Aplicación local de lisado plaquetario en úlceras posflebíticas / Local application of platelet lysate on posflebitic ulcers

El tratamiento de las úlceras postrombóticas o posflebíticas constituye un reto para la medicina debido a su cronicidad y a sus frecuentes recidivas que condicionan múltiples trastornos locales y sistémicos, con una mala calidad de vida del paciente. En este trabajo se incluyeron 80 pacientes con úlceras posflebíticas en miembros inferiores que fueron divididos en 2 grupos: 40 tratados con lisados de plaquetas alogénicas conservadas y 40 tratados convencionalmente, que conformaron el grupo control. Se consideró como buen resultado cuando a los 30 días de tratamiento o antes, el paciente presentó una respuesta parcial o total. En el 95 por ciento de los enfermos tratados con el lisado se obtuvo una buena respuesta (suma de las totales y parciales) contra el 75 por ciento en el grupo control (p>0,001). El uso del lisado plaquetario resultó un proceder simple y efectivo en el tratamiento de úlceras posflebíticas en miembros inferiores, que puede ser recomendado, ya que los pacientes pueden mantenerse en sus hogares y así se elimina el costo hospitalario que generalmente tiene el tratamiento de este tipo de lesión(AU)

Treatment of post-thrombotic ulcers or postflebitic is a challenge to medicine because of its chronicity and frequent recurrences that determine multiple local and systemic disorders with poor quality of life for patients. This study included 80 patients with lower limb posflebitic ulcers, who were grouped into 2 groups: 40 treated with preserved allogeneic platelet lysates and 40 were treated conventionally. The latter was the control group. It was considered good result when the patient had a partial or complete response after 30 days of treatment or before. Good response was found in 95 percent of patients treated with lysate (sum of total and partial values) versus 75 percent in the control group (p> 0.001). The use of platelet lysate was a simple and effective procedure in the treatment of lower limb posflebitic ulcers. This treatment can be recommended, since patients can stay at home, thus eliminating the hospital costs incurred in this type of treatment(AU)

Aplicación local de lisado plaquetario en úlceras posflebíticas / Local application of platelet lysate on posflebitic ulcers

El tratamiento de las úlceras postrombóticas o posflebíticas constituye un reto para la medicina debido a su cronicidad y a sus frecuentes recidivas que condicionan múltiples trastornos locales y sistémicos, con una mala calidad de vida del paciente. En este trabajo se incluyeron 80 pacientes con úlceras posflebíticas en miembros inferiores que fueron divididos en 2 grupos: 40 tratados con lisados de plaquetas alogénicas conservadas y 40 tratados convencionalmente, que conformaron el grupo control. Se consideró como buen resultado cuando a los 30 días de tratamiento o antes, el paciente presentó una respuesta parcial o total. En el 95 por ciento de los enfermos tratados con el lisado se obtuvo una buena respuesta (suma de las totales y parciales) contra el 75 por ciento en el grupo control (p>0,001). El uso del lisado plaquetario resultó un proceder simple y efectivo en el tratamiento de úlceras posflebíticas en miembros inferiores, que puede ser recomendado, ya que los pacientes pueden mantenerse en sus hogares y así se elimina el costo hospitalario que generalmente tiene el tratamiento de este tipo de lesión

Treatment of post-thrombotic ulcers or postflebitic is a challenge to medicine because of its chronicity and frequent recurrences that determine multiple local and systemic disorders with poor quality of life for patients. This study included 80 patients with lower limb posflebitic ulcers, who were grouped into 2 groups: 40 treated with preserved allogeneic platelet lysates and 40 were treated conventionally. The latter was the control group. It was considered good result when the patient had a partial or complete response after 30 days of treatment or before. Good response was found in 95 percent of patients treated with lysate (sum of total and partial values) versus 75 percent in the control group (p> 0.001). The use of platelet lysate was a simple and effective procedure in the treatment of lower limb posflebitic ulcers. This treatment can be recommended, since patients can stay at home, thus eliminating the hospital costs incurred in this type of treatment

Lower extremities' postthrombotic syndrome after total knee arthroplasty.

