Background
International guidelines recommend using the Villalta score (VS) to diagnose the postthrombotic syndrome (PTS). However, a high proportion of PTS detected with VS could just reflect the ...presence of preexisting primary venous insufficiency (PVI). Furthermore, it is unclear whether the contralateral VS (cl‐VS) can be used to assess for preexisting PVI.
Objectives
To estimate whether cl‐VS can be used to assess for preexisting PVI, and to assess the proportion of PTS that could be attributable to preexisting PVI.
Methods
Subanalysis of the SOX multicenter randomized trial focusing on patients with a first unilateral proximal deep vein thrombosis (DVT) followed for up to 2 years. PVI was defined as a baseline cl‐VS > 4, and PTS as VS > 4 in the leg ipsilateral to DVT starting 6 months after DVT.
Results
Among 680 patients, mean cl‐VS remained stable over time: 1.23 (standard deviation SD ±2.49) at baseline and 1.17 (±2.20), 1.59 (±2.81), 1.54 (±2.50), 1.65 (±2.82), and 1.55 (±2.63) at the 1‐, 6‐, 12‐, 18‐, and 24‐month visits, respectively. Baseline cl‐VS and ipsilateral VS measured during follow‐up were mildly correlated (Pearson correlation = 0.13‐0.25). This association disappeared after subtracting the cl‐VS measured at the same visit from the ipsilateral VS. Overall, 48.8% of patients developed PTS of whom 12.8% had baseline cl‐VS > 4.
Conclusion
In our study of patients with a first unilateral proximal DVT, the proportion of patients with PTS who had a cl‐VS > 4 is modest. However, cl‐VS appears to be stable over time. Its assessment could constitute a simple way of documenting preexisting PVI and help to classify patients as having PTS.
Epidemiology of the post-thrombotic syndrome Galanaud, Jean-Philippe; Monreal, Manuel; Kahn, Susan R.
Thrombosis research,
April 2018, 2018-04-00, 20180401, 2018-04, Volume:
164
Journal Article
Peer reviewed
The post thrombotic syndrome (PTS) refers to clinical manifestations of chronic venous insufficiency (CVI) following a deep-vein thrombosis (DVT). PTS is the most frequent complication of DVT, which ...develops in 20 to 50% of cases after proximal DVT and is severe in 5–10% of cases. The reported prevalence of PTS differs widely among studies because of differences in study populations, tools used to assess PTS, and time interval between acute DVT and PTS assessment. The two most important predictors of PTS are extensive proximal character of DVT and previous ipsilateral DVT. Other reported risk factors include pre-existing CVI, obesity, quality of anticoagulant treatment, older age and residual venous obstruction. Standardization of PTS assessment tools combined with the development of patient self-reported PTS scales are likely to constitute a breakthrough in research of the epidemiology of PTS, by allowing comparison between studies, meta-analyses and increasing the feasibility of longer follow-up of DVT patients. This should enable identification of patient populations at high risk of severe PTS, new predictors of PTS and targets for potential new treatments. In this perspective, identification of biomarkers that are predictive of PTS such as markers of inflammation is crucial in ongoing research.
•Post-thrombotic syndrome is the most frequent complication of DVT.•After a proximal DVT, 20–50% of patients will develop PTS.•Most important PTS predictors are extensive proximal DVT and ipsilateral recurrence.
Objective
We studied the relation between Parkinson disease (PD) and professional exposure to pesticides in a community‐based case‐control study conducted in a population characterized by a high ...prevalence of exposure. Our objective was to investigate the role of specific pesticide families and to perform dose‐effect analyses.
Methods
PD cases (n = 224) from the Mutualité Sociale Agricole (France) were matched to 557 controls free of PD affiliated with the same health insurance. Pesticide exposure was assessed using a 2‐phase procedure, including a case‐by‐case expert evaluation. Analyses of the relation between PD and professional exposure to pesticides were first performed overall and by broad category (insecticides, fungicides, herbicides). Analyses of 29 pesticide families defined based on a chemical classification were restricted to men. Multiple imputation was used to impute missing values of pesticide families. Data were analyzed using conditional logistic regression, both using a complete‐case and an imputed dataset.
Results
We found a positive association between PD and overall professional pesticide use (odds ratio OR = 1.8, 95% confidence interval CI = 1.1–3.1), with a dose‐effect relation for the number of years of use (p = 0.01). In men, insecticides were associated with PD (OR = 2.2, 95% CI = 1.1–4.3), in particular organochlorine insecticides (OR = 2.4, 95% CI = 1.2–5.0). These associations were stronger in men with older onset PD than in those with younger onset PD, and were characterized by a dose‐effect relation in the former group.
