a fasciectomy, but is rarely used nowadays. Patients with non-re-canalized popliteal vein thrombosis may be supported by intermittent pneumatic compression, walking exercises, alternate standing and walking with lying down. All patients with recalcitrant venous leg ulcers must wear medical elastic compression stockings with high stiffness and high compression lifelong.

Conclusions: Patients with recalcitrant venous leg ulceration are challenging. More specific treatment will heal more of these ulcers.

Epidemiology of the post-thrombotic syndrome

The post thrombotic syndrome (PTS) refers to clinical manifestations of chronic venous insufficiency (CVI) following a deep-vein thrombosis (DVT). PTS is the most frequent complication of DVT, which develops in 20 to 50% of cases after proximal DVT and is severe in 5-10% of cases. The reported prevalence of PTS differs widely among studies because of differences in study populations, tools used to assess PTS, and time interval between acute DVT and PTS assessment. The two most important predictors of PTS are extensive proximal character of DVT and previous ipsilateral DVT. Other reported risk factors include pre-existing CVI, obesity, quality of anticoagulant treatment, older age and residual venous obstruction. Standardization of PTS assessment tools combined with the development of patient self-reported PTS scales are likely to constitute a breakthrough in research of the epidemiology of PTS, by allowing comparison between studies, meta-analyses and increasing the feasibility of longer follow-up of DVT patients. This should enable identification of patient populations at high risk of severe PTS, new predictors of PTS and targets for potential new treatments. In this perspective, identification of biomarkers that are predictive of PTS such as markers of inflammation is crucial in ongoing research.

Venous Thromboembolism in Patients Diagnosed With Lung Cancer

PURPOSE

Considering the high prevalence of lung cancer, our purpose was to summarize the existing literature to identify the several factors that contribute to the increased risk of venous thromboembolism (VTE) in patients with lung cancer and to analyze the current recommendations for thromboprophylaxis and treatment of VTE in those patients.

METHODS

We searched the Medline and EMBASE databases from February 1985 to February 2014 to identify retrospective and prospective randomized controlled studies that investigate one or more risk factors for VTEs in patients with lung cancer.

RESULTS

A VTE is a major complication for patients diagnosed with lung cancer. The risk factors for VTE events in patients with lung cancer consist of cancer-related (histological type and stage of cancer), treatment-related (surgery, chemotherapy, angiogenic agents, and supportive care agents), and patient-related factors (comorbidities, immobility, performance status, and prior thrombosis). Low-molecular-weight heparins are recommended for long-term treatment of cancer-associated thrombosis. Duration of anticoagulant therapy beyond 6 months should be based on individual clinical evaluation. Thromboprophylaxis for patients with lung cancer during hospitalization and immediate postoperative period is well established.

CONCLUSIONS

Efforts to assess thrombotic risk in patients with lung cancer may improve therapeutic and preventive strategies in the future, with final goal to minimize the burden and consequences of thrombotic events in patients with lung cancer.

[Management of deep-vein thrombosis: A 2015 update]

Deep vein thrombosis (DVT) is a frequent and multifactor disease, with two major complications, post thrombotic syndrome and pulmonary embolism. Both transient (surgery, plaster immobilization, bed rest/hospitalization) and chronic/persistent (age, cancer, clinical or biological thrombophilia…) risk factors modulate treatment duration. Diagnostic management relies on clinical evaluations, probability followed by laboratory tests or imaging. So far, compression ultrasound is the diagnostic test of choice to make a positive diagnosis of DVT. Anticoagulants at therapeutic dose for at least 3 months constitute the cornerstones of proximal (i.e. involving popliteal or more proximal veins) DVT therapeutic management. The arrival of new oral anticoagulants should optimize ambulatory management of DVT.

Postthrombotic syndrome: a 2014 update

PURPOSE OF REVIEW

Postthrombotic syndrome (PTS) is the most frequent complication of deep vein thrombosis. Its pathophysiology is incompletely understood and therapeutic options are limited. This review aims to present and discuss recently published studies that have improved our knowledge related to PTS.

RECENT FINDINGS

From a prognostic point of view, some polymorphisms of plasminogen activator inhibitor-1 and platelet endothelial cell adhesion molecule 1 influence the degree of thrombus resolution after deep vein thrombosis and the subsequent rate of PTS, and could help in predicting the risk of PTS. From a therapeutic point of view, the results of a large multicenter placebo-controlled trial suggest an absence of effectiveness of elastic compression stockings to prevent PTS. In addition, although the Cavent trial of catheter-directed thrombolysis to treat ilio-femoral deep vein thrombosis showed significant reduction in the incidence of PTS that was cost-effective, secondary analyses did not show dramatic improvements in quality of life associated with use of catheter-directed thrombolysis.

SUMMARY

Choice of anticoagulant to treat deep vein thrombosis may represent a new cornerstone of PTS therapeutic management. Studies are needed to assess the impact of new oral anticoagulants and the benefit of extended courses of low molecular weight heparins on the risk of PTS.

