Surgical treatment of moderate-to-severe post-thrombotic syndrome

Abstract

Background: Severe post-thrombotic syndrome (PTS) occurs in 5% to 10% of patients after deep venous thrombosis. Medical therapy such as compression has limited effectiveness for the treatment of such patients. The objective of this study was to systematically review the effectiveness and safety of surgical approaches for the treatment of moderate-to-severe PTS.

Method: A computerized search was conducted using PubMed and reverse citation searches to retrieve English- and French-language articles, published after 1980, reporting on the endovascular and surgical treatment of PTS.

Results: Three hundred three titles were retrieved, of which 28 full publications were reviewed. Twelve articles met criteria for inclusion, reporting on 349 patients. Surgical techniques included vein dilation and stent placement (two studies), venous bypass grafting (two studies), endophlebectomy with reconstruction (one study), valve reconstruction/transplant (six studies), and interruption of perforating veins (one study). Follow-up periods ranged from 1 month to 5 years. Eleven of 12 included studies described improvement in PTS after the given surgical intervention. Seven of 12 studies found improvement in all anatomic measures assessed (e.g., venous valve competency and patency, venous filling times, or ambulant venous pressure), and 11 of 12 studies reported clinical improvement (e.g., improvement in signs and symptoms, ulcer healing, ability to return to work, or reduced need for elastic compression stockings), with rates of ulcer healing ranging from 50% to 100%. Eight of 12 studies (representing 264 patients) reported safety outcomes. Complications reported most frequently were hematoma/seroma formation and wound infection, with no reported instances of mortality or pulmonary embolism. Limitations of the studies included a lack of randomized controlled trials, absence of control groups, small sample sizes, short follow-up periods, retrospective data collection, imprecise definition of PTS, heterogeneity of study participants, and, in three studies, lack of reporting on procedure safety.

Conclusion: Surgical and endovascular treatment of moderate-to-severe PTS could have the potential to be effective where conservative and medical treatments have failed. Our review describes studies of surgical techniques to treat PTS, but highlights important limitations of such studies. Further research using stricter research methodology is needed to evaluate the potential role of surgical techniques for the treatment of moderate-to-severe PTS.