The post-thrombotic syndrome: incidence and prognostic value of non-invasive venous examinations in a six-year follow-up study

Edith M. Roumen-Klappe; Martin den Heijer; Mirian C. H. Janssen; Carine van der Vleuten; Theo Thien; Hub Wollersheim

doi:10.1160/TH05-03-0146

Thrombosis and Haemostasis, Table of Contents

Thromb Haemost 2005; 94(04): 825-830
DOI: 10.1160/TH05-03-0146

Blood Coagulation, Fibrinolysis and Cellular Haemostasis

Schattauer GmbH

The post-thrombotic syndrome: incidence and prognostic value of non-invasive venous examinations in a six-year follow-up study

Authors

Edith M. Roumen-Klappe

¹Department of General Internal Medicine
Martin den Heijer

²Epidemiology and Biostatistics
Mirian C. H. Janssen

¹Department of General Internal Medicine
Carine van der Vleuten

⁴Department of Dermatology
Theo Thien

¹Department of General Internal Medicine
Hub Wollersheim

¹Department of General Internal Medicine

⁵Centre for Quality of Care Research of the University Medical Centre Nijmegen, The Netherlands

Abstract

Summary

The ability to predict severity of the post-thrombotic syndrome (PTS) early after acute deep-vein thrombosis (DVT) is limited. The aim of our study was to examine the incidence of PTS prospectively and to evaluate the predictive value of non-invasive venous examinations shortly after DVT for the development of PTS. In 93 patients with DVT thrombosis score (TS), reflux, venous outflow resistance (VOR) and calf muscle pump dysfunction (CMP) were examined prospectively. After one, two and six years patients were evaluated for PTS using the clinical scale of the CEAP-classification (PTS present ≥3 on a scale from 0 to 6). Area under the curves (AUC) were used to evaluate the predictive value of the non-invasive examinations at one and three months after diagnosis of DVT for future PTS. The cumulative incidence of PTS increased from 49% (32/65) after one year to 55% (36/65) and 56% (27/48) after two and six years, whereas the incidence of patients with PTS class 4 progressed from 20% after two years to 33% after six years. The prognostic value to predict PTS was highest for the combination of TS, VOR and reflux measured three months after diagnosis and showed anAUC of 0.77 (0.65−0.90) for PTS after one year. In conclusion, the incidence of PTS after DVT did not increase significantly after one year, whereas during longer follow-up the severity of PTS rose in patients with PTS. Moreover, measurement of TS, VOR and reflux three months after DVT could predict, with reasonable accuracy, the risk of PTS after one year of follow-up.

Keywords

Deep-vein thrombosis - post-thrombotic syndrome - predictive value of non-invasive examinations

Full Text

References

References
1 Janssen MC, Wollersheim H, Asten WNJC. et al. The post-thrombotic syndrome, a review. Phlebology 1996; 11: 86-94.
2 Kahn SR, Solymoss S, Lamping D L. et al. Longterm outcomes after deep vein thrombosis: postphlebitic syndrome and quality of life. J Gen Intern Med 2000; 15: 425-9.
3 Nordstrom M, Lindblad B, Bergqvist D. et al. A prospective study of the incidence of deep-vein thrombosis within a defined urban population. J Intern Med 1992; 232: 155-60.
4 Van den Oever R, Hepp B, Debbaut B. et al. Socioeconomic impact of chronic venous insufficiency. An underestimated public health problem. Int Angiol 1998; 17: 161-7.
5 Bergqvist D, Jendteg S, Johansen L. et al. 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.
6 Brandjes DP, Buller HR, Heijboer H. et al. Randomised trial of effect of compression stockings in patients with symptomatic proximal-vein thrombosis. Lancet 1997; 349: 759-62.
7 Meissner MH, Caps MT, Zierler B K. et al. Determinants of chronic venous disease after acute deep venous thrombosis. J Vasc Surg 1998; 28: 826-33.
8 Klein Rouweler BJF, Kuiper JP, Brakkee AJM. Plethysmographic measurement of venous flow resistance and venous capacity in humans with deep venous thrombosis. Phlebology 1990; 5: 21-9.
9 Janssen MC, Haenen JH, van Asten WN. et al. Clinical and haemodynamic sequelae of deep venous thrombosis: retrospective evaluation after 7–13 years. Clin Sci 1997; 93: 7-12.
10 Arcelus JI, Caprini JA, Hoffman K N. et al. Laboratory assays and duplex scanning outcomes after symptomatic deep vein thrombosis: preliminary results. J Vasc Surg 1996; 23: 616-21.
11 Killewich LA, Macko RF, Cox K. et al. Regression of proximal deep venous thrombosis is associated with fibrinolytic enhancement. J Vasc Surg 1997; 26: 861-8.
12 Porter JM, Moneta GL. Reporting standards in venous disease: an update. International Consensus Committee on Chronic Venous Disease. J Vasc Surg 1995; 21: 635-45.
13 Klein Rouweler BJF, Brakkee AJM, Kuiper JP. Plethysmographic measurement of venous flow resistance and venous capacity in the human leg. Part One: method. Phlebology 1989; 4: 241-50.
14 Klein Rouweler BJF, Brakkee AJM, Kuiper JP. Plethysmographic measurement of venous flow resistance and venous capacity in human legs. Part two: Normal values related to age, sex and site of measurement. Phlebology 1989; 4: 251-7.
15 Janssen MC, Claassen JA, van Asten WN. et al. Validation of the supine venous pump function test: a new non-invasive tool in the assessment of deep venous insufficiency. Clin Sci 1996; 91: 483-8.
16 Haenen JH, van Langen H, Janssen M C. et al. Venous duplex scanning of the leg: range, variability and reproducibility. Clin Sci 1999; 96: 271-7.
17 Prandoni P, Lensing AW, Prins M H. et al. Belowknee elastic compression stockings to prevent the postthrombotic syndrome: a randomized, controlled trial. Ann Intern Med 2004; 141: 249-56.
18 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: 423-8.
19 Franzeck UK, Schalch I, Jager K A. et al. Prospective 12-year follow-up study of clinical and hemodynamic sequelae after deep vein thrombosis in low-risk patients (Zurich study). Circulation 1996; 93: 74-9.
20 Nicolaides AN. Investigation of chronic venous insufficiency: A consensus statement. (France, March 5–9, 1997). Circulation 2000; 102: E126-E163.
21 Lagerstedt C, Olsson CG, Fagher B. et al. Recurrence and late sequelae after first-time deep vein thrombosis: relationship to initial signs. Phlebology 1993; 8: 62-7.
22 Monreal M, Martorell A, Callejas J M. et al. Venographic assessment of deep vein thrombosis and risk of developing post-thrombotic syndrome: a prospective study. J Intern Med 1993; 233: 233-8.
23 Prandoni P, Frulla M, Sartor D. et al. Vein abnormalities and the post-thrombotic syndrome. J Thromb Haemost 2005; 3: 401-2.
24 Araki CT, Back TL, Padberg F T. et al. The significance of calf muscle pump function in venous ulceration. J Vasc Surg 1994; 20: 872-7.
25 Johnson BF, Manzo RA, Bergelin R O. et al. The site of residual abnormalities in the leg veins in long-term follow-up after deep vein thrombosis and their relationship to the development of the post-thrombotic syndrome. Int Angiol 1996; 15: 14-19.
26 Caprini JA, Arcelus JI, Reyna J J. et al. Deep vein thrombosis outcome and the level of oral anticoagulation therapy. J Vasc Surg 1999; 30: 805-11.