Management of the postthrombotic syndrome: the Rotterdam approach

The postthrombotic syndrome (PTS) affects the deep venous system, and may also extend to the superficial venous system of the legs in patients with a documented history of deep vein thrombosis. Clinical symptoms of PTS may vary considerably and range from scarcely visible skin changes to changes in pigmentation, pain, discomfort, venous ectasia, edema, and ulceration. Our view based on standard investigations and the proper place of advanced investigations regarding the etiology and pathophysiology of PTS has lead to the Rotterdam approach, incorporating the evidence-based diagnostics and treatments available for PTS. High-quality duplex sonography is mandatory in all patients, providing anatomical and functional (reflux) information on both the deep and superficial venous systems, and non- or partially recanalized veins (occlusion) can also be detected using this technique. If the results of duplex sonography are not clear or a venous desobstruction procedure is to take place, phlebography will be the investigation of choice. There is a lot of evidence that medical elastic stockings (MECS) are effective in the prevention of PTS with documented reflux, obstruction, or both. When prescribing MECS, it is important to examine both elasticity and hysteresis of the fabric of the stockings to apply the correct dynamic pressure for each individual patient. Patients with documented PTS should receive life-long follow-up.