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Joachim Zuther, Lymphedema Specialist. Read more

Deep Vein Thrombosis and Post-Thrombotic Syndrome


The post-thrombotic syndrome (PTS) is an important chronic complication of deep vein thrombosis (DVT). Another condition known as chronic venous insufficiency (CVI) may develop following a PTS, which in some cases can be the cause for the onset of lymphedema, which is the reason for the discussion of this topic.

To better understand the mechanics of these conditions a brief discussion of the cardiovascular system is necessary:

The cardiovascular system is an elaborate network designed to deliver oxygen and nutrients to body organs and to remove waste products of metabolism from the tissues. Its main components are the heart and a system of vessels that transports blood throughout the body. The systemic circulation is the portion of the cardiovascular system which transports oxygenated (arterial) blood away from the heart, to the rest of the body, and returns oxygen-depleted (venous) blood back to the heart.

On its way back to the heart, the venous blood passes from capillaries and small veins through progressively larger veins and connects with the right atrium of the heart via the superior and inferior vena cava.

The blood pressure inside the thin walled veins is considerably lower than the pressure in the arteries. A system of valves inside the larger veins prevents pooling of venous blood in the lower extremities and helps to ensure transporting the venous blood back to the heart efficiently. In fact, the pressure in the venous system is so low that a sufficient return of blood to the heart would not be possible without the help of the muscle and joint pumps, diaphragmatic breathing and the suction effect of the heart during the relaxation phase or diastole. Together with a functioning valvular system in the veins, these supporting mechanisms propel the venous blood back to the heart.

Deep venous thrombosis is caused by a blood clot (thrombus) that forms in the deep veins of the body, mostly in the legs; however, blood clots can form in the deep veins of the upper extremities as well. Blood clots can cause an obstruction of the return of venous blood from the extremities and form as a result of something slowing or changing the flow of blood in the veins.

Risk factors for thrombosis include:

  • Long-term bed rest
  • Crossing the legs for long periods of time when sitting, or sitting for long periods of time, such as in a plane or car
  • During and after pregnancy
  • Not having enough water in the body (dehydration)
  • Taking birth control pills or estrogen hormones (especially in women who smoke)
  • Using an intravenous catheter long-term
  • Fractures in the pelvis or legs
  • Obesity
  • Recent surgery (most commonly hip, knee, or female pelvic surgery)

Embolism is a condition that can develop when a clot breaks off and moves through the bloodstream. A blood clot can get stuck in the brain, lungs, heart, or other area, and can lead to severe damage.

Post-thrombotic syndrome (PTS) – also known as post-phlebitic syndrome or venous stress disorder – is an important long-term complication of deep vein thrombosis (DVT) and can develop in more than one third (1) of patients who experience a deep vein thrombosis in the leg. PTS is caused by damage to the veins resulting from the DVT. As a result of incompetent valves and/or persistent venous obstruction from the thrombus, the fluid dynamics inside the veins change and pressure inside the venous vessels increases. Increased pressure causes the symptoms typically associated with PTS, such as pain, swelling and redness of the lower leg (which can be worse after walking or standing for a long time and better after resting or raising the leg).

What can be done to prevent post-thrombotic syndrome?

The best way to avoid PTS is to prevent a blood clot from forming in the first place. Some individuals have a higher risk of developing blood clots, especially patients in the hospital who have had recent surgery or are confined to bed. These patients are given compression boots and stockings to prevent blood clots from forming. Medication to prevent the formation of a thrombus in high-risk hospitalized patients is often used and will prevent some cases of PTS (4).

These and other individuals who experience symptoms of PTS greatly benefit from frequent elevation of the legs, exercise and the use of compression stockings, which prevent the venous blood from pooling. Studies have shown that elastic stockings are well tolerated and that their use reduces the overall incidence of the post-thrombotic syndrome from 49% to 26% and the overall incidence of severe forms of PTS from 12% to 3.5% (5).

Severe and chronic swelling, chronic pain varicose veins and venous ulcerations are symptoms that can develop in long standing PTS – 5% – 10% of patients with deep vein thrombosis may develop this severe form of PTS (2).

Failure to effectively combat the symptoms of post-thrombotic syndrome can lead to chronic venous insufficiencies (CVI), which in turn may develop into lymphedema. More information on chronic venous insufficiency in the next entry here on the blog.

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  1. Ashrani AA, Heit JA. Incidence and cost burden of post-thrombotic syndrome. J Thromb Thrombolysis. 2009; 28: 465–476
  3. Kahn SR, Shrier I, Julian JA, et al.(2008) Determinants and time course of the post-thrombotic syndrome after acute deep venous thrombosis. Ann Intern Med 149:698707
  4. Geerts WH, Bergqvist D, Pineo GF, et al., and American College of Chest Physicians(2008) Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition) Chest 133:381S453S
  5. Paolo Prandoni, MD, PhD; Anthonie W.A. Lensing, MD, PhD; Martin H. Prins, MD, PhD; Michela Frulla, MD; Antonio Marchiori, MD; Enrico Bernardi, MD, PhD; Daniela Tormene, MD; Laura Mosena, MD; Antonio Pagnan, MD; and Antonio Girolami, MD Below-Knee Elastic Compression Stockings To Prevent the Post-Thrombotic Syndrome: A Randomized, Controlled Trial  Ann Intern Med. 17 August 2004;141(4):249-256

19 comments to Deep Vein Thrombosis and Post-Thrombotic Syndrome

  • Frances McLaughlin

    Your information is so helpful. Thanks

  • Rita Marquez PT

    Just had one walk in today. Still has the clot so will proceed cautiously.

