Management of the Postthrombotic Syndrome: The Rotterdam Approach

ABSTRACT

The postthrombotic syndrome (PTS) affects the deep venous system, and may also extend to the superficial venous system of the legs in patients with a documented history of deep vein thrombosis. Clinical symptoms of PTS may vary considerably and range from scarcely visible skin changes to changes in pigmentation, pain, discomfort, venous ectasia, edema, and ulceration. Our view based on standard investigations and the proper place of advanced investigations regarding the etiology and pathophysiology of PTS has lead to the Rotterdam approach, incorporating the evidence-based diagnostics and treatments available for PTS. High-quality duplex sonography is mandatory in all patients, providing anatomical and functional (reflux) information on both the deep and superficial venous systems, and non- or partially recanalized veins (occlusion) can also be detected using this technique. If the results of duplex sonography are not clear or a venous desobstruction procedure is to take place, phlebography will be the investigation of choice. There is a lot of evidence that medical elastic stockings (MECS) are effective in the prevention of PTS with documented reflux, obstruction, or both. When prescribing MECS, it is important to examine both elasticity and hysteresis of the fabric of the stockings to apply the correct dynamic pressure for each individual patient. Patients with documented PTS should receive life-long follow-up.

KEYWORDS

Postthrombotic syndrome - deep vein thrombosis - duplex sonography - phlebography - elastic stockings - Rotterdam model