BACKGROUND: Deep venous thrombosis (DVT) is a disease associated with high morbidity in 40-60% patients who underwent Total Knee Arthroplasty (TKA). Postthrombotic syndrome (PTS) is a common long-term complication that may develop within 6 months or more than 2 years after episode of DVT. OBJECTIVE: To examine the prevalence of PTS in patients who had history of previous DVT and non-previous DVT at least 2-year follow-up period after TKA. MATERIAL AND METHOD: Retrospective chart review was done. All patients who underwent TKA during October 2002-2005 were included. They were postoperatively assessed for PTS with Villalta score and duplex ultrasonography at > or =2 years. The confirmed diagnosis of DVT was done by contrast venography. RESULTS: 22 of 76 patients (56 previous DVT 20 non-previous DVT) had PTS based on the clinical assessment. The previous-DVT group had significantly higher risk to PTS (OR = 1.59; 95% CI: 1.294-1.949; p-value = 0.001). When diagnosed with duplex ultrasonography, 36 in 56 patients of previous-DVT group and 8 in 20 of non-previous-DVT group were found positive venous reflux. Most of venous reflux occurred at popliteal vein (77%) and posterior tibial vein (59%). CONCLUSION: After TKA, the patients who developed DVT had higher risk to PTS (OR = 1.588). Treatment of DVT may not decrease this risk. Prevention of DVT becomes an important approach to prevent PTS.

Post-thrombotic syndrome in children: a single center experience.

BACKGROUND: Development of post-thrombotic syndrome (PTS) is increasingly being recognized as a complication of deep venous thrombosis (DVT) in children. OBJECTIVE: To determine the prevalence, clinical characteristics, and predictors of moderate to severe PTS in children. METHODS: A retrospective chart review was performed on those children who were followed in the coagulation clinic for objectively confirmed DVTs from December 2004 to December 2006. The scoring system used by Kuhle et al was used to grade the severity of PTS as: mild, moderate, and severe. RESULTS: PTS developed in 20% (11/55; 95% confidence interval 9.4-30.1) of children, in which 8/11 were moderate and 3/11 were severe. Median interval between diagnosis of PTS and DVT was 90 days (range, 46 d to 3 y). The majority (72.7%) of patients in the non-PTS group received treatment intervention within 48 hours of diagnosis of DVT. Delay in treatment initiation (>48 h) and recurrence of DVT were associated with the development of PTS (P<0.05). Variables including occlusive thrombus, location and number of vessels involved with DVT, age at diagnosis, underlying thrombophilia, intensity of anticoagulation, and body mass index were not associated with the development of PTS. Other debilitating consequences of DVT requiring intervention included portal hypertension (n=2), chylothorax (n=1), and reflux sympathetic dystrophy (n=1). The small sample size and limited follow up restricted the statistical analysis. CONCLUSIONS: PTS is a significant problem in children with symptomatic DVTs. Early treatment intervention within the first 48 hours of diagnosis of DVT and prevention of thrombosis recurrence may prevent development of PTS. Although PTS refers to consequences of intravenous hypertension owing to extremity DVTs, sequlae of nonextremity DVTs require special consideration in pediatric PTS classification.

Review on the value of graduated elastic compression stockings after deep vein thrombosis.

Graduated elastic compression stockings (GECS) are commonly used in the primary prevention of deep vein thrombosis (DVT); however, their role in preventing recurrent DVT and also post-thrombotic syndrome is less well established. The aim of this review was to investigate the effect of GECS after DVT. A literature search was performed by two independent searchers in order to identify randomised controlled trials on the effect of GECS in preventing recurrent DVT and post-thrombotic syndrome. Four randomised trials, including 537 patients, were identified. Two of the studies demonstrated that below-knee GECS significantly reduced post-thrombotic syndrome during follow-up, while a smaller study showed equivocal results. GECS reduced the incidence of post-thrombotic syndrome from 54% to 25.2% [relative risk (RR) 0.47, 95% confidence interval (CI) 0.36-0.61] with the number needed to treat (NNT) being 4 (95% CI 2.7-5.0). The rate of recurrent asymptomatic DVT was also significantly reduced by GECS (RR 0.20, 95% CI 0.06-0.64; NNT 5); the reduction in symptomatic DVT was not significant (RR 0.79, 95% CI 0.50-1.26; NNT 34). In conclusion, there is level Ia evidence to suggest that GECS can significantly reduce the incidence of post-thrombotic syndrome (PTS) after DVT, and therefore these should be routinely prescribed. The evidence for recurrent DVT is less conclusive. Further research is needed towards standardising PTS diagnostic criteria and evaluating more effective preventive measures after DVT.

