New perspectives for prevention of the post-thrombotic syndrome

Published: 22 March 2022
Abstract Views: 746
PDF: 207
Publisher's note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.


While on conventional anticoagulation, up to 50% of patients with one or more episodes of proximal deep vein thrombosis (DVT) can develop post-thrombotic (PTS) manifestations. The potential strategies for PTS prevention are the treatment of acute DVT with catheter-directed thrombolysis (CDT), the use of elastic compression stockings (ECS) and that of the direct oral anticoagulants (DOAC) in place of vitamin K antagonists (VKA) for the initial and long-term treatment of DVT. Based on the results of three randomized clinical trials, CDT cannot be recommended on a routine basis because of its invasiveness, the associated risk of major bleedings and the uncertainty about its efficacy. According to the results of a placebo-controlled randomized clinical trial, ECS are no longer recommended for PTS prevention on a routine basis. However, based on the results of a recent subanalysis of a prospective cohort study, patients with residual vein thrombosis and/or popliteal valve reflux at three months are likely to benefit from ECS for at least six months. Finally, following the demonstration that the inadequacy of VKA therapy plays a key role in the PTS development, several retrospective and prospective studies have shown that the use of DOACs for the initial and long-term treatment of DVT in place of VKAs reduces the risk of PTS by approximately 50%. In conclusion, the availability of DOACs and the potential of ECS in selected patients with proximal DVT are expected to play a key role for decreasing the rate and the severity of PTS in the forthcoming years.

Kahn SR, Comerota AJ, Cushman M, et al. The postthrombotic syndrome: evidence-based prevention, diagnosis, and treatment strategies: a scientific statement from the American Heart Association. Circulation 2014;130:1636-61. DOI:

Visonà A, Quere I, Mazzolai L, et al. Post-thrombotic syndrome. Vasa 2021;50:331-40. DOI:

Guanella R, Ducruet T, Johri M, et al. Economic burden and cost determinants of deep vein thrombosis during 2 years following diagnosis: a prospective evaluation. J Thromb Haemost 2011;9:2397-405. DOI:

Prandoni P, Lensing AW, Cogo A, et al. The long-term clinical course of acute deep venous thrombosis. Ann Intern Med 1996;125:1-7. DOI:

Kahn SR, Shrier I, Julian JA, et al. Determinants and time course of the postthrombotic syndrome after acute deep venous thrombosis. Ann Intern Med 2008;149:698-707. DOI:

Rabinovich A, Kahn SR. The postthrombotic syndrome: current evidence and future challenges. J Thromb Haemost 2017;15:230-41. DOI:

Rabinovich A, Cohen JM, Cushman M, et al. Inflammation markers and their trajectories after deep vein thrombosis in relation to risk of postthrombotic syndrome. J Thromb Haemost 2015;13:398-408. DOI:

Rabinovich A, Ducruet T, Kahn SR. Development of a clinical prediction model for the postthrombotic syndrome in a prospective cohort of patients with proximal deep vein thrombosis. J Thromb Haemost 2018;16:262-70. DOI:

Rabinovich A, Gu CS, Vedantham S, et al. External validation of the SOX-PTS score in a prospective multicenter trial

of patients with proximal deep vein thrombosis. J Thromb Haemost 2020;18:1381-9. DOI:

Amin EE, Ten Cate-Hoek AJ, Bouman AC, et al. Individually shortened duration versus standard duration of elastic compression therapy for prevention of post-thrombotic syndrome: a cost-effectiveness analysis. Lancet Haematol 2018;5:e512-9. DOI:

Amin EE, van Kuijk SMJ, Joore MA, et al. Development and validation of a practical two-step prediction model and clinical risk score for post-thrombotic syndrome. Thromb Haemost 2018;118:1242-9. DOI:

Vedantham S, Goldhaber SZ, Julian JA, et al. Pharmacomechanical catheter-directed thrombolysis for deep-vein thrombosis. N Engl J Med 2017;377:2240-52. DOI:

Comerota AJ, Kearon C, Gu CS, et al. Endovascular thrombus removal for acute iliofemoral deep vein thrombosis. Circulation 2019;139:1162-73. DOI:

Enden T, Haig Y, Kløw NE, et al. Long-term outcome after additional catheter-directed thrombolysis versus standard treatment for acute iliofemoral deep vein thrombosis (the CaVenT study): a randomised controlled trial. Lancet 2012;379:31-8. DOI:

Haig Y, Enden T, Grøtta O, et al. Post-thrombotic syndrome after catheter-directed thrombolysis for deep vein thrombosis

(CaVenT): 5-year follow-up results of an open-label, randomised controlled trial. Lancet Haematol 2016;3:e64-71. DOI:

Notten P, Ten Cate-Hoek AJ, Arnoldussen CWKP, et al. Ultrasound-accelerated catheter-directed thrombolysis versus anticoagulation for the prevention of post-thrombotic syndrome (CAVA): a single-blind, multicentre, randomised trial. Lancet Haematol 2020;7:e40-9. DOI:

Notten P, de Smet AAEA, Tick LW, et al. CAVA (ultrasoundaccelerated catheter-directed thrombolysis on preventing post-thrombotic syndrome) trial: long-term follow-up results. J Am Heart Assoc 2021;10:e018973. DOI:

Brandjes DP, Büller HR, Heijboer H, et al. Randomised trial of effect of compression stockings in patients with symptomatic proximal-vein thrombosis. Lancet 1997;349:759-62. DOI:

Prandoni P, Lensing AW, Prins MH, et al. Below-knee elastic compression stockings to prevent the post-thrombotic syndrome: a randomized, controlled trial. Ann Intern Med 2004;141:249-56. DOI:

Kahn SR, Shapiro S, Wells PS, et al. Compression stockings to prevent post-thrombotic syndrome: a randomised placebo-controlled trial. Lancet 2014;383:880-8. DOI:

Stevens SM, Woller SC, Baumann Kreuziger L, et al. Antithrombotic therapy for VTE disease: second update of the CHEST guideline and expert panel report - Executive summary. Chest 2021;160:2247-59. DOI:

Rabe D, Partsch H, Heidl G, et al. Compression treatment in acute symptomatic proximal deep venous thrombosis Results of a worldwide survey. Phlebology 2021;36:526-34. DOI:

Mol GC, van de Ree MA, Klok FA, et al. One versus two years of elastic compression stockings for prevention of post-thrombotic syndrome (OCTAVIA study): randomised controlled trial. BMJ 2016;353:i2691. DOI:

Subbiah R, Aggarwal V, Zhao H, et al. Effect of compression stockings on post thrombotic syndrome in patients with deep vein thrombosis: a meta-analysis of randomised controlled trials. Lancet Haematol 2016;3:e293-300. DOI:

Dronkers CEA, Mol GC, Maraziti G, et al. Predicting postthrombotic syndrome with ultrasonographic follow-up after deep vein thrombosis: a systematic review and meta-analysis. Thromb Haemost 2018;118:1428-38. DOI:

Prandoni P, Lensing AW, Prins MH, et al. The impact of residual thrombosis on the long-term outcome of patients with deep venous thrombosis treated with conventional anticoagulation. Semin Thromb Hemost 2015;41:133-40. DOI:

Prandoni P, Lensing AW, Prins MH, et al. Elastic compression stockings for prevention of the post-thrombotic syndrome in patients with and without residual vein thrombosis and/or popliteal valve reflux. Haematologica 2022;107:303-7. DOI:

van Dongen CJ, Prandoni P, Frulla M, et al. Relation between quality of anticoagulant treatment and the development of the postthrombotic syndrome. J Thromb Haemost 2005;3:939-42. DOI:

Hull RD, Liang J, Townshend G. Long-term low-molecular-weight heparin and the post-thrombotic syndrome: a systematic review. Am J Med 2011;124:756-65. DOI:

Makedonov I, Kahn SR, Abdulrehman J, et al. Prevention of the postthrombotic syndrome with anticoagulation: a narrative

review. Thromb Haemost 2021 Dec 1. doi: 10.1055/a-1711-1263 [online ahead of print]. DOI:

van Es N, Coppens M, Schulman S, et al. Direct oral anticoagulants compared with vitamin K antagonists for acute venous thromboembolism: evidence from phase 3 trials. Blood 2014;124:1968-75. DOI:

Prandoni P, Ageno W, Mumoli N, et al. Recanalization rate in patients with proximal vein thrombosis treated with the direct oral anticoagulants. Thromb Res 2017;153:97-100. DOI:

Prandoni P, Ageno W, Ciammaichella M, et al. The risk of post-thrombotic syndrome in patients with proximal deep vein thrombosis treated with the direct oral anticoagulants. Intern Emerg Med 2020;15:447-52. DOI:

Li R, Yuan M, Cheng J, Yu S, et al. Risk of post-thrombotic syndrome after deep vein thrombosis treated with rivaroxaban versus vitamin-K antagonists: a systematic review and meta-analysis. Thromb Res 2020;196:340-8. DOI:

Prins MH, Lensing AWA, Prandoni P, et al. Risk of recurrent venous thromboembolism according to baseline risk factor profiles. Blood Adv 2018;2:788-96. DOI:

Agnelli G, Buller HR, Cohen A, et al. Apixaban for extended treatment of venous thromboembolism. N Engl J Med


Prandoni, P. . (2022). New perspectives for prevention of the post-thrombotic syndrome. Bleeding, Thrombosis, and Vascular Biology, 1(1).


Download data is not yet available.