Interpretation
Our results support an association between PD and professional pesticide exposure, and show that some pesticides (ie, organochlorine insecticides) may be more particularly involved. Ann Neurol 2009;66:494–504
Background
After a proximal lower limb deep vein thrombosis (DVT; involving popliteal veins or above), up to 40% of patients develop postthrombotic syndrome (PTS) as assessed by the Villalta scale ...(VS). Poor initial anticoagulant treatment is a known risk factor for PTS. The risk of developing PTS after isolated distal DVT (infra‐popliteal DVT without pulmonary embolism), and the impact of anticoagulant treatment on this risk, are uncertain.
Methods
Long‐term follow‐up of CACTUS double‐blind trial comparing 6 weeks of s.c. nadroparin (171 IU/kg/d) versus s.c. placebo for a first symptomatic isolated distal DVT. At least 1 year after randomization, patients had a PTS assessment in clinic or by phone using the VS.
Results
After a median follow‐up of 6 years, PTS was present in 30% (n = 54) of the 178 patients who had a PTS assessment. PTS was moderate or severe in 24% (n = 13) of cases. There was no statistically significant difference in prevalence of PTS in the nadroparin versus placebo groups (29% versus 32%, P = .6), except in patients without evidence of primary chronic venous insufficiency (9% versus 24%, P = .04). Rates of venous thromboembolism recurrence during follow‐up in the nadroparin and placebo groups were, respectively, 8% (n = 7) and 14% (n = 13; P = .2).
Conclusion
After a first isolated distal DVT, the risk of PTS is substantial but much lower than that reported after proximal DVT. Anticoagulation with nadroparin doesn't provide any clear benefit to prevent PTS, except in patients without preexisting chronic venous insufficiency. Anticoagulation might be associated with a lower risk of venous thromboembolism recurrence.
•Data on the use of DOACs after proximal gastrointestinal (GI) surgery are limited.•75 % of post-GI surgery DOAC levels were within the expected range.•Overall rates of thrombosis, and major bleeding ...were low post-GI surgery.
The post-thrombotic syndrome (PTS) is a form of chronic venous insufficiency secondary to prior deep vein thrombosis (DVT). It affects up to 50% of patients after proximal DVT. There is no effective ...treatment of established PTS and its management lies in its prevention after DVT. Optimal anticoagulation is key for PTS prevention. Among anticoagulants, low-molecular-weight heparins have anti-inflammatory properties, and have a particularly attractive profile. Elastic compression stockings (ECS) may be helpful for treating acute DVT symptoms but their benefits for PTS prevention are debated. Catheter-directed techniques reduce acute DVT symptoms and might reduce the risk of moderate-severe PTS in the long term in patients with ilio-femoral DVT at low risk of bleeding. Statins may decrease the risk of PTS, but current evidence is lacking. Treatment of PTS is based on the use of ECS and lifestyle measures such as leg elevation, weight loss and exercise. Venoactive medications may be helpful and research is ongoing. Interventional techniques to treat PTS should be reserved for highly selected patients with chronic iliac obstruction or greater saphenous vein reflux, but have not yet been assessed by robust clinical trials.
Essentials
Management of patients with calf deep vein thrombosis remains controversial.
We conducted a post‐hoc analysis of a placebo controlled LMWH randomized clinical trial.
Pain was assessed ...using visual analogue scale at inclusion, one and six weeks.
There was no difference in pain control between the two arms.
Summary
Background
The optimal management of distal deep vein thrombosis (DVT) is highly debated. The only available placebo‐controlled trial suggested the absence of clear benefit of anticoagulation. Many physicians feel that, beyond preventing thromboembolic complications, anticoagulation with low‐molecular‐weight heparin (LMWH) has the potential to improve pain control.
Objectives
To analyze whether LMWHs decrease pain in patients with distal deep vein thrombosis.
Patients and methods
Two‐hundred and fifty‐two patients included in a multicenter, placebo‐controlled, randomized clinical trial of LMWH in patients with acute distal DVT and who were asked to rate their pain at inclusion and at each medical visit, using a visual analogue pain scale (VAS).
Results
One hundred and thirty patients were randomized in the therapeutic nadroparin arm and 122 patients were randomized in the placebo arm. Mean VAS values were 4.6 (standard deviation SD 2.5) at inclusion, 2.1 (SD 2.0) at 1 week and 0.4 (SD 1.2) at 6 weeks. We calculated the individual variation in VAS between inclusion and 1 week in patients in whom VAS was available at the two study time‐points. There was no difference in the mean VAS reduction between patients treated with therapeutic nadroparin (n = 106) and with placebo (n = 109): −2.6 (SD 2.4) vs. −2.3 (SD 2.0) after 1 week and −4.4 (SD 2.8) vs. −4.0 (SD 2.4) after 6 weeks, respectively. The use of compression stockings was associated with a reduction in pain.
