Treatment of post-thrombotic syndrome

Despite the fact that such a pathology as PTFS, characterized by irreversible destruction of the valve apparatus of the venous vessels of the lower extremities, cannot be cured by medication, doctors do not give up. After all, with the help of effective drugs, compression and physiotherapy, exercise therapy and lifestyle correction, it is possible to slow down the progression of the disease, maintain working capacity and make life easier for patients who, due to the disease, are practically unable to stand.

Drug therapy

To treat post-thrombophlebitic syndrome, doctors prescribe several types of drugs that can strengthen the venous walls and protect them from the negative effects of damaging factors, restore blood microcirculation, eliminate the inflammatory process inside the vessels and reduce pain, prevent the formation of blood clots (thrombi). Through drug therapy, it is possible to restore lymphatic drainage and prevent the penetration of activated lymphocytes from the blood into soft tissues.

Patients are prescribed a course of treatment using parenteral (administered by injection or drip), oral (for oral administration) and local agents. The usual duration of the course of treatment is at least 2 months.

Since the cause of post-thrombophlebitic syndrome is considered to be the formed thrombus and the changes that occur with it subsequently, drugs that help prevent the process of thrombus formation come to the fore: antiplatelet agents and anticoagulants. The former reduce the possibility of thrombocyte adhesion, and the latter improve blood flow by reducing blood viscosity, which is also a prevention of thrombus formation.

Antiplatelet agents include: Acetylsalicylic acid, Ticlopidine, Clopidogrel, Pentoxifylline, Aspigrel, etc.

Among the anticoagulants used to prevent deep vein thrombosis, the following can be distinguished: Warfarin, Heparin, Phenindione, Dalteparin, Sulodexide, Nadroparin, etc.

But thrombus prevention alone will not help. It helps restore blood flow during vessel recanalization, but has no effect on the condition of the venous walls and valves.

There are a number of drugs that can improve the condition of venous walls and valves, increase vascular tone, thereby normalizing blood microcirculation and lymphatic drainage function. Such drugs are called phlebotonics. The list of such effective drugs for PTFS includes: Detralex, Rutoside, Vazoket, Endotelon, Antistax, Troxevasin, Phlebodia.

In secondary varicose veins, the use of local phlebotonics in the form of ointments, creams and tinctures is also indicated. These are the same "Troxevasin", "Venoruton", "Troxerutin", "Venoton".

Such external agents as Heparin Ointment, Lyoton, Venobene, Venoruton, Rutoside, Indovazin, which have a phlebotonic, anti-inflammatory and antithrombotic effect, can also alleviate the condition of patients with PTFS. These are local agents with various effects, and some of the above-mentioned drugs are combination drugs that simultaneously have several beneficial effects.

Thus, "Venobene" contains heparin and dexpanthenol, which provides the drug with antithrombotic, anti-inflammatory and regenerative action, i.e. it improves blood microcirculation in superficial vessels and metabolic processes in soft tissues at the site of application. "Indovazin" contains the anti-inflammatory and anti-edematous component indomethacin, which also helps relieve pain, as well as the angioprotector and venotonic troxerutin, which, among other things, improves the trophism of soft tissues in the affected area.

In post-thrombophlebitic syndrome, a chronic inflammatory process is observed in the vessels. To combat it, patients are prescribed oral NSAIDs, which help reduce the severity of inflammation and pain caused by it. These may be the following drugs: Diclofenac, Ibuprofen, Nimesulide, Ketoprofen, Riopyrin, etc.

To combat leg swelling and venous congestion, popular diuretics such as Furosemide, Mannitol, and Lasix are prescribed. Although many doctors believe that such treatment is ineffective and even unsafe in this case, because the forced removal of fluid from the body makes the blood more viscous, which is very undesirable in vascular pathologies. In addition, the nature of swelling in venous insufficiency is somewhat different than in those diseases where diuretics are actively included in the treatment regimen (renal, cardiac, and hepatic insufficiency).

Domestic phlebologists, unlike European ones, who usually limit themselves to prescribing phlebotonics and local remedies, adhere to a 3-stage treatment regimen using all of the above-mentioned groups of drugs.