Post-thrombotic syndrome after central venous catheter removal in childhood cancer survivors: A prospective cohort study

BACKGROUND

Although the use of central venous catheters (CVCs) has greatly improved the quality of care of children with cancer, these catheters increase the risk of deep vein thrombosis (DVT) and the potential long-term complication of post-thrombotic syndrome (PTS). We aimed to study PTS post-CVC removal using physical, functional and health related quality of life (HRQoL) domains in childhood cancer and bone marrow transplantation (BMT) survivors.

PROCEDURE

We conducted a prospective study in a cohort of childhood cancer and BMT survivors post-CVC use. Participants were evaluated for PTS with the Modified Villalta Score (MVS) and the Manco-Johnson Instrument (MJI). HRQoL was assessed using the PedsQL™ questionnaire.

RESULTS

A total of 158 children were enrolled at a median of 41 (4-149) months from CVC removal. Signs and symptoms of PTS were present in 34% (95% confidence interval [CI] 27-43%) (MVS criteria) and 30.5% (95% CI 23.1-37.8%) (MJI criteria). Diagnosis of PTS was associated with history of CVC occlusion, history of CVC-related DVT and the use of ≥2 CVCs. The presence of signs and symptoms of PTS was a predictor for low HRQoL tested by the PedsQL™ Total Scale scores and Physical Health Summary scores.

CONCLUSIONS

PTS post-CVC removal in pediatric cancer survivors is not a rare event. The association between PTS and the history of CVC occlusion confirms earlier findings, and suggests that CVC occlusion may indicate asymptomatic DVT. PTS is also associated with lower HRQoL scores highlighting the need to study preventive measures, especially for high risk groups. Pediatr Blood Cancer 2015;62:285-290. © 2014 Wiley Periodicals, Inc.

Efficacy of a short course of complex lymphedema therapy or graduated compression stocking therapy in the treatment of post-thrombotic syndrome

Treatment options for established post-thrombotic syndrome (PTS) are limited. Complex lymphedema therapy (CLT), a non-invasive treatment that improves lymphatic flow, may have the potential to improve PTS. We conducted a single-center, investigator-blind, randomized controlled trial of 31 patients with a clinically established diagnosis of PTS and compared the efficacy of graduated compression stockings alone (30-40 mmHg) with CLT, a treatment that includes compression stockings, exercise, patient education, skin care and lymphatic drainage. Primary outcomes were the 1- and 3-month changes in PTS severity by the Villalta score and disease-specific quality of life using the VEINES-QOL (Venous Insufficiency Epidemiological and Economic Study Quality of Life) questionnaire. Analysis was by intent-to-treat. We found from a baseline average score of 9.9 points, CLT reduced mean PTS severity scores by -2.4 points (p=0.02) at the 1-month and -2.3 points (p=0.05) at the 3-month follow-up. Score reductions with stockings only were similar at -2.1 (p=0.03) and -3.3 points (p=0.03) at 1 and 3 months. The differences in score between treatments were not significant. Neither treatment significantly changed the VEINES-QOL score except in patients with severe disease. Patients with moderate to severe PTS derived the greatest benefit from either therapy and the two therapies differentially impacted PTS signs and symptoms. We found a short course of lymphedema therapy and compression stockings offer similar benefit in patients with PTS; however, larger studies are needed to further explore the potential use of CLT in PTS, particularly in patients with more severe disease. ClinicalTrials.gov Identifier: NCT00633971.

Venous thromboembolism in pediatric nephrotic syndrome

Childhood nephrotic syndrome (NS) is one of the most common pediatric kidney diseases, with an incidence of 2-7 per 100,000. Venous thromboembolism (VTE) is associated with significant morbidity and mortality, and occurs in ∼3 % of children with NS, though incidence approaches 25 % in high-risk groups. VTE etiology is multifactorial, with disease-associated coagulopathy thought to be a significant contributor. Other risks include age, disease severity, and treatment-related hazards, such as the presence of central venous catheters. Non-pharmacologic preventive measures such as ambulation and compression stockings are recommended for patients with identified VTE risks. Central venous catheters should be avoided whenever possible. Symptoms of VTE include venous catheter dysfunction, unilateral extremity symptoms, respiratory compromise, flank pain, and gross hematuria. When VTE is suspected, confirmatory imaging studies should be obtained, followed by appropriate laboratory evaluation and treatment. Therapeutic goals include limiting thrombus growth, extension, and embolization by early institution of anticoagulant therapy. Anticoagulation is recommended for a minimum of 3 months, but should be continued until NS remission is achieved. Further studies are necessary to identify VTE-risk biomarkers and optimal therapeutic regimens. Observational cohort studies are needed to identify VTE-risk groups who may benefit from thromboprophylaxis and to define disease-specific treatment algorithms.