Letters to the Editor
Thromb Haemost 1999; 82: 1358
Which Is the Outcome of the Post-thrombotic Syndrome?
Dear Sir,
One of every three patients with deep-vein thrombosis (DVT) of the
lower extremities will develop within 5 years post-thrombotic sequelae
(1, 2). They vary from minor signs up to severe debilitant manifesta-
tions. Although the post-thrombotic syndrome (PTS) is generally con-
sidered to be associated with long lasting invalidation (3, 4), little is
known about its clinical course.
Between 1985 and 1991, 355 consecutive patients with a first epi-
sode of venography proven symptomatic DVT were administered an in-
itial treatment with unfractionated or low-molecular-weight heparin
followed by at least three months of oral anticoagulation. They were
discharged on warfarin treatment (targeted INR = 2.0-3.0), and were in-
structed to wear elastic compression stockings (40 mmHg at the ankle)
for at least two years. They were seen at three and six months after hos-
pital discharge and thereafter returned to the study centre every six
months for follow-up assessments (1). At any follow-up visit the pres-
ence and severity of leg symptoms (heaviness, cramps, pruritus, pares-
thesia, pain) and signs (induration of the skin, oedema, hyperpigmenta-
tion, redness, pain during calf compression, new venous ectasia) was
recorded. Each item received a score ranging from 0 to 3. The presence
of a venous ulcer of the lower limb was recorded. Patients were regard-
ed to have a severe PTS in case of skin ulceration and/or a score ≥15 on
two consecutive visits. Patients scoring from 5 to 14 on two consecutive
visits were defined as having a mild PTS (1). This score has been shown
to correlate well with patient’s perception of quality of life (5).
According to the above mentioned score, 84 patients developed a
PTS (initially severe in 13 and mild in the remaining 71), accounting
for a cumulative incidence of 28.0% after five years (1). Five patients
died soon after developing the PTS, thus 79 patients (43 males; mean
age 65 years) were available for further evaluation, of whom 13 with
severe and 66 with mild PTS. They were regularly seen at the study
centre for a period ranging from 2 up to 10 years (median, 6.5 years in
both groups of patients). Patients with a venous ulcer were treated con-
servatively (bedrest with leg elevation and daily dressing).
Of the 13 patients with severe PTS, manifestations recovered in 7,
evolved into a mild form in 5, and remained unchanged over years in 1.
Correspondence to: P. Prandoni, Dept. of Medical and Surgical Sciences,
Via Ospedale Civile 105, 35128 Padua, Italy – Tel.: +39 0498212656; FAX
Number: +39 049638004
1358
© 1999 Schattauer Verlag, Stuttgart
Of the 66 patients who referred with mild PTS, symptoms recovered in
35, remained unchanged over years in 19, and evolved into a severe
form in 12. Of the latter patients, 7 remained stable over years, 4 revert-
ed to a mild PTS, and 1 recovered. Thus, the rate of clinical improve-
ment in the 13 patients who referred with a severe PTS (92%) was sig-
nificantly higher than that of the 12 patients who developed a severe
PTS through a phase of mild manifestations (42%; p = 0.01 by Fisher
exact test).
The results of our observations challenge the common view that the
PTS is a chronic and essentially incurable problem. More than half of
patients with post-thrombotic sequelae undergo a stable improvement.
Patients with severe PTS are as likely to recover as are those with less
severe manifestations. Clinical presentation helps predict the prognosis,
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being the outcome of patients who refer with initially severe manifesta-
tions more favourable than that of patients whose symptoms progres-
sively deteriorate over time.
Paolo Prandoni 1, Anthonie W. A. Lensing2, Martin H. Prins 3, Paola
Bagatella1, Alberta Scudeller1, Antonio Girolami1
From the 1Department of Medical and Surgical Sciences, 2nd Chair of
Internal Medicine, University of Padua Medical School, Padua, Italy;
the 2 Centre for Vascular Medicine and the 3 Department of Clinical
Epidemiology, Academic Medical Centre, University of Amsterdam,
The Netherlands
References
1. Prandoni P, Lensing AWA, Cogo A, Cuppini S, Villalta S, Carta M, Cattelan
AM, Polistena P, Bernardi E, Prins MH. The long-term clinical course of
acute deep venous thrombosis. Ann Intern Med 1996; 125: 1-7.
2. Brandjes DPM, Büller HR, Heijboer H, Huisman MV, de Rijk M, Jagt J,
ten Cate JW. Randomised trial of effect of compression stockings in patients
with symptomatic proximal-vein thrombosis. Lancet 1997; 349: 759-62.
3. Bergqvist D, Jendteg S, Johansen L, Persson U, Ödegaard K. Cost of long-
term complications of deep venous thrombosis of the lower extremities: an
analysis of a defined patient population in Sweden. Ann Intern Med 1997;
126: 454-7.
4. Immelman EJ, Jeffery PC. The postphlebitic syndrome. Pathophysiology,
prevention and management. Clin Chest Med 1984; 5: 537-50.
5. Villalta S, Bagatella P, Piccioli A, Lensing AWA, Prins MH, Prandoni P.
Assessment of validity and reproducibility of a clinical scale for post-throm-
botic syndrome. Haemostasis 1994; 24 (Suppl. 1): 158a.
Received March 12, 1999 Accepted after revision March 26, 1999