Frequency and determinants of the postthrombotic syndrome after venous thromboembolism.

PURPOSE OF REVIEW: Postthrombotic syndrome (PTS) is the most common complication of deep venous thrombosis (DVT). Identifying which patients are at high risk of developing PTS would help improve the management of patients with DVT and allow physicians to provide patients with individualized information on their expected prognosis. This review discusses the knowledge gained from key studies over the last decade on the incidence and determinants of PTS, with special emphasis on published studies from the last 2 years. RECENT FINDINGS: About a third to half of DVT patients will develop PTS, in most cases within 1-2 years of acute DVT. Important risk factors for PTS appear to be ipsilateral recurrence of DVT, poor quality of initial anticoagulation for the treatment of DVT and increased body mass index. SUMMARY: Preventing DVT recurrence by providing adequate intensity and duration of anticoagulation for the initial DVT and using effective thromboprophylaxis in high-risk settings is likely to reduce the frequency of PTS. Despite some advances in identifying risk factors for PTS, however, it is still not possible to reliably predict an individual patient's risk of developing PTS after an episode of DVT. Further studies of clinical determinants and biological markers of increased risk of PTS are needed to ultimately improve long-term prognosis after DVT.

Hemodynamic and morphologic evaluation of sequelae of primary upper extremity deep venous thromboses treated with anticoagulation.

OBJECTIVES: This study was performed to describe venous function, residual morphologic abnormalities, and the occurrence of post-thrombotic syndrome in patients with conservatively treated primary upper-extremity deep venous thromboses (UEDVT). METHOD: This was a retrospective follow-up study of 31 patients with previous primary UEDVT treated with anticoagulation only, identified by a search of medical records. The mean follow-up time was 5 years. The patients were evaluated by interview, clinical examination, computerized strain-gauge plethysmography, and color duplex ultrasound imaging. The grade of post-thrombotic syndrome was rated according to the Villalta score (0 to 3 on each of four subjective and five clinically assessed features). RESULTS: The rate of venous emptying was significantly lower in the arms with DVTs than in the contralateral arms (P < .001). Eleven of the patients (35%) had a remaining outflow obstruction in the affected arm (venous emptying <68 mL/100 mL per min). Eighteen (58%) had a residual thrombus according to color duplex ultrasound scans, with four remaining occluded subclavian veins. None of the patients had deep or superficial venous reflux. There was no statistically significant relationship between plethysmographic and duplex findings. Most (77%) of the patients reported remaining symptoms in the affected arm, and there was a significant side difference in upper arm circumference (P < .001). Approximately one third had developed a moderate grade of post-thrombotic syndrome according to the Villalta score (total, 5 to 9). No significant relation was evident between the post-thrombotic syndrome score and duplex findings. Patients with post-thrombotic syndrome had a lower venous emptying value than those without (69 vs 84 mL/100 mL per min), but this difference was not statistically significant. CONCLUSIONS: Patients with conservatively treated previous primary UEDVT had significantly reduced venous outflow capacity and a residual thrombus was common. Swelling of the arm was the most common symptom, and one third had a moderate grade of post-thrombotic syndrome. However, there was no clear relation between hemodynamic and morphologic factors and the development of post-thrombotic syndrome in these 31 patients, examined at a mean of 5 years after an acute DVT episode.

[Acute-phase reactants and markers of inflammation in venous thromboembolic disease: correlation with clinical and evolution parameters]. / Reactantes de fase aguda y marcadores de inflamación en pacientes con enfermedad tromboembólica venosa: correlación con parámetros clínicos y evolutivos.