At stage 1, lasting 1-1.5 weeks, patients are prescribed injection therapy with drugs from the category of antiplatelet agents and non-steroidal anti-inflammatory drugs. Additionally, antioxidants are prescribed, part of which are vitamins (for example, B6, E, etc.). And in the presence of trophic ulcers, bacterial culture is performed and antibiotic therapy is prescribed.

At stage 2, lasting 2-4 weeks, the intake of antiplatelet agents and antioxidants continues (you can switch to oral forms), but phlebotonics and drugs that improve regenerative processes in tissues (reparants) are added to them, for example, injections of Solcoseryl or Actovegin.

Phlebotonics are continued at stage 3 of treatment, which lasts at least 6 weeks. External agents that normalize blood flow and metabolic processes in surface tissues are also actively used. If trophic disorders occur, manifested in the form of dermatitis and eczematous rashes, patients may be additionally prescribed antihistamines.

Physiotherapeutic treatment of varicose veins and PTFS

Physiotherapy for post-thrombophlebitic syndrome can be prescribed at different periods of treatment. In this case, different methods of physical influence pursue their own goals:

• intra-tissue medicinal electrophoresis with venotonics is aimed at improving the condition of the venous walls, increasing their tone, resistance to increased blood pressure,
• vacuum therapy, prescribed for secondary varicose veins and trophic ulcers, enhances microcirculation and lymph flow in areas affected by the disease, reduces swelling, helps cleanse wounds of pus and exudate, prevents the spread of infection and enhances regenerative processes,
• electrophoresis with proteolytic enzymes is prescribed for trophic ulcers and promotes the healing of such skin lesions,
• lymphatic drainage massage stimulates the outflow of lymph, treats lymphostasis and varicose veins, reduces swelling of the legs caused by the accumulation of fluid in the intercellular space,
• Low-frequency magnetic therapy improves lymphatic drainage, helps reduce swelling and pain, stimulates blood flow, while high-frequency improves the functioning of the autonomic nervous system,
• electrophoresis with drugs that prevent fibrosis (development of connective tissue at the site of thrombus resorption) of the venous wall (for example, with trypsin),
• ultrasound therapy helps to reduce the dosage of antibiotics in the treatment of trophic ulcers and cause wound healing within a week,
• laser therapy for varicose veins and PTFS has anti-inflammatory, anti-edematous and analgesic effects,
• mud therapy is used to relieve swelling, pain and heaviness in the legs,
• darsonvalization is used to stimulate lymphatic drainage, improve metabolic processes in tissues, and accelerate regenerative processes,
• electrophoresis with anticoagulants helps to reduce blood viscosity and improve blood flow in the venous system,
• Infrared saunas help strengthen the walls of blood vessels, relieve pain and heaviness in the legs, stimulate blood flow in the vessels of the lower extremities,
• pulsed magnetic therapy, amplipulse, diadynamic therapy help to increase the tone of the venous wall, strengthen the vessels, improve blood flow in them,
• Oxygen therapy, oxygen and ozone baths reduce the consequences of tissue oxygen deficiency that occurs as a result of circulatory disorders.

In case of secondary varicose veins caused by post-thrombophlebitic syndrome, doctors may prescribe multiple foot baths: turpentine, salt, radon, hydrogen sulfide, mud, etc. The choice of physiotherapy method is determined by the doctor according to the severity and degree of venous disease as a supplement to drug therapy.

Compression therapy. This method of treating venous diseases in PTFS and trophic ulcers is given special attention, because many years of experience in its use show remarkable results. More than 90% of patients who have used this treatment method for a long time noted a noticeable reduction in unpleasant symptoms. Repeated diagnostics showed a significant improvement in the condition of the venous vessels of the legs. The vast majority of patients with trophic ulcers noted their rapid and effective healing, which is difficult to achieve with other methods.

Compression therapy is included in the general scheme and is used throughout the entire treatment period. The patient must constantly wear compression stockings and tights, and if they are not available, bandage the affected limb with an elastic bandage. By the way, an elastic bandage is considered more effective at the beginning of treatment, because it allows you to adjust the density of the bandage and the level of compression. But when the patient's condition normalizes, it is better to switch to special compression hosiery.

