Late Sequelae of Acute Deep Venous Thrombosis: Evaluation Five and Ten Years after

Objective:

To study the sequelae of an acute deep venous thrombosis (DVT) 5 or 10 years afterwards.

Design:

A retrospective questionnaire study involving 70 patients with DVT, verified by phlebography 5 and 10 years earlier.

Setting:

Tampere University Hospital, Finland.

Patients:

Seventy out of 86 patients who had suffered a definite DVT answered a questionnaire on subjective symptoms and visits to health care organizations.

Interventions:

All 70 patients were treated initially with heparin and warfarin after the DVT was diagnosed.

Main outcome measures:

The frequency of late symptoms in the leg with DVT. The relation of the site of the acute DVT to late sequelae.

Results:

The frequency of asymptomatic patients was only 13%. Typical symptoms were evening pain, oedema and pigmentation. There were no differences between calf DVTs and more proximal DVTs in respect of the late symptoms. All patients with recurrent DVT were symptomatic.

Conclusions:

The late sequelae of DVT are common and necessitate a considerable number of visits to health care centres. Calf DVTs seem to cause late symptoms as often as more proximal DVTs.

The Post-Thrombotic Syndrome: A Review

Objective:

A review of the published data on epidemiology, pathophysiology, diagnostic techniques and prevention of the post-thrombotic syndrome (PTS).

Study selection:

Studies, published between 1966 and 1996, identified through the medline database, and references cited in identified articles were included.

Data synthesis:

Deep venous thrombosis (DVT) may cause outflow obstruction and valve incompetence, resulting in venous hypertension. PTS is probably the effect of venous hypertension on the microcirculation. For qualitative anatomical and functional assessment of the venous system, duplex scanning is required, and for quantitative functional assessment, plethysmographic methods are the most suitable. The best treatment of PTS is its prevention by optimizing diagnosis and treatment of DVT and by prescribing and wearing elastic compression stockings. Until valid follow-up studies have been performed, distal DVT should not be neglected when assessing the PTS risk.

Conclusions:

PTS is a serious problem in terms of prevalence, complications (venous ulcers) and treatment with considerable socio-economic consequences. Duplex and plethysmography are valuable tools in its diagnosis and might be appropriate to identify patients at risk of developing PTS.

Post-thrombotic syndrome after total hip or knee arthroplasty: incidence in patients with asymptomatic deep venous thrombosis

PURPOSE

To measure the risk of developing signs of post-thrombotic syndrome 15 to 24 months after total hip or knee arthroplasty in patients with asymptomatic deep venous thrombosis (DVT).

METHODS

A total of 85 total knee arthroplasty patients and 47 total hip arthroplasty patients were postoperatively screened for asymptomatic DVT using colour duplex ultrasound.

RESULTS

The rate of asymptomatic DVT was 37.6% (n = 32) in knee patients and 34.0% (n = 16) in hip patients. All 32 DVT cases in the knee group had thrombi located below the knee, whereas 6 of the 16 DVT cases in the hip group had thrombi located above the knee, the remaining 10 were below the knee. Patients with proximal thrombi were treated with warfarin for 3 months, whereas patients with distal DVT received 300 mg aspirin daily for the same period. All DVT cases were monitored for up to 12 weeks using repeated colour duplex scans. Signs of thrombus resolution were present at around 6 weeks (range, 4-12 weeks). Clot propagation was observed in 3 cases. In a mean of postoperative 18 months (range, 15-24 months), 28 of the 32 knee patients with asymptomatic DVT were available for follow-up: 11 had transient calf and ankle swelling, 6 had persistent oedema, and the remaining 11 were symptom free. 14 of the 16 hip patients with asymptomatic DVT were available for follow-up: 6 had transient calf and ankle swelling, 4 had persistent oedema, and 4 remained symptom free. 17 patients reported ongoing problems and were re-examined. Signs of mild-to-moderate post-thrombotic syndrome were recorded in 4 knee patients and 3 hip patients.

CONCLUSIONS

Patients with above-knee DVT were much more likely to have post-thrombotic syndrome. Despite thromboprophylaxis with low-molecular-weight heparin, asymptomatic DVT is common after total joint arthroplasty and is responsible for the development of post-thrombotic venous insufficiency and post-thrombotic syndrome in a considerable proportion of patients. Once symptomatic or asymptomatic DVT is established, treatment appears incapable of preventing the occurrence of post-thrombotic syndrome, especially in cases of above-knee DVT. Efforts should hence concentrate on combating DVT propagation and improving DVT prevention.