OBJECTIVE: To asses the association of acute reactants and interleukin 6 and 8 (IL-6 & IL-8) at diagnosis of venous thromboembolic disease (VTD) and clinical outcome. METHODS: 100 patients were diagnosed of VTD by image tests. Acute reactants (C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), fibrinogen), D-dimer and IL-6 and IL-8 we measured at the moment of diagnosis. We made a 12 month follow-up of these patients to notice any clinical evolution outcomes (recurrences, bleeding, post-phlebitic syndrome, death). RESULTS: IL-6 was increased in 9 patients and IL-8 in 3. The risk factors, time to diagnosis and pulmonary embolism rate were similar in both interleukin groups (normal and high levels). Fibrinogen levels were significantly increased in high IL-6 group (585 +/- 179 vs. 485 +/- 154 mgr/dl; p = 0.05). During follow-up there were 5 deaths, 3 recurrences, 11 bleedings and 43 postphlebitic syndromes. Normal ESR level was associated to postphlebitic syndrome (17.8 +/- 14.5 vs. 31.4 +/- 27.4 mm/1st h; p = 0.016). Patients who had high levels of IL-6 had worse survival than these with normal levels (p = 0.015). CONCLUSION: IL-6, ESR, and CPR at diagnosis of VTD could be useful to identified patients with higher risks of death and postphlebitic syndrome during the first year after diagnosis.

Reactantes de fase aguda y marcadores de inflamación en pacientes con enfermedad tromboembólica venosa: correlación con parámetros clínicos y evolutivos / Acute reactives and markers of inflammation in venous thromboembolic disease: clinical and evolution outcomes

Objetivo: Determinar si los reactantes de fase aguda, dímero D y las interleucinas 6 y 8 (IL-6 e IL-8) en el momento de diagnóstico de la enfermedad tromboembólica venosa (ETEV) se relacionan con alguna variable clínica y evolutiva relevante. Material y métodos: Se estudiaron 100 pacientes con el diagnóstico de ETEV por pruebas de imagen. Se determinaron reactantes de fase aguda (proteína C reactiva (PCR), velocidad de sedimentación globular (VSG) y fibrinógeno), dímero D así como IL-6 e IL-8 en el momento del diagnóstico. Se recogieron los eventos clínicos más relevantes (recurrencia, hemorragia, síndrome postflebítico y mortalidad) durante un período de seguimiento de 12 meses. Resultados: La IL-6 estaba elevada en 9 pacientes y la IL-8 en 3. Los factores de riesgo, la duración de los síntomas y la forma de presentación como embolismo pulmonar fueron similares entre los dos grupos. Los niveles de fibrinógeno estaban significativamente aumentados (585 ±179 vs. 485 ± 154 mg/dl; p = 0,05) en el grupo de pacientes con IL-6 elevada. En los 12 meses de seguimiento la frecuencia de fallecimientos, recurrencias, hemorragias y síndrome postflebítico fueron 5, 3, 11 y 43, respectivamente. La VSG normal se asoció de forma significativa a la aparición de síndrome postflebítico (17,8 ± 14,5 vs. 31,4 ± 27,4 mm/1ª h;p = 0,016). La supervivencia de los pacientes con cifras elevadas de IL-6 fue significativamente peor que la del resto de los pacientes (p = 0,015). Conclusiones: Niveles elevados de IL-6 y los reactantes de fase aguda (VSG y PCR) en el momento del diagnóstico de la ETEV podrían servirpara identificar a los pacientes con mayor mortalidad y mayor probabilidad de desarrollar un síndrome postflebítico durante el primer año

