Skip to main content

The Post-thrombotic Syndrome: The Forgotten Morbidity of Deep Venous Thrombosis

Abstract

The postthrombotic syndrome (PTS) is the most common complication of deep venous thrombosis (DVT) yet has received little attention from clinicians and researchers. Clinically, PTS is characterized by chronic pain, swelling, heaviness and other signs in the affected limb. In severe cases, venous ulcers may develop. PTS is burdensome and costly to patients and society because of its high prevalence, severity and chronicity. Preventing DVT with the use of effective thromboprophylaxis in high-risk patients and settings and minimizing the risk of ipsilateral DVT recurrence are likely to reduce the frequency of PTS. Compression stockings worn daily after DVT appear to reduce the incidence and severity of PTS but questions regarding their use and effectiveness remain. Future research should focus on identifying patients at high risk for PTS, assessing the role of thrombolysis in preventing PTS and evaluating the optimal use of compression stockings in preventing and treating PTS. In addition, new therapies to treat PTS should be sought and evaluated.

This is a preview of subscription content, access via your institution.

References

  1. Kahn SR, Ginsberg JS. Relationship between deep venous thrombosis and the postthrombotic syndrome. Arch Int Med 2004;164:17–26.

    Google Scholar 

  2. Kurz X, Kahn SR, Abenhaim L, et al. Chronic venous disorders of the leg: epidemiology, outcomes, diagnosis and management — Summary of an evidence-based report of the VEINES task force. Int Angiol 1999;18:83–102.

    CAS  PubMed  Google Scholar 

  3. Bernardi E, Prandoni P. The post-thrombotic syndrome. Curr Opin Pulm Med 2000;6(4):335–342.

    Article  CAS  PubMed  Google Scholar 

  4. Hopkins NF, Wolfe JH. ABC of vascular diseases. Deep venous insufficiency and occlusion. BMJ 1992;304(6819):107–110.

    CAS  PubMed  Google Scholar 

  5. Ackroyd JS, Browse NL. The investigation and surgery of the post-thrombotic syndrome. J Cardiovasc Surg (Torino) 1986;27(1):5–16.

    CAS  Google Scholar 

  6. Negus D. The post-thrombotic syndrome. Ann R Coll Surg Engl 1970;47(2):92–105.

    CAS  PubMed  Google Scholar 

  7. Markel A, Manzo RA, Bergelin RO, Strandness DE. Valvular reflux after deep vein thrombosis: Incidence and time of occurrence. J Vasc Surg 1992;15(2):377–382.

    CAS  PubMed  Google Scholar 

  8. Franzeck U, Schalch I, Bollinger A. On the relationship between changes in the deep veins evaluated by duplex sonography and the potthrombotic syndrome 12 years after deep vein thrombosis. Thromb Haemost 1997;77:1109–1112.

    CAS  PubMed  Google Scholar 

  9. Franzeck U, Schalch I, Jager K, Schneider E, Grimm J, Bollinger A. Prospective 12-year follow-up study of clinical and hemodynamic sequelae after deep vein thrombosis in low-risk patients (Zurich Study). Circulation 1996;93:74–79.

    CAS  PubMed  Google Scholar 

  10. Lindhagen A, Bergqvist D, Hallbook T, Efsing H. Venous function five to eight years after clinically suspected deep venous thrombosis. Acta Med Scand 1985;217:389–395.

    CAS  PubMed  Google Scholar 

  11. Haenen J, Janssen M, Van Maanen D, et al. The postthrombotic syndrome in relation to venous hemodynamics, as measured by means of duplex scanning and strain-gauge plethysmography. J Vasc Surg1999;29: 1071–1076.

    Article  CAS  PubMed  Google Scholar 

  12. Prandoni P, Frulla M, Sartor D, Concolato A, Girolami A. Vein abnormalities and the post-thrombotic syndrome. Journal of Thrombosis and Haemostasis 2005;3(2):401–402.

    Article  CAS  PubMed  Google Scholar 

  13. Meissner MH, Caps MT, Zierler BK, et al. Determinants of chronic venous disease after acute deep venous thrombosis. J Vasc Surg 1998;28:826–833.

