Cosmi Benilde, Stanek Agata, Kozak Matja, Wennberg Paul W, Kolluri Raghu, Righini Marc, Poredos Pavel, Lichtenberg Michael, Catalano Mariella, De Marchi Sergio, Farkas Katalin, Gresele Paolo, Klein-Wegel Peter, Lessiani Gianfranco, Marschang Peter, Pecsvarady Zsolt, Prior Manlio, Puskas Attila, Szuba Andrzej
Division of Angiology and Blood Coagulation, Department of Specialty, Diagnostic and Experimental Medicine, S. Orsola Malpighi University Hospital Research Institute IRCSS, University of Bologna, Bologna, Italy.
Inter-University Research Center on Vascular Diseases & Angiology Unit, University of Milan, L Sacco Hospital, VAS-European Independent Foundation in Angiology/Vascular Medicine, Milan, Italy.
Front Cardiovasc Med. 2022 Feb 24;9:762443. doi: 10.3389/fcvm.2022.762443. eCollection 2022.
The post-thrombotic syndrome (PTS) is the most common long-term complication of deep vein thrombosis (DVT), occurring in up to 40-50% of cases. There are limited evidence-based approaches for PTS clinical management.
To provide an expert consensus for PTS diagnosis, prevention, and treatment.
EVIDENCE-REVIEW: MEDLINE, Cochrane Database review, and GOOGLE SCHOLAR were searched with the terms "post-thrombotic syndrome" and "post-phlebitic syndrome" used in titles and abstracts up to September 2020.
English, Controlled Clinical Trial / Systematic Review / Meta-Analysis / Guideline. The relevant literature regarding PTS diagnosis, prevention and treatment was reviewed and summarized by the evidence synthesis team. On the basis of this review, a panel of 15 practicing angiology/vascular medicine specialists assessed the appropriateness of several items regarding PTS management on a Likert-9 point scale, according to the RAND/UCLA method, with a two-round modified Delphi method.
The panelists rated the following as appropriate for diagnosis: 1-the Villalta scale; 2- pre-existing venous insufficiency evaluation; 3-assessment 3-6 months after diagnosis of iliofemoral or femoro-popliteal DVT, and afterwards periodically, according to a personalized schedule depending on the presence or absence of clinically relevant PTS. The items rated as appropriate for symptom relief and prevention were: 1- graduated compression stockings (GCS) or elastic bandages for symptomatic relief in acute DVT, either iliofemoral, popliteal or calf; 2-thigh-length GCS (30-40 mmHg at the ankle) after ilio-femoral DVT; 3- knee-length GCS (30-40 mmHg at the ankle) after popliteal DVT; 4-GCS for different length of times according to the severity of periodically assessed PTS; 5-catheter-directed thrombolysis, with or without mechanical thrombectomy, in patients with iliofemoral obstruction, severe symptoms, and low risk of bleeding. The items rated as appropriate for treatment were: 1- thigh-length GCS (30-40 mmHg at the ankle) after iliofemoral DVT; 2-compression therapy for ulcer treatment; 3- exercise training. The role of endovascular treatment (angioplasty and/or stenting) was rated as uncertain, but it could be considered for severe PTS only in case of stenosis or occlusion above the inguinal ligament, followed by oral anticoagulation.
This position paper can help practicing clinicians in PTS management.
血栓形成后综合征（PTS）是深静脉血栓形成（DVT）最常见的长期并发症，发生率高达40%-50%。PTS临床管理的循证方法有限。
为PTS的诊断、预防和治疗提供专家共识。
检索了MEDLINE、Cochrane数据库综述和谷歌学术，检索词为截至2020年9月标题和摘要中使用的“血栓形成后综合征”和“血栓性静脉炎后综合征”。
英文、对照临床试验/系统评价/荟萃分析/指南。证据综合团队对有关PTS诊断、预防和治疗的相关文献进行了综述和总结。在此综述的基础上，一个由15名血管病/血管医学执业专家组成的小组根据RAND/UCLA方法，采用两轮改良德尔菲法，以9分李克特量表评估了若干PTS管理项目的适宜性。
专家小组成员将以下项目评定为适宜诊断项目：1-Villalta量表；2-既往静脉功能不全评估；3-在诊断髂股或股腘静脉DVT后3-6个月进行评估，之后根据是否存在临床相关PTS的个性化时间表定期评估。评定为适宜缓解症状和预防的项目有：1-分级压力弹力袜（GCS）或弹力绷带用于缓解急性DVT（髂股、腘或小腿）的症状；2-髂股静脉DVT后使用大腿长度的GCS（脚踝处压力为30-40 mmHg）；3-腘静脉DVT后使用膝盖长度的GCS（脚踝处压力为30-40 mmHg）；4-根据定期评估的PTS严重程度使用不同时长的GCS；5-对髂股静脉阻塞、症状严重且出血风险低的患者进行导管定向溶栓，可联合或不联合机械性血栓清除术。评定为适宜治疗的项目有：1-髂股静脉DVT后使用大腿长度的GCS（脚踝处压力为30-40 mmHg）；2-用于溃疡治疗的加压治疗；3-运动训练。血管内治疗（血管成形术和/或支架置入术）作用的评定为不确定，但仅在腹股沟韧带上方存在狭窄或闭塞且伴有口服抗凝治疗的严重PTS病例中可考虑使用。
本立场文件有助于临床执业医师进行PTS管理。
