Postthrombotic Syndrome: Causes, Symptoms & Treatment

Postthrombotic syndrome is the result of phlebothrombosis of the deep veins of the arm or leg and corresponds to reflux congestion with defects in the valves of the veins. The cause of PTS is a self-healing attempt by the body to make the veins permeable again after thrombosis. Treatment of PTS focuses on compression and exercise.

What is postthrombotic syndrome?

Thromboses are local intravascular blood clots in the circulatory system. They are usually preceded by changes in the vessel walls, abnormalities in blood flow, or changes in blood composition. Phlebothrombosis are special forms of thrombosis, understood to cause thrombotic occlusion of deep veins and associated with the risk of pulmonary embolism. Deep veins include the deep leg and arm veins. Post-thrombotic syndrome (PTS) summarizes the pathological consequences of permanent damage to the deep vein system of the leg and arm. Following an endogenous inflammatory process, damage to the venous valves often occurs as a result of the occlusion. Chronic reflux congestion is the result. The arms are less frequently affected by PTS than the legs. Postthrombotic syndrome following phlebothrombosis may develop into venous insufficiency. Four stages of PTS are known: Stage I with edema tendency, Stage II with induration, Stage III with sclerotic tissue changes, and Stage IV with extensive ulceration.

Causes

The cause of PTS is phlebothrombosis of the deep veins of the arm or leg. The occlusion is usually permanent in nature and lasts for several days. The body attempts to dissolve the clot in the vein by initiating an inflammatory process on the vein wall. Only rarely does the clot actually dissolve completely. The immunological inflammatory reaction corresponds to a self-healing attempt to make the vital veins permeable again. During inflammation, the venous valves of the affected area are often attacked or destroyed. The venous valves form an essential part of the reflux mechanism. If they are destroyed, the affected veins are no longer completely functional. Post-thrombotic syndrome develops from this condition. Almost half of all patients with thrombosis of the deep arm or leg veins suffer from the phenomenon.

Symptoms, complaints, and signs

Patients with postthrombotic syndrome suffer from a complex of different symptoms. The leading symptom is reflux congestion of the affected vein. On the basis of this phenomenon, the respective extremities experience discomfort, such as a feeling of heaviness or tightness. As a result of the congestion, edema can form over time. In addition, there are often movement restrictions of the affected extremity. Symptoms also appear on the patient’s skin as the syndrome progresses. The most common skin symptoms are trophic disorders associated with thinning of the skin epithelium. Pigmentary changes may also develop. In many cases, wound healing in the affected area is impaired. Thus, wound healing disorders can occur after the smallest injuries, which are often associated with chronic ulceration. Lower leg ulcers, swelling and pain are accompanying symptoms of PTS. The severity of PTS depends on the severity of the causative thrombosis and personal factors such as preexisting conditions, occupation, or gender.

Diagnosis and disease progression

The diagnosis of postthrombotic syndrome is made by duplex ultrasonography or on the basis of radiographic examinations with the administration of contrast medium. Venous occlusions, including bypass circulation, are usually visible without doubt on imaging. In individual cases, thromboses of the veins are not detected for several years. In these cases, postthrombotic syndrome may develop unnoticed and unanticipated before the patient has even learned of any thrombosis that has occurred. For postthrombotic syndrome patients, the prognosis depends on the severity and timing of diagnosis of the initial thrombosis. The earlier the thrombosis and subsequent syndrome are detected, the better the prognosis.

Complications

In this syndrome, affected individuals suffer from various symptoms. As a rule, severe insensitivity or disturbances in sensitivity occur in the extremities.This may make the patient’s daily life more difficult, resulting in significant limitations. In some cases, sufferers are dependent on the help of other people in their lives because of the syndrome. It is also not uncommon for movement restrictions to occur, so that the patient may require a walking aid. Furthermore, most of those affected suffer from a wound healing disorder. Even minor injuries can cause severe bleeding or wounds that do not heal. It is also not uncommon for the joints to become swollen and painful. The syndrome has a very negative effect on the patient’s quality of life and can also lead to psychological complaints or depression. The treatment of this syndrome is usually carried out with the help of medication and compression stockings. Complications do not occur. Various therapies are also necessary to permanently alleviate the symptoms. Life expectancy is not usually reduced or otherwise affected by the syndrome.

When should you see a doctor?

