Post-thrombotic syndrome

Classification according to ICD-10
I87.0	Post-thrombotic syndrome
ICD-10 online (WHO version 2019)

As post-thrombotic syndrome (PTS) refers to the effects of long-term damage to the deep venous system of the arm or leg after a previous deep vein thrombosis . During the dissolution of the clot, an inflammatory process takes place on the vein wall - but without bacteria or viruses. This reaction is a self-healing attempt by the body and makes the veins open again. However, the venous valves in the affected area are often attacked or even destroyed. This means that the most important part of the reflux mechanism is missing, the veins are no longer fully functional. The "post-thrombotic syndrome" develops. About 50 percent of all thrombosis patients are affected. Because of the rarity of arm vein thrombosis and the low static load on the arms, the arms are rarely affected by PTS.

Clinical picture

In the case of a vein thrombosis, it is very rare that the blood clot completely dissolves, thereby restoring normal vein flow. As a result of the thrombosis, there are usually strands of scarring in the vessel, sometimes with permanent occlusion of a vein. Since the scarred changes also involve the venous valves , the valves can no longer fulfill their function, so that chronic blood congestion can occur in the affected leg. In addition, the venous wall thickened as a result of inflammation. The resulting symptoms are: feeling of heaviness or tension in the leg, swelling and pain. In the further course - often months and years later - edema and secondary varicose veins can initially form. The leg can be perceived as heavy and discomfort up to tension pain can occur. If the disease has progressed for a long enough time, the deposition of iron pigment (= hemosiderin storage) can cause the skin on the lower leg to turn brown and, later, as a result of a chronic undersupply of the upper skin layers with arterial blood, structural skin damage (e.g. atrophy blanche). With further skin damage, a chronic lower leg ulcer often develops ( ulcus cruris venosum). The ulcers can occur on almost any part of the lower leg; the region around the inner and outer ankle is preferably affected.

The severity of the post-thrombotic syndrome depends on the extent of the initial thrombosis and additional factors (standing for long periods at work, female gender, obesity).

Post-thrombotic syndrome can be divided into four stages:

• Stage I: tendency to edema without hardening of the tissue (tissue sclerosis)
• Stage II: hardening of the skin and subcutaneous fatty tissue (dermatoliposclerosis)
• Stage III: sclerotic tissue changes of the skin and subcutaneous tissue and circumscribed areas of the fascia (dermatoliposclerosis regionalis)
• Stage IV: like stage III, but with extensive, sometimes circular ulcerations (ulcus cruris postthromboticum)

Diagnosis

If a previous thrombosis is known and there are typical symptoms (see above), the diagnosis is easy. It is not uncommon for thromboses to go undetected and are sometimes only made likely years later by the presence of post-thrombotic complaints.

Ultrasonic

The method of choice is the examination using color-coded duplex sonography (FKDS), in which structural damage to the deep venous system and, above all, venous valve damage can be clearly demonstrated by the experienced examiner.

Venography

An X-ray examination with contrast agent ( phlebography ) shows a chronic vein occlusion after thrombosis very well based on the large number of small bypass vessels. The venous valves can also be assessed well. However, since venography is more complex and uncomfortable for the patient compared to ultrasound , it is performed less and less.

Villalta Score

In 1994, Villalta et al. Developed a score to objectify the severity of the post-thrombotic syndrome. Sabina Villalta is Medical Director of the Clinic for Internal Medicine at Cà Foncello Hospital in Treviso , Italy .

	Rating (points)
Subjective symptoms morphological changes	No	Mild	medium	Heavy
Subjective symptoms
pain	0	1	2	3
cramps	0	1	2	3
Heaviness	0	1	2	3
Paresthesia (abnormal sensations)	0	1	2	3
Clinical changes
pretibial edema (swelling; water retention )	0	1	2	3
Induration (hardening)	0	1	2	3
pigmentation	0	1	2	3
Pain during calf compression	0	1	2	3
Venous ectasia ( bag- like enlargement of the veins)	0	1	2	3
Ulcus cruris (lower leg ulcer )	0	1	2	3

Evaluation of the Villalta Score The sum of all point values ​​in the table above is formed.