Wearing compression hosiery has a positive effect on the veins of the legs, preventing them from stretching under the pressure of blood, giving them a kind of rest during recovery, while drug therapy helps to strengthen and tone the vascular walls.

Unfortunately, some patients report a certain discomfort that worsens their condition and quality of life. Such people can be advised to resort to the help of special non-stretchable bandages from the German company Varolast, which regulate compression depending on whether the person is at rest or actively moving. Correction of pressure on the vessels helps to avoid discomfort while wearing the bandage. The inclusion of zinc paste in the composition of the bandages allows them to be used to treat trophic ulcers, which heal faster under the influence of an antiseptic.

If post-thrombophlebitic syndrome is severe with the formation of lymphedema, and trophic ulcers do not heal for a long time even under the influence of the therapy, doctors use the method of pneumatic intermittent compression, for which a special device is used that has special air cuffs with adjustable air supply. This allows you to consistently change the pressure depending on the needs of different parts of the limb. The procedure is aimed at improving venous outflow and is especially useful for patients who, for various reasons, cannot take anticoagulants.

Patients' lifestyle. The effectiveness of therapy for PTFS largely depends on the patient's desire to return to a full life. And to do this, you will have to give up some bad habits, perhaps change your job or profession, and review your diet.

What requirements do doctors place on patients with post-thrombophlebitic syndrome:

• Since after the patient's condition has stabilized, his treatment is carried out on an outpatient basis, the patient is registered with a phlebologist or vascular surgeon and is obliged to undergo regular medical examinations and prescribed diagnostic tests, the frequency of which is determined individually.
• Sore legs require limiting physical activity, i.e. heavy physical labor, carrying heavy objects, and standing for a long time are strictly prohibited for patients, since all this creates a large load on the venous vessels of the lower extremities.
• The requirement to change work activities is also associated with the limitation of physical activity if, in order to perform their professional duties, a person has to stand on their feet for a long time, work in conditions of high or low temperatures, increased vibration, or carry heavy objects.
• Bad habits such as smoking and drinking alcohol have a negative impact on the condition of blood vessels, because tobacco smoke and alcohol in large doses are considered poison for the body, causing intoxication and destruction of the circulatory system. Sometimes these favorite habits of many become one of the causes of nagging pain in the legs, which is evidence of an unhealthy vascular system. It is clear that a person who is engaged in restoring his health will have to give up harmful addictions.
• Hypodynamia has never contributed to the restoration of health. It is only a question of limiting physical activity, but motor activity should not only be maintained, but also supplemented with therapeutic physical training exercises. When and in what volume therapeutic physical training sessions will be prescribed is determined by the attending physician. And the sessions themselves should be conducted under the guidance of an experienced trainer.

• No one is surprised anymore by the fact that the quality of our food affects the condition of our blood vessels, because both useful and harmful substances from its composition enter the bloodstream. The patient's diet should be adjusted in such a way that products that contribute to an increase in blood viscosity and can negatively affect the vascular walls (for example, with a high content of harmful cholesterol or with chemical additives that have a toxic effect on the body) are removed from it.

Post-thrombophlebitic syndrome is a disease that cannot be cured completely, but the patient's well-being depends on the doctor's requirements regarding treatment procedures and lifestyle changes. And the longer it is possible to slow down the progression of the disease, the longer the person will maintain his ability to work and take care of himself without outside help.

Effective drugs

Drug therapy cannot give a person recovery, but it can maintain the blood vessels in working order for a long time, strengthening them and stopping the destructive processes occurring inside the veins and arteries. To maintain the functionality of the venous system, doctors prescribe drugs of various types. Let's consider some of the most effective drugs.

Let's start our review of drugs with phlebotonics that increase vascular tone and improve lymphatic drainage. The recognized leader among drugs in this group is the polyvalent phlebotonic drug "Detralex", which is available in tablet form and is intended for oral administration. The drug has a pronounced venotonic and angioprotective effect. It prevents venous congestion, increases the resistance of veins to stretching, and reduces the permeability of small vessels. The drug has repeatedly proven its effectiveness in the treatment of chronic venous pathologies of the lower extremities.

