Venous Stress Disorder
Pain, Swelling and Other Chronic Symptoms after a Blood Clot
By Dr. Stephan Moll, Chapel Hill, North Carolina, and Dr. Susan R. Kahn, Montreal, Canada
A number of chronic symptoms may develop in the legs and arms after a blood clot forms in a vein, or after the valves in a vein are damaged. The symptoms and findings include pain, welling, discoloration, and ulcers. These problems are common after a deep vein thrombosis (DVT), the medical term for the formation of a blood clot in the deep veins of the legs or arms.
Normally, blood from the legs and arms moves through our veins in one direction. Small valves in the veins keep the blood fl owing correctly. Problems occur if the valves are damaged, or if the veins are obstructed with clots or scar tissue. As a result of these problems, the leg or arm may become swollen and painful. Several different terms are used to label the chronic symptoms, but they all describe the same problem:
- Venous stasis syndrome
- Postthrombotic syndrome
- Venous insufficiency syndrome
- Postphlebitic syndrome
For the purpose of this article, the symptoms will be referred to as “venous stress disorder,” a term that includes a variety of problems related to the veins. Not everybody who has the symptoms of venous stress disorder has experienced a blood clot. The same symptoms may occur in patients with heart failure, obesity, dysfunction of the valves in the vein, and other causes that are not clearly identifiable.
What are the symptoms?
While some people who have had a DVT recover completely, others may have chronic arm and leg symptoms (Table 1). Sometimes, the problems can be severe enough to cause disability. Symptoms are typically worse by the end of the day. The symptoms are less in the morning, or after resting the legs or arms in an upward position. Dark pigmentation may occur, but this does not cause symptoms or damage the skin. A patient with chronic extremity swelling may develop hardened, dry, and scaly skin. Skin breakdown can occur and an ulcer may form.
Who develops it?
Typically, a more extensive DVT will result in a more severe case of venous stress disorder. However, this is not always so: even patients who have had extensive DVTs may recover completely and have no chronic symptoms. The symptoms of venous stress disorder usually occur within the first six months after a clot, but can occur up to two years after the incident. If a patient has done well for six months to two years after the clotting event, it is unlikely that he or she will develop venous stress disorder.
How do you prevent and
Prevention is the key issue. If a patient has leg swelling after an acute DVT, compression stockings should be worn to decrease the swelling. They should be properly sized by measuring the patient’s leg circumference. They need to have a certain compression pressure at different parts of the leg, which is referred to as gradient compression. The range of compression should be 30-40mmHg. The stocking should cover the entire part of the leg that has swelling. Stockings should be worn during the day, but are not needed at night. Further research on the benefit of compression stockings and the prevention of the venous stress disorder is ongoing.
Sleeves or “gauntlets” are worn for swelling or pain in the arm. Stockings come in a variety of colors, shapes, sizes and materials, and from a variety of companies. It is worthwhile for the patient to make inquiries to find the right stocking that fits correctly, is relatively comfortable, and has an acceptable appearance. “Anti Embolism Stockings” or “TED hose” are used for hospitalized patients to prevent blood clots in the legs. However, they only put mild pressure on the legs and are not useful to prevent, or treat, venous stress disorder.
While resting, elevating the arm or leg above the level of the heart is also helpful to decrease swelling. Maintaining the correct body weight may also improve the symptoms, as may regular exercise. In cases of pronounced swelling that does not improve with compression stockings, a compression pump can be tried. Such pumps can lead to significant relief and are often not considered by physicians.
Pain management is important and needs to be individualized. It can be difficult to control pain and a consultation at a specialized Pain Clinic may be necessary. Some patients have a narrowing of a vein in the pelvic area. This can be due to a congenital narrowing (May-Thurner syndrome) or to scarring of the blood vessel from a healed blood clot. If a narrowing is present, it may be helpful to undergo a vascular radiology procedure to balloon open and insert a stent into the narrowed vein.
Symptoms may dramatically improve. Skin ulcers that result from venous stress disorder may be difficult to heal. A visit with a vein or wound care specialist is recommended. Short stretch bandages, Unna boots, or foam dressings, often lead to wound healing, although this is a slow process.
A summary of treatment options and information on the products mentioned above, is found in Table 2.