Post-thrombotic syndrome (PTS) results from chronic venous insufficiency following deep vein thrombosis (DVT). It is painful and potentially disabling, limits quality of life and is costly and complex to manage. PTS develops in 20–50% of individuals within 2 years following a DVT diagnosis. Further, one-third of all cases of DVT and venous thromboembolism occur in persons older than 60 years of age (Kahn et al, 2016).
Symptoms of PTS include leg pain, a sensation of leg heaviness or fatigue, leg swelling, itching, cramps and paraesthesia, with signs including oedema, redness, cyanosis when leg dependent, telangiectasia, new varicose veins, stasis hyperpigmentation, and, in severe cases, venous ulceration. These signs and symptoms are the result of venous outflow restriction.
Objective/s
The objectives of Azirar et al's (2019) review were to assess the effectiveness of treatments for PTS, including elastic compression stockings and mechanical compression devices, compared with no intervention and placebo, and comparing between the interventions.
Intervention/methods
Several interventions reduce the risk of those with DVT developing PTS. These include ensuring an adequate duration and intensity of anticoagulation for treatment of the underlying DVT and appropriate thromboprophylaxis after discontinuation of oral anticoagulants. The best way to prevent PTS is, of course, to prevent the initial DVT (Kahn et al, 2016).
Compression therapy consists of the exertion of circular pressure on the leg using circular bandages or elastic compression stockings. Where oedema is severe, mechanical intermittent pneumatic devices using a wave-form upward motion action can be used. Compression therapy works to reduce oedema, accelerate venous blood flow and improve venous pump function, thereby supporting venous outflow (Azirar et al, 2019). However, it remains unknown whether compression therapies are effective for the treatment of PTS (Kahn et al, 2016; Azirar et al, 2019).
Azirar et al's (2019) review included randomised controlled trials (RCTs) or controlled clinical trials (CCTs) that evaluated the use of elastic compression stockings and mechanical devices in the treatment of PTS. Males and females of any age with PTS symptoms or clinical changes in the legs following a previous objectively diagnosed DVT were included. Those with leg ulcers were excluded.
The primary intervention for inclusion in the review was the use of elastic compression stockings or mechanical devices, including intermittent pneumatic compression (Azirar et al, 2019).
The primary outcomes for the review included: severity of PTS (measured from systematic clinical history taking and scoring of physical examinations) and adverse events such as discomfort, skin damage, pain, arterial leg ulceration and recurrence of thrombosis (Azirar et al, 2019).
Results
The review included four studies compr ising 116 participants meeting the inclusion criteria. Since the heterogeneity of the studies precluded a meta-analysis, a narrative report of the findings was presented.
Two studies evaluated the use of graduated elastic compression stockings on improvement of PTS symptoms (Ginsberg et al, 2001; Lattimer et al, 2013). One study found beneficial effects on symptoms, while the other did not. Two cross-over RCTs studied the use of intermittent mechanical compression devices, with both reporting an improvement in PTS severity (Ginsberg et al, 1999: O'Donnell et al, 2008). One study that evaluated the pneumatic mechanical compression device reported a significant improvement in patients' quality of life (O'Donnell et al, 2008). No other studies reported quality-of-life outcomes, and none of the studies reported on patient satisfaction with the interventions.
Conclusions
Overall, the certainty of evidence according to GRADE (Guyatt et al, 2008) for the use of elastic compression stockings to treat PTS was very low. Additionally, there is low-certainty evidence for using pneumatic compression devices for the treatment of PTS, and moderate-certainty evidence of improved quality of life. Lack of standardisation of outcome measures and the inclusion of small studies of short duration contributed to the low reliability of the evidence. There is a lack of high-certainty evidence to support the use of compression therapy in prevention of PTS, and the available evidence should be interpreted with care. In the absence of high-certainty evidence to support the use of these interventions, it is appropriate to continue with usual care including exercise and lifestyle interventions, compression therapy to manage symptoms such as oedema, pharmacotherapy and skin and ulcer care (Kearon and Kahn, 2020).
Implications for practice
The symptoms of PTS can be debilitating and impact on quality of life. Compression-based therapies have been used in an effort to reduce symptoms such as pain and oedema, thereby improving daily function. However, there is a lack of high-certainty evidence to support the use of these interventions. It is important to continue usual care, evaluate each case individually and carefully consider treatment options in the context of symptom severity, patient preference and the potential risk of harm.
Further high-quality RCTs that use standardised outcome measures and report adverse events, quality of life and patient satisfaction measures are warranted in this area.