A doctor is needed for sudden or intense disturbances in blood flow. If they persist or increase in intensity, they should be taken as a warning sign from the organism. There is a need for action, because in severe cases acute health-threatening conditions can develop. Restrictions of the movement possibilities, gait unsteadiness, dizziness or an internal weakness are to be presented to a physician. If there are changes in the appearance of the skin, sensations of discomfort on the skin or pain, the affected person needs help. Numbness in the extremities, a tingling sensation on the skin, and perceptual disturbances are considered unusual. They should be presented to a physician as soon as they occur unabated for several days or weeks. Swelling, the formation of ulcers or edema should be clarified by a physician. If there is sensitivity to pressure, changes in the layers of the skin, or a feeling of internal heaviness, a physician should be consulted. Irregularities in natural wound healing, an elevated body temperature, or a general feeling of illness should be investigated and treated. It is characteristic of the disease that even small wounds show a problematic development. If the affected person notices a decrease in physical performance, if rapid fatigue sets in, if a general feeling of malaise develops, or if there is low resilience, medical help should be sought.

Treatment and therapy

For patients with postthrombotic syndrome, the basic principle of compression application is the focus of treatment. Compression can be applied externally by the application of compression bandages with or is initiated with medical compression stockings. The muscle pump must be activated during compression therapy. For this reason, the patient must actively move the affected limb on a regular basis, for example, by means of a bicycle or walking. During the exercise sessions, the affected limb must not be overloaded. Extreme endurance sports should therefore be avoided. In the resting position, the affected extremity is ideally elevated to provide additional relief for the damaged venous system. In individual cases, patients receive diuretic medication. More frequently, anticoagulation with inhibitors such as coumarins is used to prevent recurrent thromboses. The basic principle for the duration of therapy is to walk and lie down rather than stand and sit. In the recent past, it has been shown that consistent compression therapy alone cannot sufficiently counteract the disease. Exercise is thus an inevitable therapy step. In severe cases of PTS, replacement of damaged veins may be necessary. For this purpose, either donor veins are transplanted or vein parts are manufactured by modern technology such as the 3D printer and inserted into the patient.

Prevention

Postthrombotic syndrome can be prevented to the extent that thrombosis of the deep venous systems can be prevented. As long as thrombosis does not occur, postthrombotic syndrome cannot develop. In the context of thrombosis, preventive measures include, for example, a balanced diet with sufficient fluid intake and plenty of exercise. Abstinence from nicotine is also considered a preventive measure. In addition, prolonged sitting or standing is discouraged. == Aftercare

Almost every second patient develops post-thrombotic syndrome after deep vein thrombosis.The complaints can then become so severe that there can be massive impairments in everyday life and the ability to work. A complete cure is hardly possible, which is why aftercare is aimed at improving the circulation situation and reducing existing pain. Consistent and regular aftercare treatment with follow-up examinations is therefore essential. The basic pillars of aftercare are consistent compression therapy with compression stockings (usually lifelong) and maintaining and improving the mobility of the affected patients. This is achieved, among other things, through adapted physiotherapy with improvement and maintenance of muscular activity in the affected areas. This ensures better muscle pumping function. This in turn reduces the congestion symptoms. In particular, the arthrogenic congestion syndrome (stiffening of the ankle) should be prevented. Equally effective and necessary is the prescription of lymphatic drainage to prevent feelings of tension and congestion symptoms. Furthermore, attention should be paid to careful skin care. The skin is more susceptible to injuries and to infectious pathogens, which in the worst case can lead to complications such as sepsis. Therefore, regular medical check-ups should be performed to counteract the development of venous ulcers, as mentioned.

What you can do yourself

In the case of postthrombotic syndrome (PTS), the patient should become active in any case. This is because, especially if the disease is not yet too far advanced, plenty of exercise helps the body to counteract the syndrome’s accompanying symptoms. Regardless of whether the arm or leg veins are affected, sports and exercise such as hiking, cycling, walking, etc. are recommended. However, overloading should be avoided. Overall, the rule for patients is: “It’s better to walk and lie down instead of standing and sitting.” When lying down in particular, however, they should also make sure to consistently elevate the affected extremities. At the same time, the affected areas should be compressed. This is best done with support stockings and/or compression bandages. They usually have to be worn constantly, as ordered by the physician. Since patients often find this uncomfortable, this therapeutic measure requires a high level of compliance. However, a compression stocking or hose not only supports the venous system, but also protects the skin from injury. If postthrombotic syndrome (PTS) is already advanced, patients often suffer from water retention and joint inflammation. The inflammations can be cooled carefully by the patient themselves. If water retention occurs, they should see a physician, who may prescribe diuretics.