Conclusion
These data suggests that LMWH use does not improve pain control as compared with placebo in patients with acute distal DVT.
The post-thrombotic syndrome (PTS) is a frequent, potentially disabling complication of deep vein thrombosis (DVT) that reduces quality of life and is costly. Clinical manifestations include symptoms ...and signs such as leg pain and heaviness, edema, redness, telangiectasia, new varicose veins, hyperpigmentation, skin thickening and in severe cases, leg ulcers. The best way to prevent PTS is to prevent DVT with pharmacologic or mechanical thromboprophylaxis used in high risk patients and settings. In patients whose DVT is treated with a vitamin K antagonist, subtherapeutic INRs should be avoided. We do not suggest routine use of elastic compression stockings (ECS) after DVT to prevent PTS, but in patients with acute DVT-related leg swelling that is bothersome, a trial of ECS is reasonable. We suggest that selecting patients for catheter-directed thrombolytic techniques be done on a case-by-case basis, with a focus on patients with extensive thrombosis, recent symptoms onset, and low bleeding risk, who are seen at experienced hospital centers. For patients with established PTS, we suggest prescribing 20–30 mm Hg knee-length ECS to be worn daily. If ineffective, a stronger pressure stocking can be tried. We suggest that intermittent compression devices or pneumatic compression sleeve units be tried in patients with moderate-to-severe PTS whose symptoms are inadequately controlled with ECS alone. We suggest that a supervised exercise training program for 6 months or more is reasonable for PTS patients who can tolerate it. We suggest that management of post-thrombotic ulcers should involve a multidisciplinary approach. We briefly discuss upper extremity PTS and PTS in children.
Purpose of review
Management of isolated distal deep vein thrombosis (IDDVT) remains controversial. We summarize recent studies regarding the natural history of IDDVT as well as pertinent therapeutic ...trials. We also provide our management approach.
Recent findings
IDDVT is more commonly associated with transient risk factors and less often associated with permanent, unmodifiable risk factors than proximal DVT. IDDVT has a significantly lower risk of proximal extension and recurrence than proximal DVT. Cancer-associated IDDVT has a similar natural history to cancer-associated proximal DVT, with substantially less favourable outcomes than noncancer-associated IDDVT. Anticoagulant treatment reduces the risk of proximal extension and recurrence in IDDVT at the cost of increased bleeding risk. Intermediate dosing of anticoagulation may be effective for treating noncancer-associated IDDVT in patients without prior DVT.
Summary
IDDVT with a transient risk factor can be treated for 6 weeks in patients without a prior DVT. Unprovoked IDDVT in patients without malignancy can be treated for 3 months. Outpatients without malignancy or a prior DVT can be left untreated and undergo surveillance compression ultrasound in one week to detect proximal extension, but few patients opt for this in practice. Cancer-associated IDDVT should be treated analogously to cancer-associated proximal DVT.
Abstract
The postthrombotic syndrome (PTS) is chronic venous insufficiency secondary to a prior deep vein thrombosis (DVT). It is the most common complication of venous thromboembolism (VTE) and, ...while not fatal, it can lead to chronic, unremitting symptoms as well as societal and economic consequences. The cornerstone of PTS treatment lies in its prevention after DVT. Specific PTS preventative measures include the use of elastic compression stockings and pharmacomechanical catheter-directed thrombolysis. However, the efficacy of these treatments has been questioned by large randomized controlled trials (RCTs). So far, anticoagulation, primarily prescribed to prevent DVT extension and recurrence, appears to be the only unquestionably effective treatment for the prevention of PTS. In this literature review we present pathophysiological, biological, radiological, and clinical data supporting the efficacy of anticoagulants to prevent PTS and the possible differential efficacy among available classes of anticoagulants (vitamin K antagonists VKAs, low molecular weight heparins LMWHs and direct oral anticoagulants DOACs). Data suggest that LMWHs and DOACs are superior to VKAs, but no head-to-head comparison is available between DOACs and LMWHs. Owing to their potentially greater anti-inflammatory properties, LMWHs could be superior to DOACs. This finding may be of interest particularly in patients with extensive DVT at high risk of moderate to severe PTS, but needs to be confirmed by a dedicated RCT.
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