    Article  CAS  PubMed  Google Scholar 

  14. Kakkar V, Lawrence D. Hemodynamic and clinical assessment after therapy for acute deep vein thrombosis. Am J Surg 1985;153:54–63.

    Google Scholar 

  15. Milne AA, Stonebridge PA, Bradbury AW, Ruckley CV. Venous function and clinical outcome following deep vein thrombosis. Br J Surg 1994;81(6):847–849.

    CAS  PubMed  Google Scholar 

  16. Ginsberg JS, Gent M, Turkstra F, et al. Postthrombotic syndrome after hip or knee arthroplasty. Arch Intern Med2000;160: 669–672.

    Article  CAS  PubMed  Google Scholar 

  17. Porter JM, Moneta GL, and An International Consensus Committee on Chronic Venous Disease. Reporting standards in venous disease: An update. J Vasc Surg 1995;21(4):635–645.

    Article  CAS  PubMed  Google Scholar 

  18. Rutherford RB, Padberg FT, Comerota AJ, Kistner RL, Meissner MH, Moneta GL. Venous severity scoring: An adjunct to venous outcome assessment. J Vasc Surg 2000;31:1307–1312.

    CAS  PubMed  Google Scholar 

  19. Villalta S, Bagatella P, Piccioli A, Lensing A, Prins M, Prandoni P. Assessment of validity and reproducibility of a clinical scale for the post-thrombotic syndrome (abstract). Haemostasis 1994;24(Suppl 1):158a.

    Google Scholar 

  20. Prandoni P, Lensing A, Cogo A, et al. The long-term clinical course of acute deep venous thrombosis. Ann Intern Med 1996;125(1):1–7.

    CAS  PubMed  Google Scholar 

  21. Prandoni P, Villalta S, Bagatella P, et al. The clinical course of deep-vein thrombosis. Prospective long-term follow-up of 528 symptomatic patients. Haematologica 1997;82(4):423–428.

    CAS  PubMed  Google Scholar 

  22. Beyth RJ, Cohen AM, Landefeld CS. Long-term Outcomes of Deep-Vein Thrombosis. Arch Intern Med 1995;155:1031–1037.

    Article  CAS  PubMed  Google Scholar 

  23. McColl M, Ellison J, Greer I, Tait R, Walker I. Prevalence of the post-thrombotic syndrome in young women with previous venous thromboembolism. Br J Haematol 2000;108:272–274.

    Article  CAS  PubMed  Google Scholar 

  24. Saarinen J, Sisto T, Laurikka J, Salenius JP, Tarkka M. Late sequelae of acute deep venous thrombosis: evaluation five and ten years after. Phlebology 1995;10:106–109.

    Google Scholar 

  25. Prandoni P, Lensing AWA, Prins MH, et al. Below-knee elastic compression stockings to prevent the post-thrombotic syndrome: a randomized, controlled trial. Ann Intern Med 2004;141(4):249–256.

    PubMed  Google Scholar 

  26. Browse NL, Clemenson G, Thomas ML. Is the Postphlebitic leg always postphlebitic? Relation between postphlebitic phlebographic appearances of deep-vein thrombosis and late sequelae. BMJ 1980;281:1167–1170.

    CAS  PubMed  Google Scholar 

  27. Mohr DN, Silverstein MD, Heit JA, Petterson TM, O'Fallon WM, Melton III LJ. The venous stasis syndrome after deep venous thrombosis or pulmonary embolism: a population based study. Mayo Clin Proc 2000;75:1249–1256.

    CAS  PubMed  Google Scholar 

  28. Monreal M, Martorell A, Callejas J, et al. Venographic assessment of deep vein thrombosis and risk of developing post-thrombotic syndrome: a prospective study. J Intern Med 1993;233:233–238.

    CAS  PubMed  Google Scholar 

  29. Lindner DJ, Edwards JM, Phinney ES, Taylor LM, Porter JM. Long-term hemodynamic and clinical sequelae of lower extremity deep vein thrombosis. J Vasc Surg 1986;4:436–442.