Objective: To assess the association of acute reactants and interleukin 6 and 8 (IL-6 & IL-8) at diagnosis of venous thromboembolic disease (VTD) and clinical outcome. Methods: 100 patients were diagnosed of VTD by image tests. Acute reactants (C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), fibrinogen), D-dimer and IL-6 and IL-8 we measured at the moment of diagnosis. We made a 12 month follow-up of these patients to notice any clinical evolution outcomes (recurrences, bledding, postphlebitic syndrome, death). Results: IL-6 was increased in 9 patients and IL-8 in 3. The risk factors, time to diagnosis and pulmonary embolism rate were similar in both interleukin groups (normal and high levels). Fibrinogen levels were significantly increased in high IL-6 group (585 ± 179 vs. 485 ± 154 mgr/dl; p=0.05). During follow-up there were 5 deaths, 3 recurrences, 11 bleedings and 43 postphlebitic syndromes. Normal ESR level was associated to postphlebitic syndrome (17.8 ± 14.5 vs. 31.4 ± 27.4 mm/1st ;;h; p=0.016). Patients who had high levels of IL-6 had worse survival than these with normal levels (p = 0.015). Conclusion: IL-6, ESR, and CPR at diagnosis of VTD could be useful to identified patients with higher risks of death and postphlebitic syndrome during the first year after diagnosis

Post-thrombotic syndrome is uncommon in childhood cancer survivors.

Deep vein thrombosis occurs in up to 50% of children with tunneled central venous catheters (CVCs). CVC-related deep vein thrombosis involving the upper extremity is usually asymptomatic but can result in post-thrombotic syndrome (swelling, pain, skin changes, and functional impairment). In a cohort of childhood cancer survivors evaluated clinically a mean of 7.5 +/- 2.8 years after completion of therapy who previously had CVCs in place for a median 15.5 months, none of 50 patients (95% CI = 0% to 6%) had these features diagnostic of post-thrombotic syndrome. Five patients had arm circumference 3% to 5% greater ipsilateral to the prior CVC.

The post-thrombotic syndrome after upper extremity deep venous thrombosis in adults: a systematic review.

BACKGROUND: Post-thrombotic syndrome is a chronic, potentially debilitating complication of deep vein thrombosis (DVT) of the lower extremity. Comparatively little is known about post-thrombotic syndrome after upper extremity DVT (UEDVT). OBJECTIVE: To perform a systematic review of clinical studies that have examined the incidence, clinical features, risk factors and management of post-thrombotic syndrome after UEDVT. METHODS: Using combinations of keywords venous thrombosis, postphlebitic syndrome, thrombophlebitis, arm swelling, post-thrombotic syndrome, UEDVT, Paget-Schroetter syndrome, thoracic outlet syndrome, axillary vein, subclavian vein, and central venous catheter, the MEDLINE database was searched for English language articles published between January 1967 and December 2004. Retrieval and review of articles were restricted to clinical studies in humans that described long-term outcomes after objectively confirmed UEDVT. RESULTS: Seven studies were reviewed. The frequency of PTS after UEDVT ranges from 7-46% (weighted mean 15%). Residual thrombosis and axillosubclavian vein thrombosis appear to be associated with an increased risk of PTS, whereas catheter-associated UEDVT may be associated with a decreased risk. There is currently no validated, standardized scale to assess upper extremity PTS, and little consensus regarding the optimal management of this condition. Quality of life is impaired in patients with upper extremity PTS, especially after DVT of the dominant arm. CONCLUSIONS: PTS is a frequent complication of UEDVT, yet little is known regarding risk factors and optimal management. A standardized means of diagnosis would help to establish better management protocols. The impact of upper extremity PTS on quality of life should be further quantified.

The post-thrombotic syndrome: risk factors and impact on the course of thrombotic disease.

