Systematic Review of the Surgical Treatment of Moderate to Severe Post-Thrombotic Syndrome

Post-thrombotic syndrome (PTS) occurs frequently following deep venous thrombosis (DVT) and is severe in 5–10% of patients. PTS is a burdensome and costly condition due to its chronicity. Management of PTS has included the use of medical therapy such as compression, and less frequently, surgical therapies.

To summarize surgical approaches to the treatment of PTS reported in the literature and to systematically review their effectiveness and safety.

A computerized search was conducted using PubMed and reverse citation searches to retrieve articles reporting on the surgical treatment of PTS. We limited our search to English and French language articles published after 1980. Only articles that presented results of outcomes after a surgical technique performed in patients with confirmed PTS were considered.

A total of 302 titles were retrieved, of which 27 full publications were reviewed. Eleven articles (8 prospective and 3 retrospective cohort studies) were identified that met criteria for inclusion in our review. Five were single center and six were two-center studies, and none included control patients who did not undergo surgery. The studies reported on a total of 315 patients with moderate to severe PTS who had failed medical therapy. Surgical techniques included percutaneous interventions such as vein dilation and stent placement (1 study), venous bypass grafting (2 studies), endophlebectomy with reconstruction (1 study), valve reconstruction/transplant (6 studies) and interruption of perforating veins (1 study). Follow-up period after surgery ranged from 10 months-5 years.

Effectiveness outcomes measured in the studies varied widely. Anatomical outcomes included rates of venous valve competency and patency, venous filling times and ambulant venous pressure as determined by venography or Doppler ultrasound. Clinical outcomes assessed included improvement in signs and symptoms (e.g. pain, swelling, hyperpigmentation), ulcer healing, ability to return to work and reduced need for elastic compression stockings. Three studies used a quantitative scoring system to report clinical outcomes while 8 studies reported qualitative change only. Safety outcomes reported included surgical site bleeding, vessel injury, hematoma/seroma formation, infection, DVT, cellulitis, lymphocele, dysesthesia and acute valve rejection.

Ten of 11 studies included for review described some improvement in PTS after the given surgical intervention. Seven of 11 studies found improvement in all anatomic measures assessed, 2/11 studies found anatomical improvement in valve competence and patency but no hemodynamic improvement, 1/11 studies showed no anatomical improvement and 1/11 studies did not discuss anatomical outcomes. The same 10 of 11 studies also reported clinical improvement over the follow-up period, with rates of ulcer healing ranging from 50–100%. Eight of 11 studies (representing 264 patients) reported safety outcomes; no instances of mortality or pulmonary embolism were reported. Complications reported most frequently were hematoma/seroma formation and wound infection. One study that examined transplantation of cryopreserved venous valve allografts found no improvement in PTS after surgery and had a complication rate of 12/25 (48%).

Important limitations of the studies reviewed 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 with regard to use of anticoagulants, comborbidities and DVT risk factors and in three studies, lack of reporting on procedure safety.

PTS is a frequent and chronic condition for which treatment advances are clearly needed. Surgical treatment of moderate to severe PTS to reduce venous valvular reflux and/or improve venous obstruction could have the potential to be effective where conservative and medical treatments have failed. Our review describes studies of surgical techniques that have been used 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.

No relevant conflicts of interest to declare.