    Article  CAS  PubMed  Google Scholar 

  30. Strandness D, Langlois Y, Cramer M, Randlett A, Thiele B. Long-term sequelae of acute venous thrombosis. JAMA 1983;250(10):1289–1292.

    Article  PubMed  Google Scholar 

  31. Philbrick JT, Becker DM. Calf deep venous thrombosis. A wolf in sheep's clothing? Arch Intern Med 1988;148(10):2131–2138.

    Article  CAS  PubMed  Google Scholar 

  32. Schulman S, Granqvist S, Juhlin-Dannfelt A, Lockner D. Long-term sequelae of calf vein thrombosis treated with heparin or low-dose streptokinase. Acta Med Scand 1986;219(4):349–357.

    CAS  PubMed  Google Scholar 

  33. Masuda EM, Kessler DM, Kistner RL, Eklof B, Sato DT. The natural history of calf vein thrombosis: Lysis of thrombi and development of reflux. J Vasc Surg 1998;21(1):67–73.

    Google Scholar 

  34. Saarinen J, Kallio T, Lehto M, Hiltunen S, Sisto T. The occurence of the post-thrombotic changes after an acute deep venous thrombosis. J Cardiovasc Surg 2000;41(3):441–446.

    CAS  Google Scholar 

  35. Haenen JH, Wollersheim H, Janssen MC, et al. Evolution of deep venous thrombosis: a 2-year follow-up using duplex ultrasound scan and strain-gauge plethysmography. J Vasc Surg 2001;34(4):649–655.

    Article  CAS  PubMed  Google Scholar 

  36. Meissner MH, Caps MT, Bergelin RO, Manzo RA, Strandness DE, Jr. Early outcome after isolated calf vein thrombosis. J Vasc Surg 1997;26(5):749–756.

    Article  CAS  PubMed  Google Scholar 

  37. McLafferty RB, Moneta GL, Passman MA, Brant BM, Taylor LM, Jr., Porter JM. Late clinical and hemodynamic sequelae of isolated calf vein thrombosis. J Vasc Surg 1998;27(1):50–56.

    Article  CAS  PubMed  Google Scholar 

  38. Wille-Jorgensen P, Jorgensen LN, Crawford M. Asymptomatic postoperative deep vein thrombosis and the development of postthrombotic syndrome. A systematic review and meta-analysis. Thromb Haemost 2005;93(2): 236–241.

    CAS  PubMed  Google Scholar 

  39. Hull RD, Pineo GF, Stein PD, et al. Extended out-of-hospital low-molecular-weight heparin prophylaxis against deep venous thrombosis in patients after elective hip arthroplasty: a systematic review. Ann Intern Med 2001;135(10):858–869.

    CAS  PubMed  Google Scholar 

  40. Davidson B, ensing A. Prolonged prophylaxis after joint replacement: Another step sideways? Ann Intern Med 2000;132(11):914–915.

    CAS  PubMed  Google Scholar 

  41. Sullivan SD, Kahn SR, Davidson BL, Borris L, Bossuyt P, Raskob G. Measuring the outcomes and pharmacoeconomic consequences of venous thromboembolism prophylaxis in major orthopaedic surgery. Pharmacoeconomics 2003;21(7):477–496.

    Article  PubMed  Google Scholar 

  42. Kahn SR, Kearon C, Julian JA, et al. Predictors of the post-thrombotic syndrome during long-term treatment of proximal deep vein thrombosis. J Thromb Haemost 2005.

  43. Biguzzi E, Mozzi E, Alatri A, Taioli E, Moia M, Mannucci P. The post-thrombotic syndrome in young women: retrospective evaluation of prognostic factors. Thromb Haemost 1998;80:575–577.

    CAS  PubMed  Google Scholar 

  44. Wille-Jorgensen P, Jorgensen T, Andersen M, et al. Postphlebitic syndrome and general surgery:an epidemiological investigation. Angiology, 397–403. 1991.

  45. Bauer KA. The thrombophilias: well defined risk factors with uncertain therapeutic implications. Ann Intern Med 2001;135:367–376.