BACKGROUND: The post-thrombotic syndrome (PTS) is a frequent complication of deep vein thrombosis (DVT). Patients with recurrent ipsilateral DVT have an increased risk of PTS; other risk factors are unknown. OBJECTIVES: To establish risk factors of PTS and its impact on venous thrombotic disease. PATIENTS: We prospectively followed 406 patients after a first symptomatic DVT for a median of 60 months. Patients with recurrent DVT, a natural inhibitor deficiency, the lupus anticoagulant, cancer, long-term anticoagulation, an observation time < 18 months and DVT-recurrence prior PTS-assessment were excluded. Study outcomes were occurrence of PTS and recurrent symptomatic DVT. RESULTS: PTS was assessed after 44 +/- 23 months (mean +/- SD) using a clinical classification score. PTS developed in 176 of 406 patients (43.3%). Severe PTS was rare (1.4%). Proximal DVT was the strongest risk factor of PTS [odds ratio (OR) 2.1, 95% confidence interval (CI) 1.3-3.7]. Male gender (OR 1.6, 95% CI 1.0-2.8) and elevated D-dimer levels (OR 1.9, 95% CI 1.0-3.9) were weaker risk factors. Factor V Leiden, factor II G20210A or high factor VIII did not confer an increased risk of PTS. At 4 years, the cumulative probability of recurrence was 7.4% (95% CI 3.2-11.7) among patients with PTS when compared with 1.6% (95% CI 0-3.5; P < 0.02) among patients without PTS. The risk of recurrence was 2.6-fold (95% CI 1.2-5.9) increased when PTS was present. CONCLUSIONS: Proximal DVT, male gender, and high D-dimer levels are independently associated with the development of PTS in patients with a first DVT. Patients with PTS have an increased risk of recurrent venous thromboembolism.

The post-thrombotic syndrome: incidence and prognostic value of non-invasive venous examinations in a six-year follow-up study.

The ability to predict severity of the post-thrombotic syndrome (PTS) early after acute deep-vein thrombosis (DVT) is limited. The aim of our study was to examine the incidence of PTS prospectively and to evaluate the predictive value of non-invasive venous examinations shortly after DVT for the development of PTS. In 93 patients with DVT thrombosis score (TS), reflux, venous outflow resistance (VOR) and calf muscle pump dysfunction (CMP) were examined prospectively. After one, two and six years patients were evaluated for PTS using the clinical scale of the CEAP-classification (PTS present > or = 3 on a scale from 0 to 6). Area under the curves (AUC) were used to evaluate the predictive value of the non-invasive examinations at one and three months after diagnosis of DVT for future PTS. The cumulative incidence of PTS increased from 49% (32/65) after one year to 55% (36/65) and 56% (27/48) after two and six years, whereas the incidence of patients with PTS class 4 progressed from 20% after two years to 33% after six years. The prognostic value to predict PTS was highest for the combination of TS, VOR and reflux measured three months after diagnosis and showed an AUC of 0.77 (0.65-0.90) for PTS after one year. In conclusion, the incidence of PTS after DVT did not increase significantly after one year, whereas during longer follow-up the severity of PTS rose in patients with PTS. Moreover, measurement of TS, VOR and reflux three months after DVT could predict, with reasonable accuracy, the risk of PTS after one year of follow-up.

Post-thrombotic syndrome after total hip or knee arthroplasty: incidence in patients with asymptomatic deep venous thrombosis.

PURPOSE: To measure the risk of developing signs of post-thrombotic syndrome 15 to 24 months after total hip or knee arthroplasty in patients with asymptomatic deep venous thrombosis (DVT). METHODS: A total of 85 total knee arthroplasty patients and 47 total hip arthroplasty patients were postoperatively screened for asymptomatic DVT using colour duplex ultrasound. RESULTS: The rate of asymptomatic DVT was 37.6% (n = 32) in knee patients and 34.0% (n = 16) in hip patients. All 32 DVT cases in the knee group had thrombi located below the knee, whereas 6 of the 16 DVT cases in the hip group had thrombi located above the knee, the remaining 10 were below the knee. Patients with proximal thrombi were treated with warfarin for 3 months, whereas patients with distal DVT received 300 mg aspirin daily for the same period. All DVT cases were monitored for up to 12 weeks using repeated colour duplex scans. Signs of thrombus resolution were present at around 6 weeks (range, 4-12 weeks). Clot propagation was observed in 3 cases. In a mean of postoperative 18 months (range, 15-24 months), 28 of the 32 knee patients with asymptomatic DVT were available for follow-up: 11 had transient calf and ankle swelling, 6 had persistent oedema, and the remaining 11 were symptom free. 14 of the 16 hip patients with asymptomatic DVT were available for follow-up: 6 had transient calf and ankle swelling, 4 had persistent oedema, and 4 remained symptom free. 17 patients reported ongoing problems and were re-examined. Signs of mild-to-moderate post-thrombotic syndrome were recorded in 4 knee patients and 3 hip patients. CONCLUSIONS: Patients with above-knee DVT were much more likely to have post-thrombotic syndrome. Despite thromboprophylaxis with low-molecular-weight heparin, asymptomatic DVT is common after total joint arthroplasty and is responsible for the development of post-thrombotic venous insufficiency and post-thrombotic syndrome in a considerable proportion of patients. Once symptomatic or asymptomatic DVT is established, treatment appears incapable of preventing the occurrence of post-thrombotic syndrome, especially in cases of above-knee DVT. Efforts should hence concentrate on combating DVT propagation and improving DVT prevention.

