Deep Vein Recanalization for the Treatment of Post Thrombotic Syndrome

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You were diagnosed with a deep vein thrombosis (DVT) months ago. You’ve been religiously taking blood thinning medication, wearing compression stockings, and exercising. Yet your leg is chronically swollen, painful, discolored, and starting to develop bulging varicose veins. You can barely stand on the leg for any length of time, and nothing seems to help with the symptoms. What initially seemed like a condition that would last weeks to months is now lasting much longer than you anticipated. Sound familiar?

Post Thrombotic Syndrome (PTS) (aka post phlebitic syndrome) affects over 50% of patients with DVT that extends into the thigh and/or pelvis or abdomen. PTS often develops within 1-2 years of DVT, yet most patients are NOT told this when they are initially diagnosed with DVT in the ER. Generally, patients are instructed to take a blood thinner and follow up with their PCP. For many patients, the day they are diagnosed with a DVT is the beginning of a lifelong nightmare!

As days turn into weeks and weeks turn into months of leg swelling and pain, a visit to the doctor often results in “oh, you have PTS. Not much to do. Just live with it.” In fact, some patients have no leg swelling at all and instead have chronic debilitating leg pain with an otherwise normal looking leg. These patients get treated the worst as they are often labeled as “drug seeking”. Many physicians including vascular specialists will also say there is not much that can be done for PTS, either due to a lack of knowledge or familiarity of the advances in the treatment of chronic DVT. So is there any hope? Add to this the fact that more cases of thrombosis related to Covid are being seen worldwide and it begs the question, “will PTS increase in the future as Covid-related thrombosis increases?”.

will PTS increase in the future as Covid-related thrombosis increases?

Deep vein recanalization (DVR) offers the potential for vein restoration and symptomatic relief of leg swelling and pain, and reduces the risk of recurrent blood clots even among patients considered “untreatable” as a result of long-term PTS. Deep venous recanalization is a complex, yet minimally invasive procedure that involves threading a small wire (1-2 mm in diameter) and a catheter from the ankle through the blocked veins. A balloon is advanced over the wire and inflated to open the vein (a technique known as angioplasty) and break up scar tissue that is preventing the vein wall from staying open. Once the scar tissue is broken, the previously blocked vein opens, enabling blood to drain from the legs and lower body back to the heart. For blocked veins in the abdomen and pelvis, stents are placed to keep the veins open.

FIG 1: The scar tissue within the vein is broken up (not removed) so that the vein can regain its normal diameter.
Who is a candidate for DVR?

A thorough clinical history and physical exam MUST be done first by a qualified vascular specialist. In general, DVR may be performed in patients who meet the following criteria:

  • have chronic DVT with PTS for a minimum of 6-12 months AND have maximized conservative treatment to the best of their ability (i.e. compression stockings, leg elevation, exercise, weight loss)
  • MUST be compliant and able to take blood thinning medication (potentially lifelong)
  • MUST be able to walk (not paralyzed)
  • have an optimistic “can do” attitude
Who is NOT a candidate for DVR?

DVR cannot be performed if a patient:

  • cannot take blood thinners
  • has severe heart issues (must be evaluated on a case by case basis)
  • is at high risk for general anesthesia (being put completely asleep)
  • is paralyzed and cannot walk (in rare instances, DVR may be considered in those with chronic nonhealing venous leg ulcers due to their paralysis)
How successful is DVR?

No matter how many years have gone by since the initial DVT, in experienced hands, DVR may be successfully performed. In my experience, nearly 90% of patients have significant improvement in quality of life after DVR. So why isn’t DVR being performed throughout the country? It is because DVR is one of THE most complex endovascular procedures that can be performed. As such, many vascular specialists do not have the volume of cases to develop extensive experience with DVR. It is not uncommon for DVR procedures to take 8-12 hrs due to the extensive “concrete-like” scar tissue within the veins from prior DVT. Because the process of breaking up this scar tissue can be so tedious, it is crucial that DVR be done correctly the FIRST time.

No matter how many years have gone by since the initial DVT, in experienced hands, DVR may be successfully performed.

DVR is not a “one and done” kind of procedure. Close long-term follow-up with the treating vascular specialist will ensure that patients maintain stent patency (open stent) and improvement in PTS. DVR does NOT cure PTS, replace the damaged veins, or return a patient’s leg back to normal (prior to the DVT). The primary goal of DVR is to improve a patient’s quality of life so that they can get back to doing the things they love with a more manageable level of PTS. In those with nonhealing venous ulcers, DVR can be the difference between healing the ulcer vs lifelong visits to wound care centers.

Are there any clinical trials currently underway for DVR?

The C-TRACT trial sponsored by the National Institutes of Health (NIH) is the first actively enrolling multi-center prospective randomized trial designed to determine the ability of endovascular therapy (EVT) to reduce the severity of PTS in patients with moderate-to-severe PTS due to previous DVT. More information about the C-TRACT trial can be found here

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