Chronic DVT treatment encompasses opening long-standing deep vein occlusions and managing post-thrombotic syndrome.
What is Chronic DVT?#
Chronic DVT is deep vein thrombosis that has persisted for more than 14 days from symptom onset. At this stage, the clot is organized, transformed into fibrous tissue, and adherent to the vessel wall.
Chronic DVT Characteristics:
| Feature | Acute DVT | Chronic DVT |
|---|---|---|
| Duration | <14 days | >14 days |
| Clot structure | Soft, fresh | Hard, organized |
| Lytic therapy | Effective | Ineffective |
| Main treatment | Thrombolysis | Stenting |
Post-Thrombotic Syndrome (PTS)#
Definition#
PTS is a chronic venous insufficiency syndrome that develops after DVT. It occurs in 20-50% of patients who have had DVT.
Pathophysiology#
- Venous obstruction: Residual thrombus
- Venous reflux: Valve damage
- Venous hypertension: Chronic pressure increase
- Microcirculatory damage: Tissue changes
PTS Symptoms#
Early stage:
- Leg pain and heaviness
- Swelling (especially evening)
- Cramps
- Itching
Advanced stage:
- Hyperpigmentation
- Lipodermatosclerosis
- Venous ulcer
- Chronic edema
PTS Classification#
Villalta Score#
| Symptom/Sign | None | Mild | Moderate | Severe |
|---|---|---|---|---|
| Pain | 0 | 1 | 2 | 3 |
| Cramps | 0 | 1 | 2 | 3 |
| Heaviness | 0 | 1 | 2 | 3 |
| Paresthesia | 0 | 1 | 2 | 3 |
| Itching | 0 | 1 | 2 | 3 |
| Edema | 0 | 1 | 2 | 3 |
| Skin induration | 0 | 1 | 2 | 3 |
| Hyperpigmentation | 0 | 1 | 2 | 3 |
| Redness | 0 | 1 | 2 | 3 |
| Venous ectasia | 0 | 1 | 2 | 3 |
| Calf pain | 0 | 1 | 2 | 3 |
| Venous ulcer | 0 or 15 |
Scoring:
- 0-4: No PTS
- 5-9: Mild PTS
- 10-14: Moderate PTS
- ≥15 or Ulcer: Severe PTS
CEAP Classification#
| Class | Clinical Findings |
|---|---|
| C0 | No visible venous disease |
| C1 | Telangiectasia, reticular vein |
| C2 | Varicose vein |
| C3 | Edema |
| C4a | Pigmentation, eczema |
| C4b | Lipodermatosclerosis, atrophie blanche |
| C5 | Healed venous ulcer |
| C6 | Active venous ulcer |
Chronic DVT Diagnosis#
Imaging#
Doppler Ultrasound:
- First-line evaluation
- Residual obstruction
- Reflux detection
CT Venography:
- Iliocaval segment evaluation
- Anatomical detail
- Treatment planning
MR Venography:
- Alternative method
- Soft tissue detail
Ascending Venography:
- Gold standard
- Pre-intervention evaluation
- Collateral mapping
Intravascular Ultrasound (IVUS)#
Critical role:
- True stenosis degree
- Stent sizing
- Procedural success assessment
Interventional Treatment Indications#
Who is a Candidate?#
- Iliofemoral segment involvement
- Symptoms unresponsive to medical therapy:
- Severe PTS (Villalta ≥15)
- Active or non-healing venous ulcer
- Severe edema/pain
- Good functional status
- Patient who can receive anticoagulation
Contraindications#
- Active infection
- Severe coagulopathy
- Short life expectancy
- Inability to receive anticoagulation
Interventional Treatment Techniques#
Chronic Total Occlusion Recanalization#
Technical Steps:
- Access: Popliteal or femoral vein
- Wire crossing: Crossing the CTO
- Balloon dilation: Pre-dilation
- IVUS evaluation: True sizing
- Stenting: Self-expanding stent
- Post-dilation: Optimal expansion
Venous Stenting#
Stent Selection:
| Feature | Iliac Vein | Femoral Vein |
|---|---|---|
| Diameter | 14-18 mm | 12-14 mm |
| Type | Dedicated venous | Dedicated venous |
| Length | Lesion + 1-2 cm | Lesion + 1 cm |
Dedicated Venous Stents:
- Wallstent
- Veniti Vici
- Zilver Vena
- Abre
Post-Procedure Management#
Anticoagulation:
- LMWH bridging
- Warfarin (INR 2-3) or DOAC
- Minimum 6-12 months
- Lifelong may be considered in May-Thurner
Compression:
- 30-40 mmHg below-knee stockings
- Recommended for 2 years
Treatment Outcomes#
Technical Success#
- Recanalization: 90-95%
- Primary patency (1 year): 70-80%
- Secondary patency (1 year): 85-95%
Clinical Improvement#
| Parameter | Improvement Rate |
|---|---|
| Swelling | 80-90% |
| Pain | 75-85% |
| Ulcer healing | 60-80% |
| Villalta score | Average 5-7 point decrease |
Complications#
Early:
- Access site hematoma: 3-5%
- Stent migration: <1%
- PE: <1%
- Perforation: <1%
Late:
- In-stent restenosis: 10-15%
- Stent thrombosis: 5-10%
- Stent fracture: Rare
Conservative Treatment#
In All Patients#
Compression Therapy:
- Elastic compression stockings
- 30-40 mmHg
- Symptom control
Lifestyle:
- Leg elevation
- Regular exercise
- Weight control
Medical Treatment:
- Anticoagulation (continuation)
- Venotonics (limited evidence)
- Wound care (for ulcers)
Special Situations#
Combined with May-Thurner Syndrome#
- Left iliac vein compression
- Decompression with stenting
- Long-term anticoagulation
Bilateral Involvement#
- Staged approach
- Symptomatic side first
- Both sides can be stented
IVC Involvement#
- IVC stenting may be required
- Larger diameter stents
- Careful planning
Follow-up Protocol#
Regular Check-ups#
- 1 week: Clinical check
- 1 month: Doppler US
- 6 months: Doppler US ± CT venography
- Annual: Doppler US
Monitoring Criteria#
- Stent patency
- Symptom changes
- Anticoagulation compliance
- Compression use
Frequently Asked Questions#
What is chronic DVT?
What is post-thrombotic syndrome (PTS)?
Can chronic DVT be treated?
When should chronic DVT treatment be considered?
Does a venous stent stay for life?
Appointment and Contact#
To schedule an appointment for chronic DVT and post-thrombotic syndrome evaluation:
📍 Eurasia Hospital - Beştelsiz Mah. 101. Sokak No:107, Zeytinburnu, Istanbul
📞 Phone: +90 212 665 50 50 (Ext: 4012)
This content has been prepared by Assoc. Prof. Habib Çil for general informational purposes. Please consult a cardiology specialist for definitive diagnosis and treatment.
Related Venous Interventions#
Other services related to chronic DVT treatment:
- Acute DVT Treatment - Newly formed clot treatment
- May-Thurner Syndrome - Iliac vein compression
- Varicocele and Pelvic Congestion - Venous insufficiency
- Lower Extremity Arterial Disease - Leg vessel treatment