Patterns of venous insufficiency after an acute deep vein thrombosis.

BACKGROUND: The purpose of this study was to investigate patterns of venous insufficiency during a 12-month period after an acute deep vein thrombosis. STUDY DESIGN: Seventy limbs in 67 patients with an acute deep vein thrombosis (DVT) involving 147 anatomic segments were evaluated with duplex scanning at 1 month, 3 months, 6 months, and 1 year. Venous segments were examined whether they were occluded, partially recanalized, or totally recanalized, and the development of venous reflux was evaluated. RESULTS: The segments investigated were the common femoral vein (38 segments), femoral vein (33 segments), popliteal vein (36 segments), and calf veins (40 segments). There were 35 limbs with isolated DVT and the remaining 35 had multisegment DVT. At 1 year, thrombi had fully resolved in 76% of the segments, 20% remained partially recanalized, and 5% were occluded. The venous occlusion was most predominant in the femoral vein (21%) at 1 year. On the contrary, rapid recanalization was obtained in calf veins than in proximal veins at each examination (p < 0.01). Deep vein insufficiency was detected as early as 1 month after development of DVT, and the reflux was most predominant in popliteal veins (56%), followed by femoral veins (18%). No reflux was found in calf veins. Multisegment DVTs had a significantly higher incidence of deep vein insufficiency than single segment DVTs at 1 year. Development of superficial venous insufficiency was found in 5 limbs (7%) and perforating vein insufficiency in 5 (7%). CONCLUSIONS: Lower extremity venous segments showed different proportions of occlusion, partial recanalization, and total recanalization. Calf veins showed more rapid recanalization than proximal veins. Venous reflux was noted as early as 1 month. The limbs involving multisegment DVTs on initial examination had a higher incidence of deep vein insufficiency and could require much longer followup studies.

[Prospective study of the risk factors for the development of post-thrombotic syndrome after proximal deep venous thrombosis]. / Estudio prospectivo de los factores de riesgo de desarrollo de síndrome postrombótico tras una trombosis venosa profunda proximal.

BACKGROUND AND OBJECTIVE: The incidence and risk factors for the development of post-thrombotic syndrome (PTS) are not well known, so the aim of our study is to evaluate the development of PTS after proximal deep vein thrombosis (DVT) and its relationship with several clinical, laboratory and therapeutic factors. PATIENTS AND METHOD: Prospective, observational study. INCLUSION CRITERIA: consecutive patients with acute symptomatic proximal DVT in the lower extremities diagnosed between February 2000 and July 2002. EXCLUSION CRITERIA: life expectancy < 12 months, impossibility for follow-up, renal or hepatic failure, previous PTS or varicosis and recurrent thrombosis during follow up. Endpoint: PTS at 12 months. Explicative variables: clinical risk factors for DVT, D-dimer value, hypercoaguable state, anticoagulant therapy and compression stockings compliance. Multivariable analysis (logistic regression) was performed. RESULTS: One hundred and seventy two patients with DVT were evaluated for inclusion. Sixty nine were excluded and 87 patients completed follow-up. PTS appeared in 47 patients (54%). Compliance of compression stockings was adequate in 57% of patients and decreased 45% the risk for PTS (p = 0.01). No significant associations were observed between PTS and others variables. Multivariable analysis confirmed the protective effect of compression stockings (RR = 0.3; p < 0.01) and previous ipsilateral DVT appeared significatively associated with PTS development (RR = 8; p = 0.01) CONCLUSIONS: About 50% of patients with proximal DVT develop PTS within 1 year. Previous ipsilateral DVT is the strongest risk factor for PTS. Regular compression stocking use decreases the risk of PTS by 50%.

