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. 2022 Feb 24:9:762443.
doi: 10.3389/fcvm.2022.762443. eCollection 2022.

The Post-thrombotic Syndrome-Prevention and Treatment: VAS-European Independent Foundation in Angiology/Vascular Medicine Position Paper

Benilde Cosmi  1   2 , Agata Stanek  3 , Matja Kozak  4 , Paul W Wennberg  5 , Raghu Kolluri  6 , Marc Righini  7 , Pavel Poredos  8 , Michael Lichtenberg  9 , Mariella Catalano  2 , Sergio De Marchi  2   10 , Katalin Farkas  11 , Paolo Gresele  12 , Peter Klein-Wegel  13 , Gianfranco Lessiani  14 , Peter Marschang  15 , Zsolt Pecsvarady  16 , Manlio Prior  2   10 , Attila Puskas  17 , Andrzej Szuba  18
Affiliations

The Post-thrombotic Syndrome-Prevention and Treatment: VAS-European Independent Foundation in Angiology/Vascular Medicine Position Paper

Benilde Cosmi et al. Front Cardiovasc Med. .

Abstract

Importance: The post-thrombotic syndrome (PTS) is the most common long-term complication of deep vein thrombosis (DVT), occurring in up to 40-50% of cases. There are limited evidence-based approaches for PTS clinical management.

Objective: To provide an expert consensus for PTS diagnosis, prevention, and treatment.

Evidence-review: MEDLINE, Cochrane Database review, and GOOGLE SCHOLAR were searched with the terms "post-thrombotic syndrome" and "post-phlebitic syndrome" used in titles and abstracts up to September 2020.

Filters were: English, Controlled Clinical Trial / Systematic Review / Meta-Analysis / Guideline. The relevant literature regarding PTS diagnosis, prevention and treatment was reviewed and summarized by the evidence synthesis team. On the basis of this review, a panel of 15 practicing angiology/vascular medicine specialists assessed the appropriateness of several items regarding PTS management on a Likert-9 point scale, according to the RAND/UCLA method, with a two-round modified Delphi method.

Findings: The panelists rated the following as appropriate for diagnosis: 1-the Villalta scale; 2- pre-existing venous insufficiency evaluation; 3-assessment 3-6 months after diagnosis of iliofemoral or femoro-popliteal DVT, and afterwards periodically, according to a personalized schedule depending on the presence or absence of clinically relevant PTS. The items rated as appropriate for symptom relief and prevention were: 1- graduated compression stockings (GCS) or elastic bandages for symptomatic relief in acute DVT, either iliofemoral, popliteal or calf; 2-thigh-length GCS (30-40 mmHg at the ankle) after ilio-femoral DVT; 3- knee-length GCS (30-40 mmHg at the ankle) after popliteal DVT; 4-GCS for different length of times according to the severity of periodically assessed PTS; 5-catheter-directed thrombolysis, with or without mechanical thrombectomy, in patients with iliofemoral obstruction, severe symptoms, and low risk of bleeding. The items rated as appropriate for treatment were: 1- thigh-length GCS (30-40 mmHg at the ankle) after iliofemoral DVT; 2-compression therapy for ulcer treatment; 3- exercise training. The role of endovascular treatment (angioplasty and/or stenting) was rated as uncertain, but it could be considered for severe PTS only in case of stenosis or occlusion above the inguinal ligament, followed by oral anticoagulation.

Conclusions and relevance: This position paper can help practicing clinicians in PTS management.

Keywords: deep vein thrombosis; diagnosis; post-phlebitic syndrome; post-thrombotic syndrome; prevention; treatment.

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Conflict of interest statement

BC declares speakers's fees from Instrumentation Laboratory, Werfen IL, Sanofi, Aspen, Bristol-Myers-Squibb, advisory board fees for Viatris, Techdow Farma Italy. ASt declares receiving grants from Metrum Cryoflex, honorario for lectures from Alfa Sigma, President of the Polish Society of Cryotherapy, unpaid. GL reports Leadership or fiduciary role in other board, society, committee or advocacy group, paid or unpaid: Vice President of Italian Society of Angiology and Vascular Disease (2018–2021); consulting fees from Alfa Sigma. PM declares Payment for a lecture from Bayer (2018), President of the Austrian Society of Vascular Medicine (ÖGIA) 2018–2019, unpaid. MP declares payment or honoraria for lectures of Alfa Sigma, Aspen, BMS Pfizer, support for travel from Alfa Sigma. MC Honorary President UEMS, Division of Angiology unpaid. PG is President of the Italian Society for the Study of Haemostasis and Thrombosis (SISET: 2020–2022) unpaid. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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