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Peripheral Artery Disease: causes and consequences

Coronary Artery Disease: causes and consequences

Complications of Venous Thromboembolism

This section focusses on the complications of VTE, particularly on the management of PTS and CTEPH


PTS is the most common complication of DVT and typically causes chronic pain and swelling in the affected leg, and in severe cases can result in venous ulcers1

  • After symptomatic DVT, 20–50% of patients develop PTS1
  • PTS is associated with substantial morbidity2


The exact cause of PTS is not well understood, but it may result from damage to venous valves, ultimately leading to increased venous pressure.3


Symptoms of PTS include:3

  • Chronic pain
  • Sensation of heaviness
  • Cramps, itching and tingling


Signs of PTS include:3

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


In general, patients with PTS are managed using compression therapy and leg elevation.3,4

  • 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
  • There is no evidence that diuretics are helpful in the management of PTS
  • Surgical intervention may be appropriate if patients have chronic obstruction of the veins, sometimes in combination with endophlebectomy, bypass surgery or valvular repair


CTEPH is a form of pulmonary hypertension caused by partial obstruction of the major pulmonary arteries resulting from an unresolved PE.5

  • Occurs as a late complication in 3–4% of patients who survive PE
  • Causes the right side of the heart to work harder than normal because of abnormally high blood pressure in the arteries of the lungs. This can lead to heart failure and other serious consequences


Although CTEPH is a serious long-term complication of PE, it can be difficult to diagnose because clinical symptoms and signs are non-specific or absent in early CTEPH. Many of the symptoms of CTEPH are similar to those for acute PE, including:6

  • Dyspnoea
  • Chest pain with exertion
  • Pre-syncope or syncope
  • Haemoptysis


Without intervention, the 5-year survival rate once the mean pulmonary artery pressure reaches 40 mm Hg is about 30%.7


CTEPH is generally first identified using echocardiography and can be confirmed by right-sided heart catheterization and perfusion imaging.6


Patients with CTEPH may be managed surgically via pulmonary endarterectomy or, in those for whom this in inappropriate, lung transplantation.6 Riociguat (Adempas®, Bayer) is approved for the treatment of CTEPH in patients with inoperable or persistent/recurrent CTEPH after pulmonary endarterectomy.8 For patients who have failed on/are not suitable for the above treatment options, drugs approved for idiopathic pulmonary arterial hypertension may be useful for managing the symptoms of CTEPH.9


Next section: Patients with VTE and Renal Impairment

  • Kahn SR. The post-thrombotic syndrome: the forgotten morbidity of deep venous thrombosis. J Thromb Thrombolysis 2006;21:41–48. Return to content
  • Cohen AT, Tapson VF, Bergmann JF et al. Venous thromboembolism risk and prophylaxis in the acute hospital care setting (ENDORSE study): a multinational cross-sectional study. Lancet 2008;371:387–394. Return to content
  • Kahn SR. How I treat postthrombotic syndrome. Blood 2009;114:4624–4631. Return to content
  • Puggioni A, Lurie F. Advances in the surgical treatment of postthrombotic syndrome. Phlebolymphology 2007;14:99–104. Return to content
  • Pengo V, Lensing AWA, Prins MH et al. Incidence of chronic thromboembolic pulmonary hypertension after pulmonary embolism. N Engl J Med 2004;350:2257–2264. Return to content
  • Galie N, Humbert M, Vachiery JL et al. 2015 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension: The Joint Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS): Endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC), International Society for Heart and Lung Transplantation (ISHLT). Eur Heart J 2016;37:67–119. Return to content
  • Fedullo PF, Auger WR, Kerr KM, Rubin LJ. Chronic thromboembolic pulmonary hypertension. N Engl J Med 2001;345:1465–1472. Return to content
  • Bayer AG. Adempas (riociguat) Summary of Product Characteristics. 2018. Available at: http://www.ema.europa.eu/docs/en_GB/document_library/EPAR_-_Product_Information/human/002737/WC500165034.pdf [accessed 22 August 2018]. Bayer AG. Adempas (riociguat) Summary of Product Characteristics. 2018. Available at: http://www.ema.europa.eu/docs/en_GB/document_library/EPAR_-_Product_Information/human/002737/WC500165034.pdf [accessed 22 August 2018]. Return to content
  • Mendoza V, Scharf ML. Evaluation and management of chronic pulmonary thromboembolic disease. Hosp Pract (Minneap) 2011;39:50–61. Return to content

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