Post-thrombotic syndrome is a chronic obstruction of venous outflow from the lower extremities, developing after deep vein thrombosis. Clinically, disease can manifest itself several years after acute thrombosis. Patients have a bursting feeling in the affected limb and painful night convulsions, ring-shaped pigmentation and puffiness form, which eventually acquires fibrous density. Diagnosis of post-thrombotic syndrome is based on anamnestic data and the results of ultrasound of the veins of the lower extremities. The increasing decompensation of venous circulation serves as an indication for surgical treatment.
Causes
With thrombosis, a blood clot forms in the lumen of the vessel. After the acute process subsides, the thrombotic masses are partially lysed, partially replaced by connective tissue. If lysis prevails, recanalization occurs (restoration of the lumen of the vein). When connective tissue elements are replaced, occlusion occurs (disappearance of the vessel lumen).
The restoration of the vein lumen is always accompanied by the destruction of the valve apparatus at the site of the thrombus localization. Therefore, regardless of the predominance of a particular process, the outcome of phlebothrombosis is a persistent violation of blood flow in the deep vein system.
Increased pressure in deep veins leads to dilation (ectasia) and insolvency of perforating veins. Blood from the deep vein system is discharged into the superficial vessels. The subcutaneous veins dilate and also become insolvent. As a result, all the veins of the lower extremities are involved in the process.
The deposition of blood in the lower extremities causes microcirculatory disorders. Violation of skin nutrition leads to the formation of trophic ulcers. The movement of blood through the veins is largely provided by muscle contraction. As a result of ischemia, the contractility of the muscles weakens, which leads to further progression of venous insufficiency.
Classification
There are two variants of the course (edematous and edematous-varicose forms) and three stages of post-thrombotic syndrome.
- transient edema, “heavy leg syndrome”;
- persistent edema, trophic disorders (skin pigmentation disorders, eczema, lipodermatosclerosis);
- trophic ulcers.
Symptoms
The first signs of post-thrombotic syndrome may appear several months or even years after acute thrombosis. In the early stages, patients complain of pain, a feeling of bursting, heaviness in the affected leg when walking or standing. When lying down, giving the limb an elevated position, the symptoms decrease rapidly. A characteristic sign of post-thrombotic syndrome is painful cramps in the muscles of the diseased limb at night.
Modern research in the field of clinical phlebology shows that in 25% of cases post-thrombotic syndrome is accompanied by varicose veins of the affected limb. Edema of varying severity is observed in all patients. A few months after the development of persistent edema, indurative changes in soft tissues appear. Fibrous tissue develops in the skin and subcutaneous tissue. Soft tissues become dense, the skin is soldered with subcutaneous tissue and loses mobility.
A characteristic feature of post-thrombotic syndrome is ring-shaped pigmentation, which begins above the ankles and covers the lower third of the lower leg. Subsequently, dermatitis, dry or wet eczema often develop in this area, and in the later periods of the disease, poorly healing trophic ulcers occur.
The course of post-thrombotic syndrome can be different. In some patients, the disease manifests itself for a long time with mild or moderate symptoms, in others it progresses rapidly, leading to the development of trophic disorders and persistent disability.
Diagnostics
If a post-thrombophlebitis disease is suspected, the doctor finds out whether the patient suffered from thrombophlebitis. Some patients with thrombophlebitis do not turn to a phlebologist, therefore, when collecting anamnesis, it is necessary to pay attention to episodes of pronounced prolonged edema and a feeling of swelling of the affected limb.
To confirm the diagnosis, ultrasound of the veins of the lower extremities is performed. Radionucleoid phlebography, ultrasound angioscanning and rheovasography of the lower extremities are used to determine the shape, localization of the lesion and the degree of hemodynamic disorders.
Treatment
Conservative therapy
During the adaptation period (the first year after thrombophlebitis), patients are prescribed conservative therapy. The indication for surgical intervention is early progressive decompensation of blood circulation in the affected limb.
At the end of the adaptation period, treatment tactics depend on the form and stage of post-thrombotic syndrome. In the stage of compensation and subcompensation of circulatory disorders (CVI 0-1), constant wearing of elastic compression means, physiotherapy is recommended. Even in the absence of signs of circulatory disorders, hard work, work in hot workshops and in the cold, work associated with prolonged stay on their feet is contraindicated for patients.
When decompensating blood circulation, the patient is prescribed antiplatelet agents (dipyridamole, pentoxifylline, acetylsalicylic acid), fibrinolytics, drugs that reduce inflammation of the vein wall (horse chestnut extract, hydroxyethylrutoside, troxerutin, tribenoside). In trophic disorders, pyridoxine, multivitamins, desensitizing agents are indicated.
Surgical treatment
Surgical intervention cannot completely cure a patient with post-thrombotic syndrome. The operation only helps to delay the development of pathological changes in the venous system. Therefore, surgical treatment is carried out only if conservative therapy is ineffective.
There are the following types of operations for post-thrombotic syndrome:
- reconstructive interventions (resection and plastic surgery of veins, bypass bypass surgery);
- corrective operations (phlebectomy and miniflebectomy – removal of dilated subcutaneous veins, ligation of communicating veins).
Forecast
To date, no type of treatment, including surgical interventions, can stop the further development of the disease in its unfavorable course. Within 10 years from the moment of diagnosis of post-thrombotic syndrome, disability occurs in 38% of patients.