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Editorials |

Getting a Leg Up on the Postthrombotic Syndrome

Lawrence W. Raymond, MD, ScM, FCCP
Author and Funding Information

Affiliations: Charlotte, NC
 ,  Dr. Raymond is Director of Occupational and Environmental Medicine at Carolinas HealthCare System in Charlotte, and Professor of Family Medicine at the University of North Carolina at Chapel Hill.

Correspondence to: Lawrence W. Raymond, MD, ScM, FCCP, Department of Family Medicine, Carolinas Medical Center, PO Box 32861, Charlotte, NC 28232; e-mail: lwr@med.unc.edu



Chest. 2003;123(2):327-330. doi:10.1378/chest.123.2.327
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This ancient Chinese teaching would surely dampen the hubris of any clinician who has just made a difficult, serious diagnosis. But it is no time for complacency, as illustrated by deep venous thrombosis (DVT), “a wolf in sheep’s clothing,”1 even without its insidious complication, the postthrombotic syndrome (PTS). Despite enormous advances in recent years in the diagnosis and treatment of DVT,2 much less progress has been made in the understanding and management of PTS. Some of this shortfall stems from variations in PTS case definition, especially in earlier studies. Estimates of the incidence and prevalence of PTS have accordingly spanned a wide range. In the preheparin era, Bauer3 documented a relentless deterioration of patients with DVT, 80% of whom eventually acquired ulceration, ie, severe PTS, 15 years after their initial thrombosis. Even in studies over the past 20 years, the prevalence of PTS ranged from 21 to 88%,6 depending on the basis for diagnosis, the presence of underlying medical conditions, and the treatment employed. Recently, more uniform, reproducible classifications like that of Villalta et al7 lent more order to this area of investigation. That scale scores five symptoms (pain, cramping, limb heaviness, pruritus, paresthesias) and six signs (edema, induration, pigmentation, venous ectasia, redness, calf tenderness). By grading each element from 0 to 3 in severity, a combined score is developed. Even here, the categories of mild/moderate (score of 5 to 14) vs severe (≥ 15, or stasis ulceration) create a somewhat awkward delineation. Use of the scale of Villalta et al7 has yet to be reported as a means of monitoring patients after DVT. Nor are there validated physiologic measures to predict which patients are destined to acquire PTS. Though limited by the lack of “gold standard” criteria for diagnosis, physicians in 2003 can give patients with DVT a global estimate that even with optimal therapy, approximately one third of them go on to acquire PTS.46 Could such somber information lead patients to follow treatment advice more fully? Does it spur us clinicians to do a better job in following guidelines for primary prevention of DVT?8

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