• Score 0-4: No PTS
• Score 5-9: Mild PTS
• Score 10-14: Moderate PTS
• Score 14 or leg ulcer: Severe PTS

therapy

The basic principle of the treatment is the application of external compression either by applying a compression bandage with short-stretch bandages or by putting on a medical compression stocking . Depending on the severity of the PTS and the shape of the leg, round or flat-knit stockings are used. At the same time, it is important to activate the muscle pump , which can be achieved by regularly and actively moving the affected extremity (cycling, walking). Overloading the leg through extreme endurance sports should, however, be avoided. Elevating the leg also relieves the venous system. Diuretic drugs are only useful in individual cases and then only for a short time. Anticoagulation with coumarins makes sense if there is a renewed risk of thrombosis. Compression therapy with stockings should be continued for life to prevent relapses .

However, a Canadian multicentre, randomized, placebo-controlled study in over 800 patients came to the conclusion in 2013 that compression therapy with compression stockings cannot prevent the development of post-thrombotic syndrome. The subjects received either a compression stocking with a pressure of 30 to 40 mmHg or a stocking with only 5 mmHg. There was little difference in the development of the post-thrombotic syndrome in the two groups. This study has now attracted criticism for a number of reasons. This includes that the stockings were not issued until two weeks after the diagnosis, the wearing behavior of the participants - or whether the test persons put on the stockings at all - was not checked and a weekly wearing period of only three days was assessed as "particularly compliant ".

The effect of compression improves with movement, as it activates the calf muscle pump and the ankle pump. In principle, therefore, the true 3S3L rule : S Itzen and S tehen is S chlecht - L ieber L aufen and L ying.

Individual evidence

1. ^ German Society for Angiology - Society for Vascular Medicine eV
2. ↑ Karina Schleimer et al .: Therapy of the post-thrombotic syndrome. The importance of endovascular recanalization of chronic venous obstructions of the pelvic floor in Deutsches Ärzteblatt , 50/2016, doi: 10.3238 / arztebl.2016.0863 , pp. 863–870.
3. ↑ Guideline for the diagnosis and treatment of post-thrombotic syndrome (including leg ulcers) on the website of the German Society for Vascular Surgery , accessed on March 16, 2018.
4. ↑ Eberhard Rabe (Ed.): Guidelines for the diagnosis and therapy of venous diseases: Grundwerk Deutsche Gesellschaft für Phlebologie. Schattauer, Stuttgart 1999 (online at Google Books), accessed March 20, 2018.
5. ^ S Villalta, P Bagatella, A Piccioli, AW Lensing, MH Prins, P Prandoni: Assessment of validity and reproducibility of a clinical scale for the post-thrombotic syndrome (abstract). In: Haemostasis . tape 24 , 1994, pp. 158a .
6. ↑ Stephanie Reich-Schupke, Markus Stücker (ed.): Modern compression therapy . A practical guide , Viavital Verlag, Cologne 2013, ISBN 978-3-934371-50-7 , p. 82.
7. ↑ Stephanie Reich-Schupke , Markus Stücker (ed.): Modern compression therapy . A practical guide , Viavital Verlag, Cologne 2013, ISBN 978-3-934371-50-7 , p. 106 f.
8. ^ Susan R Kahn et al.: Compression stockings to prevent post-thrombotic syndrome: a randomized placebo-controlled trial. In: The Lancet. 2014; 383, pp. 880-888. doi : 10.1016 / S0140-6736 (13) 61902-9 .
9. ↑ Kerstin Protz: Modern wound care. Practical knowledge, standards and documentation , 7th edition, Elsevier Verlag, Munich 2014, ISBN 978-3-437-27884-6 , p. 98.

Web links

• The Post-Thrombotic Disease Venenzentrum Frankfurt am Main, accessed on March 21, 2018.
• S2 guideline : Diagnosis and therapy of venous thrombosis and pulmonary embolism, register number 065-002, status 06/2010, [1]

This article is about a health issue. It is not used for self-diagnosis and does not replace a diagnosis by a doctor. Please note the information on health issues !