Post Thrombotic Syndrome

Post thrombotic syndrome (PTS) is a late complication of deep venous thrombosis (DVT) characterized by chronic pain, heaviness, and leg swelling in the effected limb. On physical exam edema, telangectasia, and hyperpigmentation may be seen and in severe cases venous ulceration may develop. The pathophysiology is felt to be an interplay between the presence of an acute thrombus and attempts at vein recanalization leading to valvular incompetence in the weeks following a DVT. This leads to venous hypertension which causes edema and ulceration.

Traditionally, conservative management with compression stockings has been the mainstay of therapy in most patients. Newer endovascular techniques such as iliocaval stenting are becoming more popular especially due to poor patient compliance with traditional therapy. 

Endovascular thrombolysis is evolving as a therapy for DVTs with the hope of preventing the development of PTS. Some of the first endovascular methods were catheter directed thrombolysis (CDT) and percutaneous mechanical thrombectomy (PMT) which were determined to have safety limitations precluding their widespread use. Yet a newer technique called pharmacomechanical catheter directed thrombolysis combines CDT and PMT and is currently being studied in the ATTRACT clinical trial. In this method, intravenous thrombolytic agents are administered and combined with mechanical maceration of clot which further disperses the fibrinolytic drug and accelerates thrombolysis. This helps dissolve clot fragments which would otherwise embolize to the lungs. 

The use of endovascular DVT therapy as first line treatment may improve patient outcomes by prevention of development of PTS.


REFERENCES
Kahn SS. The post-thrombotic syndrome: the forbidden morbidity of deep venous thrombosis. J Thromb Thrombolysis 2006;21(1):41-8.
Vedantham S. Deep venous thrombosis: the opportunity at hand. AJR Am J Roentgenol 2009;193(4):922-7.