    CAS  PubMed  Google Scholar 

  46. Anderson FA, Wheeler B, Goldberg RJ, et al. A population-based perspective of the hospital incidence and case-fatality rates of deep vein thrombosis and pulmonary embolism. Ann Intern Med 1991;151:933–938.

    Google Scholar 

  47. Silverstein MD, Heit JA, Mohr DN, Petterson TM, O'Fallon WM, Melton LJ, III. Trends in the incidence of deep vein thrombosis and pulmonary embolism: a 25-year population-based study. Arch Intern Med 1998;158(6):585–593.

    Article  CAS  PubMed  Google Scholar 

  48. Heit JA, Silverstein MD, Mohr DN, et al. The epidemiology of venous thromboembolism in the community. Thromb Haemost 2001;86:452–463.

    CAS  PubMed  Google Scholar 

  49. Nordstrom M, Lindblad B, Bergqvist D, Kjellstrom TK. A prospective study of the incidence of deep-vein thrombosis within a defined urban population. J Intern Med 1992;232:155–160.

    CAS  PubMed  Google Scholar 

  50. Heit JA, Rooke TW, Silverstein MD, et al. Trends in the incidence of venous stasis syndrome and venous ulcer: a 25-year population-based study. J Vasc Surg 2001;33(5):1022–1027.

    Article  CAS  PubMed  Google Scholar 

  51. O'Donnell TF, Browse NL, Burnaud KG, Thomas ML. The Socioeconomic Effects of an lliofemoral Venous Thrombosis. J Surg Res 1977;22:483–488.

    Article  PubMed  Google Scholar 

  52. Lamping DL, Schroter S, Kurz X, Kahn SR, Abenhaim L. Evaluating outcomes in chronic venous disorders of the leg: Development of a scientifically rigorous, patient-reported measure of symptoms and quality of life. J Vasc Surg 2003;37(2):410–419.

    Article  PubMed  Google Scholar 

  53. Kahn SR, Hirsch A, Shrier I. Effect of post-thrombotic syndrome on health-related quality of life after deep venous thrombosis. Arch Intern Med 2002;162:1144–1148.

    Article  PubMed  Google Scholar 

  54. Kahn SR, M'Lan CE, Lamping DL, et al. The influence of venous thromboembolism on quality of life and severity of chronic venous disease. J Thromb Haemost 2004; 2:2146–2151.

    Article  CAS  PubMed  Google Scholar 

  55. Bergqvist D, Jendteg S, Johansen L, Persson U, Odegaard K. Cost of long-term complications of deep venous thrombosis of the lower extremities: an analysis of a defined patient population in Sweden. Ann Intern Med 1997;126(6):454–457.

    CAS  PubMed  Google Scholar 

  56. Harrison M, Graham I, Friedberg E, Lorimer K, Vandevelde-Coke S. Assessing the population with leg and foot ulcers. Canadian Nurse 2001;97(2):18–23.

    CAS  PubMed  Google Scholar 

  57. Bosanquet N. Costs of venous ulcers: from maintenance therapy to investment programmes. Phlebology 1992;7(Suppl 1):44–46.

    Google Scholar 

  58. Van den Oever R, Hepp B, Debbaut B, Simon I. Socio-economic impact of chronic venous insufficiency. An underestimated public health problem. Int Angiol. 17[3], 161–167. 1998.

    PubMed  Google Scholar 

  59. Abenhaim L, Kurz X. The VEINES study (VEnous INsufficiency Epidemiologic and Economic Study): An international cohort study on chronic venous disorders of the leg. Angiology 1997;48(1):59–66.

    CAS  PubMed  Google Scholar 

  60. Phillips T, Stanton B, Provan A, Lew R. A study of the impact of leg ulcers on quality of life: financial, social, and psychologic implications. J Am Acad Dermatol 1994;31:49–53.

    CAS  PubMed  Google Scholar 

  61. Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004;126(3 Suppl):338S–400S.

    CAS  PubMed  Google Scholar 

  62. Arnold DM, Kahn SR, Shrier I. Missed opportunities for prevention of venous thromboembolism: an evaluation of the use of thromboprophylaxis guidelines. Chest 2001;120:1964–1971.

