Postphlebitic Syndrome

The end stage result of the inflammatory process caused by clot formation in the deep vein is the permanent destruction of the integrity of the vein and is guardian valves. The body has the capability to dissolve some of the clot but this often leaves the vein wall narrowed and renders the valves incompetent. In more severe cases, or cases where there is an unrecognized chronic clotting condition (coagulopathy) the deep vein pathway is completely closed and this will cause permanent swelling of the leg and lead to severe skin changes (lipodermatosclerosis, atrophie blanche) and venous ulceration. The venous blood will try to form new ways to get around the blocked deep vein using the superficial venous system. This can lead to the formation of large varicose veins or the process may be more diffuse and hidden deep inside the thickened skin of the swollen leg. Traditional therapy advocates rapid anticoagulation with heparin, administered in a hospital setting, until outpatient transition can be made to a Vitamin K antagonist such as Coumadin or Warfarin . To minimize the long term disabilities that can result, anticoagulants are recommended for a period of 6 to 12 months as well as lifelong use of graduated elastic compression stockings. Today the standard of care in severe cases is rapidly moving toward a more proactive treatment model utilizing the skill of the interventional therapist to remove as much of the clot as possible with enzymatic and mechanical devices such as TPA infusion, Angiojet, Trellis device, angioplasty and stents. This still needs to be followed by oral anticoagulation and stockings. Less severe cases are now being treated on an outpatient basis with self administered dosing of newer agents such as Lovenox, Enoxaprin and Fondaparinux.. These medicines are prepackaged, simple to use and similar to the concept diabetics giving themselves their own insulin injection. The patient still needs to transition to oral agents and we recommend thigh high, open toed graduated elastic compression stockings: Carolan, Jobst, Juzo, Medi, Sigvaris, and Venosan on a life time basis. Contrary to the popular belief that removing varicose veins associated with post phlebitis syndrome would aggravate venous drainage, Professor Peter Gloviczki, MD of the Mayo Clinic and others have proved that ablating the incompetent superficial veins and perforator will improve the patient’s condition as long as they continue to wear graduated elastic compression stockings.