REFERENCES

• 1 Van den Oever R, Hepp B, Debbaut B, Simon I. Socio-economic impact of chronic venous insufficiency. An underestimated public health problem.  Int Angiol. 1998;  17 161-167
• 2 Widmer L K, Plechl S C, Leu H J et al.. Venenerkrankungen bei 1800 Berufstätigen. Basel Studie II.  Schweiz Med Wochenschr. 1967;  97 107-110
• 3 Porter J M, Moneta G L. Reporting standards in venous disease: an update. International Consensus Committee on Chronic Venous Disease.  J Vasc Surg. 1995;  21 635-645
• 4 Eklof B, Rutherford R B, Bergan J et al.. Revision of the CEAP classification for chronic venous disorders: consensus statement.  J Vasc Surg. 2004;  40 1248-1252
• 5 Rutherford R B, Padberg Jr F T, Comerota A J, Kistner R L, Meissner M H, Moneta G L. Venous severity scoring: an adjunct to venous outcome assessment.  J Vasc Surg. 2000;  31 1307-1312
• 6 Prandoni P, Lensing A W, Cogo A et al.. The long-term clinical course of acute deep venous thrombosis.  Ann Intern Med. 1996;  125 1-7
• 7 Brandjes D P, Büller H R, Heijboer H et al.. Randomised trial of effect of compression stockings in patients with symptomatic proximal-vein thrombosis.  Lancet. 1997;  349 759-762
• 8 Kolbach D N, Neumann H A, Prins M H. Definition of the post-thrombotic syndrome, differences between existing classifications.  Eur J Vasc Endovasc Surg. 2005;  30 404-414
• 9 Nordstrøm M, Lindblad B, Bergqvist D, Kjellstrom T. A prospective study of the incidence of deep-vein thrombosis within a defined urban population.  J Intern Med. 1992;  232 155-160
• 10 Prandoni P, Villalta S, Bagatella P et al.. The clinical course of deep-vein thrombosis. Prospective long-term follow-up of 528 symptomatic patients.  Haematologica. 1997;  82 423-428
• 11 Charpy J, Audier M. Les troubles Trophiques des Membres Inférieurs d'Origine Veneuse. Paris; Masson et Cie 1956
• 12 Haenen J H, Wollersheim H, Janssen MCH et al.. Evolution of deep venous thrombosis: a 2-year follow-up using duplex ultrasound scan and strain-gauge plethysmography.  J Vasc Surg. 2001;  34 649-655
• 13 Bollinger A, Jäger K, Geser A, Spier F, Seglias J. Transcapillary and interstitial diffusion of Na-fluorescein in chronic venous insufficiency with atrophy.  Int J Microcirc Clin Exp. 1982;  1 5-17
• 14 Burnand K G, Whimster I, Naidoo A, Browse N L. Pericapillary fibrin in the ulcer-bearing skin of the leg: the cause of lipodermatosclerosis and venous ulceration.  BMJ. 1982;  285 1071-1077
• 15 Neumann HAM, van den Broek MJTB, Boersma I H, Veraart JCJM. Transcutaneous oxygen tension in patients with and without pericapillary fibrin cuffs in chronic venous insufficiency, porphyria cutanea tarda and non-venous leg ulcers.  VASA. 1996;  25 127-133
• 16 Coleridge Smith P D, Thomas P, Scurr J H, Dormandy J A. Causes of venous ulceration: a new hypothesis.  BMJ. 1988;  296 1726-1727
• 17 Edwards A T, Herrick S E, Suarez-Mendez V J, McCollum C N. Oxidants, antioxidants and venous ulceration.  Br J Surg. 1992;  79 443-444
• 18 Falanga V, Eaglestein W H. The “trap” hypothesis of venous ulceration.  Lancet. 1993;  341 1006-1008
• 19 Blaauw GHM, Neumann HAM, Berretty PJM. La lipodermatosclérose et l'épaisseur dermale.  Phlebologie. 1993;  46 25-31
• 20 Neumann HAM. Measurement of microcirculation. In: Altmeyer P, El-Gammal S, Hoffmann K Wound Healing and Skin Physiology. Berlin; Springer 1995: 115-126
• 21 Veraart JCM, Neumann HAM. Morphological and functional skin changes in chronic venous insufficiency.  Scripta Phlebologica. 1995;  3 25-29
• 22 Nicolaides A N. Investigation of chronic venous insufficiency: a consensus statement (France, March 5-9, 1997).  Circulation. 2000;  102 E126-E163
• 23 Neumann HAM, Maessen-Visch M B. Plethysmography. Management of leg ulcers.  Curr Probl Dermatol. 1999;  27 114-123
• 24 Partsch H. Venous pressure measurement in phlebology.  Hautarzt. 1981;  32 53-58
• 25 Neumann HAM. Compression therapy with medical elastic stockings for venous disease.  Dermatol Surg. 1998;  24 765-770
• 26 Fischer H. Action of the compression on veins.  Phlebologie. 1979;  32 171-178
• 27 Stolk R, Wegen van der-Franken C P, Neumann H A. A method for measuring the dynamic behavior of medical compression hosiery during walking.  Dermatol Surg. 2004;  30 729-736
• 28 De Vleeschauwer P, Horsch S, Erasmi H, Pichlmaier H. Venous thrombectomy.  Acta Chir Belg. 1984;  84 31-37
• 29 Tawes R L, Barron M L, Coello A A, Joyce D H, Kolvenbach R. Optimal therapy for advanced chronic venous insufficiency.  J Vasc Surg. 2003;  37 545-551
• 30 Dutch Society for Dermatology and Venereology .Richtlijn Diagnostiek en behandeling van het ulcus cruris venosum [in Dutch]. Utrecht, The Netherlands; Dutch Society for Dermatology and Venereology 2005
• 31 Schmeller W, Roszinski S. Shave therapy for surgical treatment of persistent venous ulcer with large superficial dermatoliposclerosis.  Hautarzt. 1996;  47 676-681
• 32 European Committee for Standardization .ENV 12718: Adopted European Prestandard for Medical Compression Hosiery. Brussels, Belgium; European Committee for Standardization 2001
• 33 Prandoni P, Lensing AWA, Prins M H et al.. Below-knee elastic compression stockings to prevent the post-thrombotic syndrome. A randomized controlled trial.  Ann Intern Med. 2004;  141 249-256
• 34 Junger M, Steins A, Zuder D, Klyscz T. Physical therapy of venous disease.  Vasa. 1998;  27 73-79
• 35 Palma E C, Esperon R. Vein transplants and grafts in the surgical treatment of the postphlebitic syndrome.  J Cardiovasc Surg (Torino). 1960;  1 94-107