The purpose of this scientific statement is to provide an up-to-date overview of the postthrombotic syndrome (PTS), a frequent, chronic complication of deep venous thrombosis (DVT), and to provide practical recommendations for its optimal prevention, diagnosis, and management The intended audience for this scientific statement includes clinicians and other healthcare professionals caring for patients with DVT

Members of the writing panel were invited by the American Heart Association Scientific Council leadership because of their multidisciplinary expertise in PTS Writing Group members have disclosed all relationships with industry and other entities relevant to the subject The Writing Group was subdivided into smaller groups that were assigned areas of statement focus according to their particular expertise After systematic review of relevant literature on PTS (in most cases, published in the past 10 years) until December 2012, the Writing Group incorporated this information into this scientific statement, which provides evidence-based recommendations The American Heart Association Class of Recommendation and Levels of Evidence grading algorithm (Table 1) was used to rate the evidence and was subsequently applied to the draft recommendations provided by the writing group After the draft statement was approved by the panel, it underwent external peer review and final approval by the American Heart Association Science Advisory and Coordinating Committee External reviewers were invited by the American Heart Association The final document reflects the consensus opinion of the entire committee Disclosure of relationships to industry is included with this document (Writing Group Disclosure Table)

View this table:

Table 1 
Classification of Recommendations and Levels of Evidence



### Background

DVT refers to the formation of blood clots in ≥1 deep veins, usually of the lower or upper extremities PTS, the most common long-term complication of DVT, occurs in a limb previously affected by DVT PTS, sometimes referred to as postphlebitic syndrome or secondary venous stasis syndrome, is considered a …

The Postthrombotic Syndrome: Evidence-Based Prevention, Diagnosis, and Treatment Strategies A Scientific Statement From the American Heart Association

Background: The ATTRACT trial (Acute Venous Thrombosis: Thrombus Removal with Adjunctive Catheter-Directed Thrombolysis) previously reported that pharmacomechanical catheter–directed thrombolysis (...

/pdf/endovascular-thrombus-removal-for-acute-iliofemoral-deep-4c6m2u33wv.pdf

Endovascular Thrombus Removal for Acute Iliofemoral Deep Vein Thrombosis.

May–Thurner Syndrome: Update and Review

The post-thrombotic syndrome (PTS) is a frequent, potentially disabling complication of deep vein thrombosis (DVT) that reduces quality of life and is costly. Clinical manifestations include symptoms and signs such as leg pain and heaviness, edema, redness, telangiectasia, new varicose veins, hyperpigmentation, skin thickening and in severe cases, leg ulcers. The best way to prevent PTS is to prevent DVT with pharmacologic or mechanical thromboprophylaxis used in high risk patients and settings. In patients whose DVT is treated with a vitamin K antagonist, subtherapeutic INRs should be avoided. We do not suggest routine use of elastic compression stockings (ECS) after DVT to prevent PTS, but in patients with acute DVT-related leg swelling that is bothersome, a trial of ECS is reasonable. We suggest that selecting patients for catheter-directed thrombolytic techniques be done on a case-by-case basis, with a focus on patients with extensive thrombosis, recent symptoms onset, and low bleeding risk, who are seen at experienced hospital centers. For patients with established PTS, we suggest prescribing 20-30 mm Hg knee-length ECS to be worn daily. If ineffective, a stronger pressure stocking can be tried. We suggest that intermittent compression devices or pneumatic compression sleeve units be tried in patients with moderate-to-severe PTS whose symptoms are inadequately controlled with ECS alone. We suggest that a supervised exercise training program for 6 months or more is reasonable for PTS patients who can tolerate it. We suggest that management of post-thrombotic ulcers should involve a multidisciplinary approach. We briefly discuss upper extremity PTS and PTS in children.

/pdf/guidance-for-the-prevention-and-treatment-of-the-post-294pd4f92f.pdf

Guidance for the prevention and treatment of the post-thrombotic syndrome

Background— For patients with acute iliofemoral deep vein thrombosis, it remains unclear whether the addition of intravascular high-frequency, low-power ultrasound energy facilitates the resolution of thrombosis during catheter-directed thrombolysis.

Methods and Results— In a controlled clinical trial, 48 patients (mean age 50±21 years, 52% women) with acute iliofemoral deep vein thrombosis were randomized to receive ultrasound-assisted catheter-directed thrombolysis (N=24) or conventional catheter-directed thrombolysis (N=24). Thrombolysis regimen (20 mg r-tPA over 15 hours) was identical in all patients. The primary efficacy end point was the percentage of thrombus load reduction from baseline to 15 hours according to the length-adjusted thrombus score, obtained from standardized venograms and evaluated by a core laboratory blinded to group assignment. The percentage of thrombus load reduction was 55%±27% in the ultrasound-assisted catheter-directed thrombolysis group and 54%±27% in the conventional catheter-directed thrombolysis group ( P =0.91). Adjunctive angioplasty and stenting was performed in 19 (80%) patients and in 20 (83%) patients, respectively ( P >0.99). Treatment-related complications occurred in 3 (12%) and 2 (8%) patients, respectively ( P >0.99). At 3-month follow-up, primary venous patency was 100% in the ultrasound-assisted catheter-directed thrombolysis group and 96% in the conventional catheter-directed thrombolysis group ( P =0.33), and there was no difference in the severity of the post-thrombotic syndrome (mean Villalta score: 3.0±3.9 [range 0–15] versus 1.9±1.9 [range 0–7]; P =0.21), respectively.

Conclusions— In this randomized controlled clinical trial of patients with acute iliofemoral deep vein thrombosis treated with a fixed-dose catheter thrombolysis regimen, the addition of intravascular ultrasound did not facilitate thrombus resolution.

Clinical Trial Registration— URL: . Unique identifier: [NCT01482273][1].

 [1]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT01482273&atom=%2Fcirccvint%2F8%2F1%2Fe002027.atom

Deb Sepanski

Papers

Postthrombotic morbidity correlates with residual thrombus following catheter-directed thrombolysis for iliofemoral deep vein thrombosis.

Catheter-Directed Thrombolytic Intervention Is Effective for Patients with Massive and Submassive Pulmonary Embolism