In case of venous insufficiency and lymphostasis caused by post-thrombophlebitic syndrome, Detralex is prescribed in a dosage of 1000 mg per day, which should be divided into 2 doses. The first dose is taken at lunchtime, the second in the evening. Take the tablets during meals.

The only contraindication to the use of the drug, noted in the official instructions, is hypersensitivity to its components. The drug can be prescribed to pregnant women only with the permission of an obstetrician-gynecologist. Experiments have not revealed a negative effect of the drug on the fetus, but no studies have been conducted on humans.

Common side effects during the drug intake include reactions from the gastrointestinal tract: nausea, vomiting, bloating, diarrhea. Less common are dizziness, headaches, deterioration of the general condition, dermatological manifestations in the form of rashes on the body and itching.

"Rutoside" is an angioprotector of the glycoside quercetin, which is otherwise called rutin, so the effect of the drug is similar to the effects of taking vitamin P. It reduces the permeability of small vessels, strengthens venous and arterial walls, slows down the aggregation of red blood cells. In venous insufficiency and congestive processes in the lymphatic system, characteristic of post-thrombophlebitic syndrome, the drug significantly reduces pain and swelling of soft tissues, helps to combat trophic disorders and ulcerative process.

The drug is available in the form of tablets (forte) or capsules for internal use and a gel for local treatment.

Tablets and capsules should be taken with food. Capsules are usually taken 2-3 times a day, and tablets - 2 times (one per dose) for a course of at least 2 weeks. But in case of chronic venous disorders and lymphostasis, the dose can be increased by 2-3 times, so there is no need to worry about an overdose of the drug. The best effect can be achieved if you take ascorbic acid in parallel.

The gel has a cooling effect and helps combat pain and swelling when applied externally. It should be applied to the skin and rubbed in with massage movements twice a day. The symptoms disappear within 2-3 weeks. However, doctors recommend continuing the treatment for at least another 2 weeks to consolidate the result.

The drug is contraindicated in the first three months of pregnancy (especially in oral forms), as well as in case of individual sensitivity to its components, manifested in the form of allergic reactions. Side effects of the drug are limited to reactions from the gastrointestinal tract (heaviness in the stomach, flatulence, stool disorders), headaches (sometimes there are complaints of sensations similar to hot flashes during menopause), allergic reactions. Local treatment may be accompanied by skin irritation and rashes at the site of application.

"Phlebodia" is a French-made angioprotector based on bioflavonoids with selective action. It has no effect on the tone of arterial vessels. Its action is aimed at increasing the tone of small venous vessels (venules), which helps improve venous outflow and lymphatic drainage. The drug also has a moderate anti-inflammatory and antiplatelet effect.

The medicine is produced in the form of tablets for oral administration with a dosage of 600 mg. Penetrating from the gastrointestinal tract into the blood, it is concentrated mainly in the walls of large and small veins. The content of the active substance in the surrounding tissues is much lower.

The drug is prescribed for symptoms corresponding to the clinical picture of post-thrombophlebitic syndrome, such as heaviness and pain in the lower limbs, leg swelling, trophic disorders. Tablets should be taken in the morning before meals, 1 tablet per day. The course of treatment with the drug lasts on average for 2 months.

The drug is not prescribed for hypersensitivity to the components of the drug. Most often, such reactions occur in relation to the red dye (additive E124), present in the drug. During pregnancy, taking the drug is not prohibited, but the need and safety of taking it should be discussed with a doctor. But when breastfeeding, taking the drug is generally undesirable.

The drug's side effects are similar to those of other venotonics: digestive system disorders, headaches, mild allergic reactions in the form of rashes and itching on the body.

"Indovazin" is a combination product based on a bioflavonoid with angioprotective action of troxerutin (the active ingredient of the popular drug "Troxevasin") and a non-steroidal anti-inflammatory component called "indomethacin". Troxerutin reduces capillary permeability and increases venous tone, has an anti-inflammatory and anti-edematous effect on nearby soft tissues, improves cellular nutrition. Indomethacin enhances the effect of troxevasin, since it has a pronounced anti-inflammatory effect, relieves pain and swelling of the legs well.