The post-thrombotic syndrome

One of every three patients with deep-vein thrombosis of the lower extremities will develop, within 5 years, post-thrombotic sequelae that vary from minor signs to severe manifestations such as chronic pain, intractable edema, and leg ulceration. The post-thrombotic syndrome (PTS) develops as a result of the combination of venous hypertension due to persistent outflow obstruction or valvular incompetence and abnormal microvasculature or lymphatic function. Among factors potentially related to the development of PTS, recurrent ipsilateral thrombosis plays a major role. Whether the extent and the location of the initial thrombosis are associated with the development of PTS is still controversial. The diagnosis of PTS can be accepted on clinical grounds for patients with a history of venous thrombosis. The combination of a standardized clinical evaluation with the results of compression ultrasonography and Doppler ultrasonography helps diagnose or exclude a previous proximal-vein thrombosis. Prevention of recurrent thrombosis and use of compression elastic stockings are the cornerstones of PTS prevention. The management of this condition is demanding and often frustrating. Although several surgical procedures have been tested, conservative treatment is largely preferable, as more than 50% of patients either remain stable or improve during long-term follow-up, if carefully supervised and instructed to wear proper elastic stockings. Clinical presentation helps predict the prognosis, being the outcome of patients who refer with initially severe manifestations more favorable than that of patients whose symptoms progressively deteriorate over time.

Duplex ultrasound in the hemodynamic evaluation of the late sequelae of deep venous thrombosis

PURPOSE

The use of duplex ultrasound scanning to evaluate the hemodynamic outcome of deep venous thrombosis 7 to 13 years after the original diagnosis.

METHODS

Duplex ultrasound was used to re-examine 1212 segments of vein from 72 patients (49 men, 23 women) with deep venous thrombosis previously diagnosed by means of phlebography to detect reflux and obstruction and evaluate flow; 611 segments were initially thrombosed and 601 segments were open. To define reflux, reversed flow in 31 healthy persons was measured.

RESULTS

In a review of all veins of the 72 patients, 8 patients (11%) had completely normal duplex results in all veins, 33 (46%) had reflux, 6 (8%) had at least one noncompressible vein segment, and 25 (35%) had a combination of both. In the proximal vein segments without initial thrombosis a higher percentage was normal (73%) than in segments with initial thrombosis (46%). There was a significantly higher frequency of reflux (46%, p = 0.05) and noncompressibility (12%, p < 0.01) in initially thrombosed proximal vein segments than in vein segments without initial thrombosis (reflux 25%, noncompressibility 3%). Distal to the knee 125 (17%) of 720 vein segments were not traceable. Significantly more initially thrombosed vein segments were not traceable (p < 0.01). In distal vein segments there was no significant difference in reflux (7% versus 5%) and noncompressibility (10% versus 5%) between vein segments with and without initial thrombosis. Flow was present in 99% of the 611 previously thrombosed proximal and distal segments.

CONCLUSIONS

Most patients with deep venous thrombosis still had venous abnormalities 7 to 13 years after the initial diagnosis. The most common abnormality was reflux. Significantly more abnormalities were found in initially thrombosed segments. The abnormalities were found in the proximal vein segments and in the distal vein segments, although less frequently in the latter.

Prospective 12-year follow-up study of clinical and hemodynamic sequelae after deep vein thrombosis in low-risk patients (Zürich study)

BACKGROUND

No prospective study of the long-term sequelae of more than 10 years after acute deep vein thrombosis exists so far. Therefore, 58 low-risk patients with DVT were included in a prospective study to evaluate the natural history of postthrombotic syndrome.

METHODS AND RESULTS

Clinical and hemodynamic examinations were performed at the time of admission; after 3, 6, and 12 months; after the 2nd, 3rd, 4th, 5th years; and finally after the 12th year. All patients received heparin initially and oral anticoagulants subsequently. After 12 years, 64% of the patients exhibited normal findings. Mild skin changes were found in 28%, marked trophic changes in 5%, and only one venous ulcer occurred. Regular use of compression stockings was reported by 54% of the patients with multilevel thrombosis. Although mean maximum venous outflow was significantly reduced from the acute event to 12 years later (P<.003) compared with the contralateral leg, a significant (P<.05) improvement was observed 6 months later. Recanalization of calf vein thrombosis was detected by Doppler sonography after 3 months. Sixty-four percent of the multilevel thromboses were recanalized completely or in part after 1 year; in 69%, valvular incompetence was found.

CONCLUSIONS

In contrast to earlier reports, this prospective study up to 12 years after deep vein thrombosis demonstrates a low incidence of postthrombotic syndrome by administration of oral anticoagulants and regular compression therapy. However, the adverse clinical event rate (mortality 14%) and a recurrence rate of 24% show that the prognosis after deep vein thrombosis does not appear favorable even in low-risk patients.