Essence of this Article

Between 20% and 50% of patients who develop deep vein thrombosis (DVT) go on to develop post-thrombotic syndrome (PTS), a condition that is associated with substantial morbidity and mortality. Patients with PTS are generally managed using compression therapy and leg elevation, although surgical intervention may be appropriate in some cases. Chronic thromboembolic pulmonary hypertension (CTPH) occurs as a complication in 3–4% of patients who survive pulmonary embolism (PE). Patients with CTPH may be managed surgically via pulmonary endarterectomy or, if this is inappropriate, lung transplantation. Drugs approved for idiopathic pulmonary arterial hypertension may be useful for managing the symptoms of CTPH in patients who are not appropriate for surgery.

Treatment of the complications of venous thromboembolism

Post-thrombotic syndrome

Between 20% and 50% of patients who develop DVT go on to develop PTS, a condition that is associated with substantial morbidity and mortality.171 The exact cause of PTS is not well understood, but it may involve damage to venous valves, ultimately leading to increased venous pressure.192 The main symptom is chronic pain. Signs of PTS include:

  • Swelling
  • Discolouration of the affected leg
  • Skin ulceration (severe cases)

In addition to pain, patients with PTS may experience a sensation of heaviness, as well as cramps, itching and tingling.171

In general, patients with PTS are managed using compression therapy and leg elevation.171 In particular, elastic compression stockings can reduce leg swelling, heaviness and aching. There is some evidence that venoactive or phlebotonic remedies such as aescin or rutoside may reduce the symptoms of PTS, but this remains unproven.171 There is no evidence that diuretics are helpful in the management of PTS.171 Surgical intervention may be appropriate in cases where patients have chronic obstruction of the veins, sometimes in combination with endophlebectomy, bypass surgery or valvular repair.172

Chronic thromboembolic pulmonary hypertension

CTPH is a form of pulmonary hypertension caused by partial obstruction of the major pulmonary arteries resulting from an unresolved PE and occurs as a late complication in 3–4% of patients who survive PE.147

Symptoms include progressive shortness of breath and exercise intolerance. Later in the course of the disorder, chest pain with exertion and syncope may occur. Without intervention, the five-year survival rate once the mean pulmonary artery pressure reaches 40 mm Hg is about 30%.173

CTPH is generally first indicated by echocardiography and can be confirmed by right-sided heart catheterization and perfusion imaging. Patients with CTPH may be managed surgically via pulmonary endarterectomy or, in those for whom this in inappropriate, lung transplantation. Drugs approved for idiopathic pulmonary arterial hypertension may be useful for managing the symptoms of CTPH in patients who are not appropriate for surgery.174

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