Post-thrombotic Syndrome - Causes, Symptoms, and Management

What Is Post-thrombotic Syndrome?

Post-thrombotic syndrome (PTS) is a long-term disorder arising from deep vein thrombosis (DVT). The veins in the arms and legs have little valves that secure the blood flow back toward the heart. Deep vein thrombosis is a blockage or clot that hinders the vein and leads to damaged valves.

What Causes Post-thrombotic Syndrome?

The following conditions are responsible for the occurrence of post-thrombotic syndrome:

• Recent surgery reduces body mobility and improves inflammation in the body, which leads to clotting.

• Medical conditions such as an injury or stroke.

• Long duration of travel that hampers body mobility.

• Damage to a deep vein.

• Inherited blood disorders that boost clotting.

• Pregnancy.

• Cancer treatment.

What Are the Signs and Symptoms of Post-thrombotic Syndrome?

The usual five symptoms of post-thrombotic syndrome are:

• Pain in the legs.

• Cramps in the affected legs.

• Heaviness in the affected limbs.

• Pruritus (an irritating sensation that creates an urge to scratch the affected part).

• Paresthesia (a tingling sensation in the legs).

Other symptoms include:

• Leg pain and swelling are typically brought on by prolonged standing or walking, and they are typically relieved by lying down or elevating the leg.

• Ulcers or sores on the legs.

• Widening of leg veins.

The most common six signs of post-thrombotic syndrome are:

• Edema (puffiness due to excessive water in the body tissues).

• Skin induration.

• Hyperpigmentation (dark patches on the skin).

• Venous ectasia: It is venous insufficiency in the affected leg leading to disturbed blood outflow.

• Redness.

• Pain during calf compression.

The severity of each symptom and sign is valued as

• Zero means absent.

• One means mild.

• Two means moderate.

• Three stands for severe pain.

Who Is At Risk for Post-thrombotic Syndrome?

Certain factors may increase the risk for post-thrombotic syndromes, such as:

• Obesity.

• Deep-vein thrombosis that is present above or below the knee.

• Increased venous pressure in the legs.

• No therapy by blood thinners like Aspirin in case of deep-vein thrombosis.

How Is Post-thrombotic Syndrome Diagnosed?

The patient will be asked for medical history in case of any history of deep-vein thrombosis, followed by the symptoms.

There will be a physical examination of the leg, including some tests, such as:

• Ultrasound: It is done to watch for disorders related to the leg vein valves.

• Blood Test: It is done to look for blood-related disorders.

Doctors use a Villalta score to analyze post-thrombotic syndrome. This scale amounts to the harshness of the symptoms and signs in a patient. If the score exceeds 15, the patient suffers from severe post-thrombotic syndrome.

Review of the Total Villalta Score:

• If the score is zero to four, it means no pro-thrombotic syndromes.

• If the score is five to nine, it means mild pro-thrombotic syndromes.

• If the score is 10 to 14, it means moderate pro-thrombotic syndromes.

• If the score is greater than 15, it means severe pro-thrombotic syndromes.

How Is the Treatment and Pain Management Done in Pro-thrombotic Syndrome?

Treatment depends on the severity of the condition. Treatment includes:

1. Elevation and Exercise:

• The affected limb is elevated in a resting or sleeping state. This position leads the blood to return to the heart with the help of gravitational force.

• Flexion of the ankle and strengthening of the calves with exercise help to manage the affected limbs.

2. Compression Stockings: For the treatment of post-thrombotic syndrome, compression stockings are the most commonly used method. The following are the required conditions for increasing the effectiveness of compression stockings:

• Fitting should be proper.

• The exact amount of compression should be applied.

• These should be made up of a particular elastic fabric that can apply pressure on the affected body.

The conditions mentioned above must be focused on improving blood flow and reducing pain and swelling. The concerned doctor guides the patient on which compression stockings are to be used and how much pressure to apply after reviewing the severity of the disease. Compression therapy is the primary treatment for post-thrombotic syndrome. This therapy helps increase the blood flow in the veins, decreasing symptoms.

• Components of the Compression Stockings:

  • There are prescription-grade compression stockings that apply the required pressure on the affected leg. These should be worn on the leg affected by deep vein thrombosis during the day.

  • An intermittent pneumatic compression (IPC) device is used to apply pressure on the veins of the affected leg.

  • Barrier creams containing zinc oxide are also used.

  • Lubricating creams like petroleum jelly are used to keep the affected skin moist. Steroid creams or ointments are also used to treat the skin of the affected part.

  • Special treatment is also given in case the patients develop leg sores.

3. Medications:

• Rutosides: These are used to decrease capillary filtration and microvascular permeability.

• Defibrotide: These drugs downregulate the release of plasminogen activator inhibitor-1 and upregulate the production of prostacyclin, prostaglandin E2, and thrombomodulin.

• Hidrosmin: The mechanism of action is unknown.

4. Venous Ulcer Management: In the patients suffering from deep-vein thrombosis, around five percent to ten percent of patients show severe post-thrombotic syndrome. Post-thrombotic ulcers in patients are treated using a multidisciplinary approach that involves an internist, dermatologist, vascular surgeon, and wound care nurse. The following are the methods used to treat post-thrombotic venous ulcers:

• Compression therapy includes compression bandages, leg elevation, topical dressings, and some hemorheological agents such as Pentoxifylline. The healing period usually extends from a few weeks to months. There are chances of recurrence of these ulcers as these post-thrombotic venous ulcers can be refractory to the therapy.

What Are the Possible Complications and Their Management?

The following are some of the post-thrombotic syndrome complications:

• Leg sores or ulcers: Drugs like Aspirin and Pentoxifylline are used to heal leg sores.

• Infected ulcers: Antibiotics are used in case the leg ulcers become infected.

• The infection occurs due to improper wound care. Severe ulcers that do not respond to medication are removed with the help of surgical procedures.

Conclusion:

Post-thrombotic syndrome is an incurable condition that causes pain and lasts a long time. The leading cause behind this severe condition is deep vein thrombosis, in which blood clot form in the leg's deep veins. The signs and symptoms of this condition need to be reviewed to prevent its occurrence. Otherwise, there is no cure for this. However, doctors use various management techniques like compression stockings in high-risk patients.