Definition of the post-thrombotic syndrome, differences between existing classifications.

BACKGROUND: Accepted diagnostic criteria exist for the diagnosis of deep vein thrombosis (DVT). However, no uniform definition for the diagnosis and treatment of the post-thrombotic syndrome (PTS) exists. We examined the various definitions of PTS that are used and their relationships with invasive venous pressure measurement. METHODS: Patients who had previously suffered a documented DVT underwent clinical evaluation of both lower limbs in which we used five clinical definitions to grade PTS. We included the definition of Widmer, the CEAP classification, the venous clinical severity score (also without compression therapy), and the definitions according to Prandoni and Brandjes in the evaluation. We compared all the clinical scoring systems with invasive ambulatory venous pressure measurement. RESULTS: In total 124 patients were enrolled in whom both legs were evaluated. Thirteen patients had previously suffered bilateral DVT and nine patients had had an ipsilateral recurrent DVT. In the limbs with DVT, 10 (7%) to 29 (21%) were defined as severe PTS, compared to 0-4 (4%) in the control legs. Mild-to-moderate PTS in the DVT legs ranged from 23 to 49%, compared to 13-34% in the control legs. Overall the presence of any PTS in the DVT legs varied from 30% (VCS without compression) to 66% (Brandjes). The scoring systems of Brandjes and VCS showed a tendency towards more legs to be defined as severe PTS. Absolute frequencies of PTS in DVT legs were highest for the classifications according to Widmer, Prandoni and Brandjes. Differences in proportions of any PTS calculated between DVT and control legs varied from 18 to 39%, while odds ratios varied between 2.2 and 5.2 for the different definitions. The CEAP classification and definition of Brandjes show a moderate relation to Widmer, kappa=0.53 and 0.52, respectively. The VCS shows in all comparisons a poor correlation (kappa 0.22-0.41). Prandoni has a moderate correlation with most definitions (kappa 0.40-0.44). CONCLUSION: All clinical definitions of PTS were highly associated with the reference standard of ambulatory venous pressure, with higher AVPs observed in the more severely affected groups. The ability of the scoring systems to discriminate between DVT and control legs as well as the observed prevalence of PTS differed substantially. In part this is due to the considerable overlap in AVP in the different clinical groups, reflecting the fact that our reference standard has substantial deficiencies. No clear advantage was found in any one system of classification over the rest.

Division of incompetent perforator veins and subfascial interposition of a polypropylene foil in post-thrombotic syndrome. Preliminary results.

AIM: The safety, feasibility and early efficacy of subfascial endoscopic perforator surgery was gradually accepted for patients who had severe chronic venous insufficiency but, in the literature, the recurrence rate of ulceration is about 10-40%, especially in patients with previous deep vein thrombosis (DVT). METHODS: From October 1998 to February 2002, 205 patients with 280 inferior leg ulcers were followed; 115 had venous ulcers but only 20 patients had chronic ulcers with previous DVT; 4 patients were excluded and only 16 patients (9 female, 7 male, mean age 61 years) with 18 chronic ulcers were included. These patients underwent sub-aponeurotic interruption of perforating veins with blind technique in association with subfascial interposition of a hand-made polypropylene foil. Eight of these patients had persistent non-healing ulcers at the time of surgery and 10 had chronic recurrent ulceration healed at the time of the surgical procedure. All patients were assessed clinically and with duplex scanning. RESULTS: The follow-up was done clinically and with eco-Doppler from 6 to 38 months with a mean follow up period of 23.2 months. The healing rate was 100%. The 2-year life table incidence of ulcer recurrence was 0%. Hospital stay ranged from 1-2 days, early operative complications included extensive ecchymosis in 1 patient, oedema in 3 patients. CONCLUSION: The division of perforating veins, with the subfascial support of a polypropylene foil give promising results in the treatment of venous ulcers in post-thrombotic syndrome with low morbidity and short hospital stay.

Postphlebitic syndrome after total knee arthroplasty: 405 patients examined 2-10 years after surgery.

