Post- thrombotic Syndrome

A 61-year-old woman comes for review. Around one year ago she finished a 6 month course of warfarin after being diagnosed with an unprovoked, proximal deep vein thrombosis. For the past few weeks she has been experiencing 'heaviness' and 'aching' in the the same leg. This is associated with an itch and some swelling, although this seems to go down each night.
Past medical history of note includes osteoarthritis and type 2 diabetes mellitus.
On examination prominent varicose veins are seen on the affected leg with some brown discolouration of the skin above the medial malleolus. There is no difference in the circumference of the calves. Her temperature is 36.9 C, pulse 78/min and blood pressure 108/82 mmHg.

What is the most likely diagnosis?
A. Recurrence of deep vein thrombosis
B. Post-thrombotic syndrome
C. Cellulitis
D. Ruptured Baker's cyst
E. Necrobiosis lipoidica

Answer: B. Post-thrombotic syndrome

Discussion: The slowly progressive symptoms of pruritus and pain accompanied by the examination findings are strongly suggestive of post-thrombotic syndrome.

Post-thrombotic syndrome It is increasingly recognized that patients may develop complications following a DVT. Venous outflow obstruction and venous insufficiency result in chronic venous hypertension. The resulting clinical syndrome is known as post thrombotic syndrome.


The following features maybe seen:
 painful, heavy calves
 pruritus
 swelling
 varicose veins
 venous ulceration

Compression stockings should be offered to all patients with deep vein thrombosis to help reduce the risk of post-thrombotic syndrome.

NICE state the following:
Offer below-knee graduated compression stockings with an ankle pressure greater than 23 mmHg to patients with proximal DVT a week after diagnosis or when swelling is reduced sufficiently and if there are no contraindications, and:
 advise patients to continue wearing the stockings for at least 2 years
 ensure that the stockings are replaced two or three times per year or according to the manufacturer's instructions  
 advise patients that the stockings need to be worn only on the affected leg or legs.