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Post Thrombotic Syndrome
Post Thrombotic Syndrome Buffalo


Post Thrombotic Syndrome - General Considerations



First, post thrombotic syndrome is a “syndrome”, rather than a disease. As such, it can present differently in each patient, with symptoms varying considerably from individual to individual.


Technically, PTS is a complication of deep venous thrombosis. Some patients will go on to recover completely from DVT, but a significant percentage will have lingering complications from the disease.


Post thrombotic syndrome is a well described sequela of DVT, and symptoms can appear and disappear over time. It is a chronic condition, though, and one that can last your entire life. Over time, the symptoms can also become more severe, resulting in significant pain and discomfort, and even in permanent disability.


Post thrombotic syndrome is a constellation of typical symptoms and signs that ranges from pain, pigmentation of the skin, leg swelling, and formation of venous stasis ulcers.


Most cases of PTS present within six months of treatment for deep venous thrombosis, but some can take up to two years. In addition, each patient will have different symptoms and symptom combinations. The only true way to determine if you suffer from post thrombotic syndrome is to undergo an examination by a medical professional (preferably the doctor who treated your DVT).


The Villalta Scale was described in the 1990’s to diagnose and classify the severity of post thrombotic syndrome. Clinical studies done by Dr. Khan show that the Villalta scale is a “reliable, valid, acceptable and responsive measure of PTS in patients with previous, objectively confirmed DVT” and was published in the Journal of Thrombosis and Heamostasis (volume 7, pages 884-888, 2009).


Dr. hratch Karamanoukian is a member of the American College of Phlebology AND a Diplomate of the American Board of Phlebology. He can be contacted by calling 716-839-3638 or 



Dr. Raffy Karamanoukian is a member of the American College of Phlebology AND a Diplomate of the American Board of Phlebology. He can be contacted by calling 310-998-5535 or 


Drs. Raffy and Hratch Karamanoukian have authored 6 books about venous disease. The books are available on Amazon Kindle and Nook books for download.





Dr. Hratch Karamanoukian Publishes a Book About Post Thrombotic Syndrome - 'Post Thrombotic Syndrome and Deep Vein Thrombosis' - available on Amazon Kindle and Nook Books.



Post Thrombotic Syndrome and Deep Vein Thrombosis 


For a free pdf copy of the book contact Dr. Karamanoukian through his website - established patients of Dr. Karamanoukian can get a free copy of this book.




What is Post Thrombotic Syndrome ? Buffalo Vein Expert


Post thrombotic syndrome can be a frightening reality for many people who have suffered from deep venous thrombosis (DVT) – and it can occur whether it was treated appropriately with anticoagulants (blood thinners) or not !


It should be remembered that in the period following DVT, morbidity and mortality can occur from a clot embolizing to the heart and lungs, known as pulmonary embolism.


The long term consequences of deep vein thrombosis are recurrent DVT, venous thromboembolism (VTE) and post thrombotic syndrome. Venous thromboembolism is the condition where the blood clot dislodges and travels (embolizes) to the heart and lungs.


In fact, a significant percentage of DVT sufferers go on to develop post thrombotic syndrome. Understanding what this syndrome is can be of vital help for those who have had one or more episodes of DVT.





Post Thrombotic Syndrome - One Leg or Both Legs - Buffalo Vein Expert



Post thrombotic syndrome is:



  • A venous syndrome


  • A painful, debilitating condition that can result in pain and loss of mobility


  • Can be present in one or both legs


  • Frequently seen in patients who have developed deep venous thrombosis


  • More common in patients with certain high-risk factors


  • A syndrome that costs $200 million annually in the US, with an estimated cost of almost $4,000 per patient (based on 1990 US dollar value according to a Swedish study by Bergqvist published in the Ann of Internal Medicine in 1997)




 Pathophysiology of Post Thrombotic Syndrome - Buffalo Vein Expert



Post thrombotic syndrome always begins with deep venous thrombosis. While not all DVT sufferers will go on to develop post thrombotic syndrome, those without DVT will not develop PTS. Therefore, the underlying cause of the syndrome lies in what occurs during deep venous thrombosis.


