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Post-thrombotic syndrome

Key sources
The following summarized guidelines for the evaluation and management of post-thrombotic syndrome are prepared by our editorial team based on guidelines from the European Society for Vascular Surgery (ESVS 2022; 2021), the American College of Chest Physicians (ACCP 2021), the Interdisciplinary Expert Panel on Iliofemoral Deep Vein Thrombosis (InterEPID 2015), the American Heart Association (AHA 2014), the Society for Vascular Surgery (SVS 2014), and the American Academy of Family Physicians (AAFP 2013).
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Guidelines

1.Classification and risk stratification

Severity assessment: consider using the r-VCSS and the Villalta scale for PTS for the assessment of clinical severity and treatment success in patients with chronic venous disease.
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2.Medical management

Vasoactive agents: insufficient evidence to support the use of rutosides, hidrosmin, or defibrotide for the treatment of patients with PTS.
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3.Nonpharmacologic interventions

Compression stockings: as per ESVS 2022 guidelines, consider offering below knee elastic compression stockings exerting a pressure of 20-40 mmHg at the ankle to reduce the severity of symptoms in patients with PTS.
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  • Physical therapy

4.Therapeutic procedures

Intermittent pneumatic compression: as per ESVS 2022 guidelines, consider offering adjuvant intermittent pneumatic compression to reduce the severity of symptoms in patients with PTS.
C

5.Surgical interventions

Indications for surgery: as per ESVS 2022 guidelines, consider performing surgical or hybrid deep venous reconstruction in patients with iliac vein outflow obstruction and severe PTS, if endovascular options alone are not appropriate.
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6.Specific circumstances

Patients with venous leg ulcers: offer compression therapy in preference to primary dressing alone or non-compression bandage for the treatment of venous ulcers in patients with PTS.
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  • Patients with iliofemoral DVT

7.Preventative measures

Primary prevention, compression stockings, ACCP: avoid using compression stockings routinely to prevent PTS in patients with acute DVT of the leg.
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  • Primary prevention (thromboprophylaxis)

  • Primary prevention (catheter-directed thrombolysis)

  • Primary prevention (systemic thrombolysis)

  • Primary prevention (surgical thrombectomy)