We assessed the prevalence and relevance of putative risk factors for significant postphlebitic syndrome (PPS) in a cohort of 405 patients who underwent single limb cemented total knee arthroplasty. All patients were studied by means of a questionnaire and clinical examination to detect the presence of lower limb venous insufficiency. We found 52 (13%) new cases of postphlebitic syndrome. Comparison of those patients with and without PPS revealed no significant differences in the median age, sex ratio, preoperative mass, primary joint pathology or relevance of primary or revision surgery. A confirmed history of pre- or post-operative deep vein thrombosis was associated with the development of disease. Most cases seemed to develop within 5 years of surgery.

[Site of phlebographically determined venous changes in postphlebitic syndrome with varicose ulcer]. / Etagenverteilung phlebographisch erfassbarer Venenveränderungen beim postthrombotischen Syndrom mit Ulcus cruris.

In 207 legs with venous leg ulcers and postthrombotic syndrome proved by phlebography, the frequency of involvement of the 4 levels of deep venous system was assessed. Level A: deep veins of the lower leg. Level B: poplieal vein and gastrocranial veins. Level C: femoral veins. Level D: iliac veins. Our investigations showed that in 35% damages of the deep veins only in level A (lower leg) were responsible for venous ulcer. In cases with combinations of levels, Level A in 95% also was involved. One can say that postthrombotic leg ulcer correlates above all with the pathomorphological alterations of the lower leg veins.

[Expert assessment of so-called post-thrombotic syndrome in compulsory accident insurance]. / Die Begutachtung des sogenannten postthrombotischen Syndroms in der gesetzlichen Unfallversicherung.

Expertising a late damage after thrombosis requires most careful investigation of the findings, a detailed description of the damage, and a definition of the impairment of functions. This is imperative for arriving at an administrative decision to implement the conclusions arrived at by the expert without committing a legal error by such implementation. Estimation and determination of the damage and of awarding a reasonable compensation requires a detailed consideration of the circumstances of each case and observance of the legal principle of equal rights.

[The diagnosis and treatment of postthrombotic disease]. / Diagnostika i lechenie posttromboticheskoi bolezni.

A 10-year experience in the analysis of stationary examination and treatment of 163 patients with post-thrombotic disease of lower extremities is given in this article. Surgical treatment was conducted in 102 cases, medical treatment was applied for 61 patients. There is a classification of diseases which defines medical tactics. On the basis of the data obtained during these studies the authors make a conclusion that in cases of varicose, indurative of indurative-ulcerated forms of this disease surgical treatment is indicated in the accordance with the character of vein affection. Otherwise, it is more preferable to apply medical treatment in cases of eodemata.

[Post-thrombotic venous disease of the legs. Current data]. / Maladie post-thrombotique veineuse des membres inférieurs. Données actuelles.

The post-thrombotic syndrome (PTS) is the first cause of the severe chronic venous insufficiency (CVI) of which the total cost is very high. The lack of precise definitions, the long latency time between the deep vein thrombosis (DVT) and the trophic changes, the difficulties in treating the post-thrombotic ulcers, are partly responsible for the difficulties in analysing the problem of the PTS (epidemiology, pathophysiology, exploration) and consequently for the lack of interest in this disease. The recent data show that: 1) trophic venous changes are not all of PTS origin, 2) calf DVT are not to be neglected concerning the PTS risk, 3) the calf deep valvular destruction and the calf perforating veins reflux play the first part in the PTS evolution, 4) we should take into consideration the whole venous hemodynamic function of the lower limbs (macro and microcirculation) when analysing the long term clinical and hemodynamical consequences of a DVT. Today, the best treatment of a PTS is still its prevention not only by a better diagnosis and treatment of DVT but also by a long term ambulatory elastic stocking therapy with the aim of prolonging the disease-free interval.

Clinical study of late-stage postthrombotic lower extremities.

Through clinical and venographic study of 353 diseased limbs, the authors advocate a new classification for the postthrombotic syndrome of the deep veins of the lower extremity. The postthrombotic lower extremities may be divided into two types: (1) lesions of the whole lower extremity, consisting of the completely obstructed, partially recanalized, and completely recanalized types; (2) local lesions, such as segmental obstruction of the iliac, iliofemoral, superficial femoral, femoropopliteal veins, and the tibioperoneal venous trunk and the venous plexus in calf muscles. Each type has its characteristics related to the duration of symptoms and clinical features, and their management is not the same at all. The authors suggest that clinically this new classification may be of great help in estimating the status of the diseased limb and in selecting proper method of treatment.