  • Jessica Ziegler, OT

    I know that acute DVT is a contraindication of MLD. Is there a time where you would use MLD? Is it effective?

    • Joachim Zuther

      You are correct, acute DVT represents a contraindication. Once the patient is on anticoagulants and you have the okay from the treating/referring MD, treatment can be initiated. However, deep techniques (edema/fibrosis) and strong compression needs to be avoided.

  • Jessica

    Thanks for the quick response. Have you treat anyone with May-Thurner Syndrome?

  • Jessica Ziegler, OT

    Have you engaged in CDT with a May-Thurner Syndrome patient? What tips/advice or recommendations would you have?

    • Joachim Zuther

      Dear Jessica: This syndrome is associated with DVT and therefore presents a contraindication for MLD. Should there be a lymphatic issue associated with May-Thurner, MLD (and CDT) can only be applied with specific orders from the treating physician

  • Do you mind if I quote a couple of your articles as long as I provide credit and sources back to your website?
    My blog is in the very same area of interest as yours
    and my users would certainly benefit from a lot of the information you provide here.
    Please let me know if this alright with you.

    • Joachim Zuther

      Sure, please go ahead and use whatever you think is of interest. Please do credit your source appropriately.
      Kind regards,

  • Pamela Craig

    I was born with LIPEDEMA and then I was diagnosed with Lymphedema due to a DVT. I found all your articles helpful. Why is it in the US why our doctors don’t have a clue about this… i fond this frustrating and sad. I would like to know how do I battle this fatigue? I am starting with water aerobics and I hoping it will build up my stamina. Also, I would like to know are there any doctors who treat lymphedema patients in my area of Lanham, Maryland 20706.

  • Jean

    Dear Joachim,

    After a 10-hours plane trip to China, my leg began to hurt and I was diagnosed with a DVT.
    I have a question : the chinese doctor told me I had to walk to make the healing faster, but a friend back home told me that I should avoid doing too much movement, otherwise I would increase the risk of embolism. He advised me to stay home and only do some small walks home during 3 weeks.
    I was wondering if there were a real risk of embolism if I were to do more movement (walk two hours a day for example).
    Could you help me ?

    Thank you !

  • Michelle

    I am 35 female who underwent a re due auxiliary lymphnode dissection 8 weeks ago. Recently the space between right Breast and armpit is hard as a rock and larger then a tennis ball it starts from end of dissection scar to breast, then on same breast I have red hot area with a veiny appearance.

    Could my large hard area be a thrombosis or would it be more likely a lymphodema? My energy has drastically dropped in the last few days and am now running a low grade fever.

    • Joachim Zuther

      Dear Michelle: Without knowing you personally, it is impossible to supply you with an answer. I would strongly suggest you see your primary care physician to clarify the cause of the symptoms you are describing.

  • Cheri Davies

    Dear Joachim
    Thank you for the helpful information on your site. I’m a 40 year old female who suffered with bi-lateral DVT and suspected PEOPLE at the age of 25. I was discovered to have mild Protein C Deficiency. I have since taken Clexane injections during one pregnancy and two lots of foot surgery but do not take long term medication. I’m returning to exercise after a 14 month break (work, and family commitments got in the way) and since training (brisk walking every morning and Thsi Boxing twice a week) I have developed swelling and tightness in my lore leg, ankles and feet that worsens during the day (more pronounced in the right leg – this was the keg with the larger clot).
    I haven’t suffered with any swelling for years. I occasionally swell on flights and in hot climates but this feels strange. I thought venous insufficiency was meant to improve with activity. I’d appreciate any advise you could give? Do you think I need to consult my GP?
    Many thanks in advance. Cheri

    • Joachim Zuther

      Dear Cheri: Venous insufficiencies progress through stages and in most cases compression is necessary to contain the swelling.

  • Segrid Nelson

    I have lymphedema in my right leg and have been having it treated for approximately 3 years. About two months ago I had a DVT (clots in left leg, extensive clots in right leg and three PEs in one lung). (I was discovered to have a rare blood disorder and will be taking a blood thinning medicine for the rest of my life.) My lymphedema clinic PT says he has successfully treated many patients with DVT and lymphedema using only MLD (with loose or no wrapping). My doctor told me that he knows very little about lymphedema but will not approve any lymphedema treatments because of DVT. I don’t know which one to believe. I have had MLD twice since then (by a skilled and educated Certified Massage Therapist) and felt markedly better. Am I putting myself at risk by continuing MLD with my CMT? Am I putting myself at risk by not treating my lymphedema for the rest of my life?

    • Joachim Zuther

      MLD is performed with minimal pressure and should not be confused with massage, which is applied with much deeper pressure. As long as you are on anticoagulants MLD can be performed as long as it is applied by a trained and certified lymphedema therapist. Abdominal and deep abdominal techniques, as well as edema and fibrosis techniques are contraindicated.

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