Natalie S Evans

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

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 …

Associations of diabetes mellitus and other cardiovascular disease risk factors with decline in the ankle–brachial index:

We compared the associations of diabetes mellitus (DM) and other cardiovascular disease (CVD) risk factors with decline in the ankle–brachial index (ABI) over 4 years in participants with and without peripheral artery disease (PAD). A total of 566 participants, 300 with PAD, were followed prospectively for 4 years. Mean (SD) baseline ABI values were 0.70 (0.13) for participants with both PAD and DM, 0.67 (0.14) for participants with only PAD, 1.10 (0.13) for participants with only DM, and 1.10 (0.10) for participants with neither PAD nor DM. After adjusting for age, sex, and baseline ABI, the corresponding ABI change from baseline to 4-year follow-up were −0.02, –0.04, +0.05, and +0.05, respectively. Compared to participants with neither PAD nor DM, participants with only PAD showed significantly more ABI decline (p <0.01), while the decline in participants with both PAD and DM was borderline non-significant (p = 0.06). After adjustments for baseline ABI, age, sex, African American ethnicity, and other CVD risk factors, independent factors associated with ABI decline in participants with PAD in the lower ABI leg were older age and elevated D-dimer. DM was not related to ABI decline. Despite being an important risk factor for PAD, DM was not independently associated with ABI decline. This could reflect the effect of DM promoting both PAD and lower-extremity arterial stiffness, resulting in a small decline in the ABI over time. In conclusion, ABI change over time in persons with diabetes may not accurately reflect underlying atherosclerosis.

Approach to Lower Extremity Edema

Opinion statementLower extremity edema is extremely common among patients seen across multiple specialties. The differential diagnosis is broad and ranges from simple dependent edema to more complex conditions such as chronic venous disease and lymphedema. Several key features from the history and physical exam can assist with the diagnosis. Imaging is rarely necessary at the initial visit unless venous thromboembolism is suspected. Treatment is specific to the etiology of the edema, but compression stockings, elevation, exercise, and weight loss remain the cornerstone in most cases.

Raynaud’s phenomenon

What is Raynaud’s phenomenon? Raynaud’s phenomenon is a condition that affects your blood vessels. If you have Raynaud’s phenomenon, you have periods of time called “attacks” when your body does not send enough blood to the hands and feet. Attacks usually happen when you are cold or feeling stressed. During an attack, your fingers and toes may feel very cold or numb. Raynaud’s phenomenon is also called Raynaud’s disease or Raynaud’s syndrome.

Vascular Disease Patient Information Page: The post-thrombotic syndrome.

The post-thrombotic syndrome is a condition that sometimes occurs after deep vein thrombosis (DVT) of the leg, or, less commonly, of the arm. Veins are the blood vessels that return blood from the arms, legs, and organs to the heart. In DVT, blood clots form in the veins, often leading to pain, swelling, and redness of the affected limb. These symptoms usually subside, but some patients may go on to develop chronic pain, swelling, and skin changes in the affected leg; this is known as the post-thrombotic syndrome, or PTS. In PTS, symptoms may come and go, and in some patients symptoms may be made worse by prolonged sitting, standing, and sometimes by walking. Much is unknown about PTS, but it is thought to occur when blood clots damage the valves of the veins, or when persistent blood clots block the flow of blood in the veins. Valves are small flaps of tissue that help keep blood flowing in only one direction. When they are damaged, blood can flow backward (called reflux), leading to swelling and chronic skin changes such as skin darkening (hyperpigmentation), hardening (induration), and, in severe cases, poorly healing sores (ulcers). Similarly, persistent blockage of the vein can cause these problems.

Vascular Disease Patient Information Page: Peripheral artery disease

Peripheral artery disease (PAD) is narrowing of the arteries, which are the blood vessels that carry oxygen-rich blood away from the heart to the body. The narrowing is usually caused by atherosclerotic plaque. Atherosclerosis, or hardening of the arteries, affects arteries throughout the body. The symptoms depend on which part of the body is involved. When the leg arteries are blocked, the condition is called PAD.

Superficial vein thrombosis

Superficial vein thrombosis (SVT), sometimes called superficial vein thrombophlebitis, refers to a blood clot that forms in one of the surface veins of the body. It is different from deep vein thrombosis (DVT), which occurs in veins deeper inside the body and which can have serious health consequences if not treated promptly with an anticoagulant medication, or ‘blood thinner’ (see Vascular Disease Patient Information Page: Venous thromboembolism1). The term ‘phlebitis’ means inflammation of the vein, which may occur when there is no clot present, often in cases when a vein becomes irritated by physical trauma or after an intravenous line (IV). On physical examination, phlebitis may be indistinguishable from SVT. Although SVT typically is not lifeor health-threatening, it is important for patients with the symptoms of SVT to be examined by a health care provider.

The swollen leg

Leg swelling, known as edema, is a common problem, representing more than half of new referrals to a large vascular medicine practice. Edema occurs when fluid builds up in the tissues, and it may happen suddenly or develop slowly and last for months or years. Most frequently edema is a result of harmless conditions, but occasionally it is caused by more serious underlying health problems. When thinking about the causes of leg edema, it is helpful to divide them into causes involving both legs versus involving just one leg, as some conditions may cause swelling in one or both legs. Often, the most important clues to the cause of leg edema are in the patient’s reported history and in the physical examination, and a doctor may not need blood work or any other tests to make a diagnosis.

Inferior vena cava (IVC) filters

IVC filters are medical devices that are placed in the large vein of the abdomen to prevent blood clots from traveling from the veins of the legs to the lungs. They are most commonly used when a patient cannot receive blood thinners to treat leg blood clots (DVT). IVC filter insertion can be done as an outpatient under local anesthesia, with only a puncture to a vein in the leg or neck. Most IVC filters are designed to be removed when no longer necessary. IVC filter complications are uncommon.

Direct Oral Anticoagulants

Four direct oral anticoagulants (DOACs)—dabigatran, a direct thrombin inhibitor, and the direct factor Xa inhibitors rivaroxaban, apixaban, and edoxaban—have been approved for prevention of stroke in non-valvular atrial fibrillation and treatment of venous thromboembolism (VTE). All except edoxaban also are approved to prevent VTE in hip and knee replacement surgery. In the atrial fibrillation trials, the DOACs were non-inferior to warfarin dose-adjusted to international normalized ratio (INR) 2.0–3.0 in preventing stroke, with similar or better safety profiles. Rates of intracranial hemorrhage were lower for the DOACs. Results were similar in the VTE trials, with similar or better efficacy and safety. Because of their beneficial pharmacokinetic and pharmacodynamics profiles, the DOACs do not require routine monitoring. A reversal agent, idarucizumab, is approved for patients on dabigatran with serious bleeding or in need of an urgent invasive procedure. A reversal agent for the factor Xa inhibitors has been studied but is not yet approved. To date, data on use of the DOACs in patients with cancer or thrombophilia or at extremes of weight are sparse, as few of these patients were included in the published DOAC trials. Further, the role of anticoagulation with DOACs such as rivaroxaban in patients with stable atherosclerotic vascular disease has been revisited with recent data from COMPASS, but additional studies are still needed to define its exact utility.