Technically, PTS is all about damage caused to the leg’s venous system and complications from that damage. During deep venous thrombosis, a blood clot forms in the leg (or in more than one leg). The blood clot alone is a significant problem and can result in serious repercussions. However, treatment can usually offer help.


While the exact underlying cause of post thrombotic syndrome remains somewhat cloudy, medical professionals point to the relationship between the syndrome and the damage caused by blood clots in leg veins. Even if the clot does not break free and threaten to embolize to the heart and lung(s), it’s mere presence causes problems for the venous system in the leg.


When a blood clot forms, it damages the valves within the vein. The damage is two-fold. First, the presence of the blood clot increases blood pressure within the vein, causing inflammation.


 Second, the clot itself can cause valve damage. In both cases, the valve loses its ability to restrict blood flow to a one-way path and the blood begins to backslide down into the lower leg. Backsliding blood combined with the presence of the clot results in venous hypertension in the leg.


Even once the clot has been successfully removed (mechanically with catheters) or lysed (with fibrinolytic agents) and deep venous thrombosis treatment has occurred, the residual damage from the disease can have lifelong repercussions.


In a summary by Caprini and colleagues published in Value in Health, volume 6, pages 59-74, the authors summarize that “PTS results from the increased venous pressure owing to residual obstruction or valvular reflux as well as general damage to or destruction of the [deep] venous valves and walls of the deep veins and communicating veins of the leg following DVT and obliteration of the thrombosed veins rather than recanalization.”



Iliocaval Stenting for Iliocaval Obstruction



Iliocaval stenting has been the treatment of choice for iliofemorocaval obstruction. It has replaced 'bypass procedures' and has improved patency outcomes. Using ultrasound imaging, the veins are accessed and intravenous ultrasound used to visualize the iliocaval thrombus (clot). A balloon is used to dilate the scarred thrombus and a self expanding stent is deployed in the stenotic lesion. Commonly used diameters for stnets are 12–14 mm with a technical success rate exceeding 95%. Studies have shown significant improvement of the Venous clinical severity score (VCSS) from an average value of 8.5 to 2. Patency rates at 3 years exceeded 73% with 97% survival at 5 years according to a study by Hartung and colleagues in the Journal of Vascular Surgery 2005.







The Crossover Bypass Procedure for Iliocaval Obstruction and Post Thrombotic Syndrome




These crossover byass procedure, also known as the Palma-Dale procedure, is used for cases where stenting has failed or stenting is not technically possible or it is done in cases of unsuccessful stenting or restenosis. There are some technical criteria for crossover femoral grafts which include 1) a patent opposite (contralateral) iliofemoral vein and caval run-off (patent or open vena cava), 2) supine resting pressure gradient in excess of 4 to 5 mmHg between the femoral veins in the involved and opposite limbs and 3) adequate distal venous system (a patent profunda femoris vein, preferably with an open or partially recanalized superficial femoral vein), 4) a patent and competent greater saphenous vein on the recipient side with a minimal diameter of 4 to 5 mm, 5) and no varicose veins. Tyically, the great saphenous vein from the oposite leg is used for this procedure and rarely PTFE grafts. An arteriovenous fistula is made between the posterior tibial artery and vein to increase flow through the graft thus maintaining graft patency and the fistula is usually closed 6 weeks after surgery. Patients are anticoagulated for 3 months after the procedure.






Endophlebectomy for iliac vein obstruction



Endophlebectomy for iliac vein obstruction is a surgical procedure where the fibrotic scar tissue resulting from a long stadning clot is surgically shaved from the vein wall. Removal of such tissue increases. Removal of the constricting bands and endophlebectomy is also called disobliteration. Patency rates after endophlebectomy is approximately 77% at 1 year follow-uo.






Read the following articles about Post Thrombotic Syndrome by Dr. Karamanoukian:


 Management of Post Thrombotic Syndrome


Diagnostic Criteria for Post Thrombotic Syndrome


Clinical Presentation of Post Thrombotic Syndrome


Validation of the Villalta Scoring System for Post Thrombotic Syndrome


Post Thrombotic Syndrome - Educate and Prevent

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