Guideline sources The following summarized guidelines for the evaluation and management of post-thrombotic syndrome (PTS) 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 Society for Vascular Surgery (SVS 2014), the American Heart Association (AHA 2014), and the American Association of Family Physicians (AAFP 2013). 1 2 3 4 6 7 8 Calculator Villalta score for post-thromboti Guidelines 1. Classification and risk stratification https://web.pathway.md/diseases/recjeAS8A8kRCIg3y 1/5 6/29/23, 11:21 PM Post-thrombotic syndrome Pathway Severity assessment: consider using the revised Venous Clinical Severity Score and the Villalta scale for PTS for the assessment of clinical severity and treatment success in patients with chronic venous disease. B 2. Medical management Vasoactive agents: insufficient evidence to support the use of rutosides, hidrosmin, or defibrotide for the treatment of patients with PTS. I 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. C As per AHA 2014 guidelines, consider offering a trial of elastic compression stockings in patients with PTS unless contraindicated (such as arterial insufficiency). C As per SVS 2014 guidelines, offer knee- or thigh-high compression stockings exerting a pressure of 30-40 mmHg in patients with clinical CEAP C1-4 disease related to prior deep vein thrombosis. B Physical therapy: consider offering a supervised exercise training program consisting of leg strength training and aerobic activity for at least 6 months in patients with PTS able to tolerate the exercises. C 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 As per AHA 2014 guidelines, consider offering a trial of an intermittent compression device in patients with moderate or severe PTS and significant edema. 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. C As per AHA 2014 guidelines, consider performing surgical intervention, such as femorofemoral or femorocaval bypass, C or percutaneous endovenous recanalization, such as stenting or balloon angioplasty, in severely symptomatic patients with iliac vein or vena cava occlusion. C https://web.pathway.md/diseases/recjeAS8A8kRCIg3y 2/5 6/29/23, 11:21 PM Post-thrombotic syndrome Pathway Show 2 more 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. A Show 3 more Patients with iliofemoral DVT: consider offering class II (30-40 mmHg) below-knee elastic compression stockings as soon as possible following initiation of anticoagulant therapy and continue for a minimum of 2 years. B Show 2 more 7. Preventative measures Primary prevention, compression stockings: As per ACCP 2021 guidelines, avoid using compression stockings routinely to prevent PTS in patients with acute deep vein thrombosis of the leg. D As per ESVS 2021 guidelines: Consider offering below-knee compression stockings to reduce the risk of PTS in patients with proximal deep vein thrombosis. B Limit the use of below-knee stockings to 6 or 12 months in patients with proximal deep vein thrombosis and with limited symptoms and signs, as described in the Villalta score. A As per AHA 2014 guidelines, insufficient evidence to support the use of elastic compression stockings for the prevention of PTS in patients with deep vein thrombosis. I As per AAFP 2013 guidelines, offer compression stockings to prevent PTS in patients following deep vein thrombosis. A Primary prevention, thromboprophylaxis: As per AHA 2014 guidelines, initiate thromboprophylaxis in patients at significant risk for deep vein thrombosis as a means of preventing PTS. B Show 4 more As per SVS 2014 guidelines, consider initiating LMWH over vitamin K antagonist therapy of 3-month duration to decrease the risk of PTS in patients with acute deep vein thrombosis. C Primary prevention, catheter-directed thrombolysis: As per AHA 2014 guidelines, consider performing catheter-directed thrombolysis or pharmacomechanical catheter-directed thrombolysis (in experienced centers) in selected patients with acute ( 14 days) symptomatic, extensive proximal deep vein thrombosis with a good functional capacity, 1-year life expectancy, and low expected bleeding risk. C Show 2 more As per SVS 2014 guidelines, consider performing catheter-directed thrombolysis to decrease the risk of PTS in patients with low bleeding risk with iliofemoral deep vein thrombosis of duration < 14 days. C https://web.pathway.md/diseases/recjeAS8A8kRCIg3y 3/5 6/29/23, 11:21 PM Post-thrombotic syndrome Pathway Primary prevention (systemic thrombolysis): do not administer systemic thrombolysis for the treatment of deep vein thrombosis. D Primary prevention (surgical thrombectomy): consider performing surgical thrombectomy (in experienced centers) in selected patients with acute ( 14 days) symptomatic, extensive proximal deep vein thrombosis with a good functional capacity and 1-year life expectancy, if percutaneous catheter-directed thrombolysis and pharmacomechanical catheter-directed thrombolysis are not appropriate. C Clinical findings Symptoms Past medical history Claudication of lower limb DVT Leg cramping Obesity Leg fatigue Venous leg ulcer Leg itching Integument exam Leg pain Leg paresthesia Leg discoloration Leg swelling Leg hyperpigmentation Leg telangiectasia Social history Leg ulcer Tobacco use Skin thickening References 1. Scott M Stevens, Scott C Woller, Lisa Baumann Kreuziger et al. Antithrombotic Therapy for VTE Disease: Second Update of the CHEST Guideline and Expert Panel Report. Chest. 2021 Dec;160 6):e545-e608. Open 2. David Liu, Erica Peterson, James Dooner et al. Diagnosis and management of iliofemoral deep vein thrombosis: clinical practice guideline. CMAJ. 2015 Nov 17;187 17 1288 1296. Open 3. Marianne G De Maeseneer, Stavros K Kakkos, Thomas Aherne et al. Editor's Choice European Society for Vascular Surgery ESVS 2022 Clinical Practice Guidelines on the Management of Chronic Venous Disease of the Lower Limbs. Eur J Vasc Endovasc Surg. 2022 Feb;63 2 184 267. Open 4. O'Donnell TF Jr, Passman MA, Marston WA et al. Management of venous leg ulcers: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg. 2014 Aug;60 2 Suppl):3S 59S. Open 5. Peter Gloviczki, Anthony J Comerota, Michael C Dalsing et al. The care of patients with varicose veins and associated chronic venous diseases: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg. 2011 May;53 5 Suppl):2S 48S. Open 6. Kathryn P Trayes, James S Studdiford, Sarah Pickle et al. Edema: Diagnosis and Management. Am Fam Physician. 2013 Jul 15;88 2 102 10. Open 7. Susan R Kahn, Anthony J Comerota, Mary Cushman et al. The postthrombotic syndrome: evidence- based prevention, diagnosis, and treatment strategies: a scientific statement from the American Heart Association. Circulation. 2014 Oct 28;130 18 1636 61. Open https://web.pathway.md/diseases/recjeAS8A8kRCIg3y 4/5 6/29/23, 11:21 PM Post-thrombotic syndrome Pathway 8. Stavros K Kakkos, Manjit Gohel, Niels Baekgaard et al. Editor's Choice European Society for Vascular Surgery ESVS 2021 Clinical Practice Guidelines on the Management of Venous Thrombosis. Eur J Vasc Endovasc Surg. 2021 Jan;61 1 9 82. Open https://web.pathway.md/diseases/recjeAS8A8kRCIg3y 5/5