Asymptomatic postoperative deep vein thrombosis and the development of postthrombotic syndrome. A systematic review and meta-analysis.

Perioperative antithrombotic clinical regimens have reduced the incidence of postoperative deep venous thrombosis (DVT). Long-term effects of asymptomatic postoperative DVT have been studied in a number of clinical trials and the present review describes the clinical significance of asymptomatic postoperative DVT regarding the possible development of postthrombotic syndrome (PTS). We performed a systematic review of reference databases focusing upon studies including patients suspected of having postoperative DVT and reporting subsequent cases of PTS at the end of a well-defined follow-up period. The included studies were stratified according to type of screening method and applied statistics. Over-all evaluation included meta-analyses based upon the Cochrane software package. The overall relative risk of developing PTS was 1.58 (95% confidence intervals: 1.24-2.02) in patients suffering from asymptomatic DVT as compared to patients without DVT (p<0.0005). In conclusion, asymptomatic postoperative DVT is associated with an increased risk of late development of PTS. The finding emphasizes that postoperative DVT, diagnosed by means of well-defined objective measures, remains the correct scientific endpoint in trials evaluating the efficacy of preoperative antithrombotic treatment regimens.

Incidence of post-thrombotic syndrome in patients with previous pulmonary embolism. A retrospective cohort study.

There is little information available about the true incidence of post-thrombotic syndrome (PTS) after pulmonary embolism (PE). The aim of this study was to investigate the incidence of PTS in patients with previous pulmonary embolism without concomitant ultrasonographically-detectable deep vein thrombosis (DVT). A retrospective cohort study was conducted at a single tertiary care centre, Cosenza, Italy. Forty-seven consecutive patients with proved PE without DVT within the previous 2 to 6 years, 45 patients with previous DVT in the same years, and 45 patients with diseases unrelated to venous thromboembolism (VTE) underwent a blind assessment for PTS using a clinical score. Two of 47 (4.2%, 95%CI: 0.01-9.9) patients with PE, 2 of 45 (4.4%, 95%CI: 0.01-10.4) patients with diseases unrelated to VTE, and 23 of 45 (53.3%, 95%CI: 38.7-67.9) patients with DVT showed signs and symptoms of PTS. The difference between the first two groups was not statistically significant (p = 0.7). In conclusion, the incidence of PTS after pulmonary embolism without DVT is low, and no different from that of patients without previous VTE.

Incidence of post-thrombotic syndrome and its association with various risk factors in a cohort of Spanish patients after one year of follow-up following acute deep venous thrombosis.

Post-thrombotic syndrome (PTS) is a frequent complication of deep venous thrombosis (DVT). However, neither the incidence nor the moment of PTS appearance are known. The main reason are the criteria used to define PTS, the characteristics of the patients, the study design and the time of follow-up. Our aims were to estimate the early incidence of PTS and its associated factors in a cohort of carefully defined DVT patients. 135 patients with a previous episode of acute idiopathic, phlebographically confirmed DVT, in the lower limbs, were followed up over 12 months. Phlebography was then repeated to determine the appearance of PTS. In addition, we used a validated clinical scale in order to assess the correlation between the clinical and phlebographical diagnosis of the PTS. This scale was applied at 6 and 12 months. The incidence of phlebographically confirmed PTS within the first year was 56.3% for the isolated PTS and 5.9% for PTS plus recurrent DVT, regardless of age, sex, platelet count, INR, or anticoagulation. None of these patients could be diagnosed as having PTS using the clinical validated scale. However, those patients with phlebographically diagnosed PTS had a higher clinical score than those without (P=0.012). The only factor related to a higher risk of developing a PTS was the localization of the DVT, subjects with both proximal and distal DVT having the highest incidence (P=0.001). In conclusion, although patients had appropriate anticoagulation, early incidence of PTS was very high, thus making it necessary to develop better diagnostic methods in order to evaluate the PTS impact.