    Article  CAS  PubMed  Google Scholar 

  63. Goldhaber SZ, Visani L, De Rosa M. Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER). Lancet 1999;353(9162):1386–1389.

    Article  CAS  PubMed  Google Scholar 

  64. Stratton MA, Anderson FA, Bussey HI, et al. Prevention of venous thromboembolism: adherence to the 1995 American College of Chest Physicians consensus guidelines for surgical patients. Arch Intern Med 2000;160(3): 334–340.

    Article  CAS  PubMed  Google Scholar 

  65. Bratzler DW, Raskob GE, Murray CK, Bumpus LJ, Piatt DS. Underuse of venous thromboembolism prophylaxis for general surgery patients: physician practices in the community hospital setting. Arch Intern Med 1998;158(17):1909–1912.

    Article  CAS  PubMed  Google Scholar 

  66. Cogo A, Bernardi E, Prandoni P, et al. Acquired Risk Factors for Deep-Vein Thrombosis in Symptomatic Outpatients. Arch Intern Med 1994;154:164–168.

    Article  CAS  PubMed  Google Scholar 

  67. Kearon C, Gent M, Hirsh J, et al. A comparison of three months of anticoagulation with extended anticoagulation for a first episode of idiopathic venous thromboembolism. N Engl J Med 1999;340(12):901–907.

    Article  CAS  PubMed  Google Scholar 

  68. Schulman S. Optimal duration of oral anticoagulant therapy in venous thromboembolism. Thromb Haemost 1997;78:693–698.

    CAS  PubMed  Google Scholar 

  69. Couturaud F, Kearon C. Treatment of deep vein thrombosis. Seminars in Vascular Medicine 2001;1(1):43–54.

    Article  CAS  PubMed  Google Scholar 

  70. Kearon C, Ginsberg JS, Kovacs MJ, Anderson DR, Wells P, Julian JA et al. Comparison of Low-Intensity Warfarin Therapy with Conventional-Intensity Warfarin Therapy for Long-Term Prevention of Recurrent Venous Thromboembolism. N Engl J Med 2003;349:631–639.

    Article  CAS  PubMed  Google Scholar 

  71. Wells P, Forster AJ. Thrombolysis in deep vein thrombosis: Is there still an indication? Thromb Haemost 2001;86:499–508.

    CAS  PubMed  Google Scholar 

  72. Goldhaber S, Buring J, Lipnick R, Hennekens C. Pooled analyses of randomized trials of streptokinase and heparin in phlebographically documented acute deep venous thrombosis. Am J Med 1984;76:393–397.

    CAS  PubMed  Google Scholar 

  73. Mewissen M, Seabrook G, Meissner M, Cynamon J, Labropoulos N, Haughton S. Catheter-directed thrombolysis for lower extremity deep venous thrombosis: report of a national multicenter registry. Radiology 1999;211(1):39–49.

    CAS  PubMed  Google Scholar 

  74. Goldhaber SZ, Meyerovitz MF, Green D, et al. Randomized controlled trial of tissue plasminogen activator in proximal deep venous thrombosis. Am J Med 1990;88(3):235–240.

    Article  CAS  PubMed  Google Scholar 

  75. O'Donnell TFJ, Rosenthal DA, Callow AD, Ledig BL. Effect of elastic compression on venous hemodynamics in postphlebitic limbs. JAMA 1979;242(25):2766–2768.

    Article  PubMed  Google Scholar 

  76. Pierson S, Pierson D, Swallow R, Johnson GJ. Efficacy of graded elastic compression in the lower leg. JAMA 1983;249(2):242–243.

    Article  CAS  PubMed  Google Scholar 

  77. Jones NA, Webb PJ, Rees RI, Kakkar VV. A physiological study of elastic compression stockings in venous disorders of the leg. Br J Surg 1980;67(8):569–572.

    CAS  PubMed  Google Scholar 

  78. Noyes LD, Rice JC, Kerstein MD. Hemodynamic assessment of high-compression hosiery in chronic venous disease. Surgery 1987;102(5):813–815.