The drug is produced in the form of a gel or ointment and is intended for local application at the site of the lesion. The medicine easily penetrates deep into the tissue and quickly relieves pain and fever at the site of inflammation.

The drug is intended for the treatment of patients over 14 years of age. It should be applied to the skin of the sore leg 3-4 times a day and gently massaged. The effective dosage is determined by the length of the strip of cream squeezed out of the tube. On average, it should be 4-5 cm, but not more than 20 cm per day.

This combination drug has slightly more contraindications. In addition to hypersensitivity to the components of the drug and NSAIDs, this includes bronchial asthma, pregnancy and breastfeeding. The external agent cannot be applied to open wounds, so its use is limited in trophic ulcers.

In most cases, Indovazin does not cause side effects. Rarely, there are complaints about the irritating effect of the drug, which manifests itself in the form of a burning sensation and warmth on the skin, reddening of tissues, the appearance of a rash and itching on them. With prolonged use, in addition to local reactions, systemic ones may also occur: dyspeptic phenomena and minor disruptions in the liver, manifested by an increase in specific enzymes, asthma attacks, anaphylactic reactions.

"Venoton" is a herbal preparation with a venotonic, anti-inflammatory and anti-edematous effect. It is available in the form of a balm (tincture), gel and capsules, the composition of which may differ slightly, but all of them can be used to treat post-thrombophlebitic syndrome.

The balm contains extracts of horse chestnut and oat seeds, sophora and rowan fruits, hazel leaves, celandine and sweet clover. Due to this composition, the natural medicine reduces capillary permeability, strengthens venous walls and makes them more elastic, restores blood filling of veins, reduces blood clotting, helps remove bad cholesterol from the body, and effectively fights inflammation and swelling.

The gel has a similar composition, which is supplemented with essential oils (mint, lemon, juniper), which help to effectively combat spider veins on the legs. As in the tincture, the main component in it is horse chestnut extract, which is used as a good venotonic and antithrombotic agent.

The capsules "Venoton" have a completely different composition:

• garlic extract, which improves blood circulation, cleanses blood vessels and has an antibacterial effect on the entire body,
• buckwheat extract, rich in such a healthy vascular substance as rutin, which strengthens arterial and venous vessels, prevents their sclerosis, reduces capillary permeability, reduces swelling caused by lymphovenous insufficiency,
• Vitamin C, which reduces blood viscosity and strengthens blood vessels, exhibiting a pronounced antioxidant effect.

The balm is intended for systemic treatment of varicose veins and PTFS, i.e. it should be taken orally, diluting 1 teaspoon of the preparation in 50-60 ml of water. Take the medicine half an hour before meals 3 or 4 times a day, but not more than 20 ml per day. The treatment course consists of 20 days, after which you can take a ten-day break and repeat the treatment.

"Venoton" capsules should be taken during meals, 1 piece 3 times a day. The course of treatment is 21-28 days, it can be repeated 2-3 times a year.

The gel is used for local treatment of the disease. It is applied to the skin in a thin layer 2 or 3 times a day, and then rubbed in with massage movements. After applying the product, wearing compression hosiery or using elastic bandages that tighten the superficial veins of the diseased limbs gives a good effect.

Contraindications to the use of the drug in any form of release are hypersensitivity to the components of the drug, the presence of internal bleeding or predisposition to them, severe renal dysfunction (especially for oral forms), angina pectoris, epilepsy. The drug is not used during pregnancy and lactation (even external forms).

"Venoton" capsules are approved for use from the age of 12; tincture and gel are not used in the treatment of children at all.

Applying the gel requires some caution. It cannot be applied to the surface of wounds, but can be applied to intact skin around trophic ulcers that may appear with PTFS. It is also not recommended to rub the product intensively into the skin. The movements should be soft and non-traumatic.