    CAS  PubMed  Google Scholar 

  79. Evers EJ, Wuppermann T. Effect of different compression therapies on the reflux in deep veins with a post-thrombotic syndrome. VASA 1999;28(1):19–23.

    Article  CAS  PubMed  Google Scholar 

  80. Benko T, Cooke EA, McNally MA, Mollan RA. Graduated compression stockings: knee length or thigh length. Clin Orthop 2001;(383):197–203.

    PubMed  Google Scholar 

  81. Brandjes DPM, Buller HR, Heijboer H, Hulsman MV, de Rijk M, Jagt H. Randomized trial of effect of compression stockings in patients with symptomatic proximal-vein thrombosis. Lancet 1997;349:759–762.

    Article  CAS  PubMed  Google Scholar 

  82. Ginsberg J, Hirsh J, Julian J, et al. Prevention and treatment of postphlebitic syndrome: results of a 3-part study. Arch Intern Med 2001;161(17):2105–2109.

    Article  CAS  PubMed  Google Scholar 

  83. Kolbach D, Sandbrink M, Hamulyak K, Neumann H, Prins M. Non-pharmaceutical measures for prevention of post-thrombotic syndrome. Cochrane Database of Systematic Reviews 2004;1, 2004.(CD004174).

  84. Buller HR, Agnelli G, Hull RD, Hyers TM, Prins MH, Raskob GE. Antithrombotic therapy for venous thromboembolic disease: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004;126(3 Suppl):401S–428S.

    CAS  PubMed  Google Scholar 

  85. Prandoni P. Elastic stockings, hydroxyethylrutosides or both for the treatment of post-thrombotic syndrome. Thromb Haemost 2005;93(1):183–185.

    PubMed  Google Scholar 

  86. Ginsberg J, Brill-Edwards P, Kowalchuk G, Hirsh J. Intermittent compression units for the postphlebitic syndrome: a pilot study. Ann Intern Med 1989;149:1651–1652.

    CAS  Google Scholar 

  87. Ginsberg JS, Magier D, MacKinnon B, Gent M, Hirsh J. Intermittent compression units for severe post-phlebitic syndrome: a randomized crossover study. CMAJ 1999;160:1303–1306.

    CAS  PubMed  Google Scholar 

  88. Diehm C. Comparison of leg compression stocking and oral horse-chestnut seed extract therapy in patients with chronic venous insufficiency. Lancet 347, 292–294. 1996.

    Article  CAS  PubMed  Google Scholar 

  89. Pittler M, Ernst E. Horse-chestnut seed extract for chronic venous insufficiency. Arch Dermatol 1998;134:1356–1360.

    Article  CAS  PubMed  Google Scholar 

  90. Weingarten M. State-of-the-art treatment of chronic venous disease. Clin Infect Dis 2001;32:949–954.

    Article  CAS  PubMed  Google Scholar 

  91. Alguire P, Mathes B. Chronic venous insufficiency and venous ulceration. J Gen Intern Med 1997;12:374–383.

    Article  CAS  PubMed  Google Scholar 

  92. Krasner D. Painful venous ulcers: themes and stories about their impact on quality of life. Ostomy/Wound Management 1998;44(9):38–49.

    CAS  PubMed  Google Scholar 

  93. Smith JJ, Guest MG, Greenhalgh RM, Davies AH. Measuring the quality of life in patients with venous ulcers. J Vasc Surg 2000;31:642–649.

    Article  CAS  PubMed  Google Scholar 

  94. Ruckley C. Socioeconomic impact of chronic venous insufficiency and leg ulcers. Angiology 1997;48(1):67–69.

    CAS  PubMed  Google Scholar 

Download references

Author information

Affiliations

Authors

Corresponding author

Correspondence to Susan R. Kahn MD, MSc.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Kahn, S.R. The Post-thrombotic Syndrome: The Forgotten Morbidity of Deep Venous Thrombosis. J Thromb Thrombolysis 21, 41–48 (2006). https://doi.org/10.1007/s11239-006-5574-9

Download citation

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11239-006-5574-9

Key Words

  • deep venous thrombosis
  • post-thrombotic syndrome
  • epidemiology