A common side effect of various forms of the drug is the possibility of developing allergic reactions with increased sensitivity of the body to various components of the complex herbal remedy. When the drug is used locally, everything is usually limited to reddening of the skin, rashes and itching, sometimes patients note heat and burning at the site of application of the gel. When taken orally, such a complication as Quincke's edema is also possible.

Taking tincture and capsules may also be accompanied by pain behind the breastbone on the left, increased heart rate (tachycardia), decreased blood pressure, and unpleasant sensations in the gastrointestinal tract (nausea, dyspepsia, heartburn, diarrhea).

Exceeding the doses of oral forms of the drug can provoke the appearance of overdose symptoms, which manifests itself in the form of headaches, gastrointestinal disorders (even vomiting is possible), dizziness and fainting, respiratory disorders. If such symptoms appear, you must immediately wash out the stomach and take a sufficient number of tablets of "Activated carbon" (1 for every 10 kg of the victim's weight) or any other sorbent.

All of the listed medications used in the treatment regimens for post-thrombophlebitic syndrome can be purchased at a pharmacy without a prescription. But they all require dosage adjustments depending on the existing pathology and its severity, which is impossible without a doctor's prescription. Self-medication in this case may not bring the expected result, but only harm, worsening an already unattractive situation.

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Surgical treatment

Since conservative treatment of post-thrombophlebitic syndrome does not allow to completely get rid of the disease, various surgical methods of treatment of this serious pathology were developed in parallel. However, surgical treatment of post-thrombotic disease is possible only after restoration of blood flow in the affected deep vessel, i.e. its recanalization. And in this task, medication and physiotherapy come to the fore. After all, if blood flow is not restored, the operation, which implies the suppression of bypass (collateral) blood flow paths, can have a negative effect on the patient's well-being.

Once the blood flow in the venous system of the lower extremities is restored, the doctor may offer the patient one of the surgical options that are effective for PTS. The most popular are surgical interventions on perforating and superficial veins, for which local anesthesia is often sufficient.

The most common operation for PTFS is considered to be crossectomy. Its essence lies in ligation of large and small subcutaneous veins at the place of their connection with deep veins (in the area of perforating vessels). An incision is made in the inguinal or popliteal fossa, the damaged vessel is ligated in two places, and then removed using a special probe.

Crossectomy as an independent operation is rarely performed. It is often part of a complex operation that includes crossectomy (ligation of affected superficial veins), stripping (their extraction using a probe), miniphlebectomy (removal of the extracted vein), removal of the perforating vein that does not perform its function and allows blood reflux from the deep veins to the superficial ones.

In essence, we are talking about removing part of the superficial veins in the presence of such a complication as reflux. But there are other methods of restoring impaired venous blood flow. For example, the Psatakis method involves correcting blood flow using a tendon in the popliteal region. A kind of loop is made from the isolated section of the tendon for the affected vein, which will squeeze it while walking, acting on the principle of a pump.

When the patency of the iliac veins is impaired, the Palm method of vessel bypass comes to the rescue. The shunt is inserted into the affected vein of the inguinal region at the point where it connects with a normally functioning one. The design, which often has the shape of a spiral, maintains the lumen of the vessel constant, preventing its walls from stretching too much under the pressure of the blood.

This ensures a tighter fit of the vein valves, which only allow blood to pass in one direction and work on the principle of a pump. Loose valves or their destruction are the cause of blood stagnation in the lower extremities, because the blood itself will not flow upward. Unfortunately, such operations are not very popular due to the high risk of repeated thrombosis.

Occlusion in the femoropopliteal region is treated by phlebectomy and installation of an autograft vessel (most often a section of vein with good valves taken from the armpit is used as an implant). If reflux remains, part of the subcutaneous vessels are removed. In advanced cases of post-thrombophlebitic syndrome with damage to large veins after their recanalization, an operation called saphenectomy is prescribed, which involves removing such vessels.

Since most phlebologists see the cause of venous insufficiency in the failure of the valve system, active development of artificial vascular valves (intra- or extravascular) is underway today. For now, such operations are at the testing stage and are being improved, because less than fifty percent success is not sufficiently convincing evidence of the effectiveness of the methods being introduced to correct the functioning of venous valves.