A 56-year-old woman comes to the office due to left lower extremity pain and swelling. One year ago, the patient had a provoked left femoropopliteal deep venous thrombosis and completed 6 months of antithrombotic therapy. Over the past 3 months, she has had slowly worsening intermittent pain, fatigue, and swelling of the left leg, especially toward the end of the day. Medical history is significant for obesity and tobacco use. Temperature is 36.6 C (97.9 F), blood pressure is 122/74 mm Hg, pulse is 83/min, and respirations are 14/min. Oxygen saturation is 98% on room air. Mild pitting edema is noted on left lower extremity examination. There are scattered dilated superficial veins, but no skin erythema or calf tenderness is present. The right lower extremity has no abnormalities. Lower extremity venous ultrasonography is negative for thrombus. Which of the following is the most appropriate next step in management of this patient?

Question

A 56-year-old woman comes to the office due to left lower extremity pain and swelling.  One year ago, the patient had a provoked left femoropopliteal deep venous thrombosis and completed 6 months of antithrombotic therapy.  Over the past 3 months, she has had slowly worsening intermittent pain, fatigue, and swelling of the left leg, especially toward the end of the day.  Medical history is significant for obesity and tobacco use.  Temperature is 36.6 C (97.9 F), blood pressure is 122/74 mm Hg, pulse is 83/min, and respirations are 14/min.  Oxygen saturation is 98% on room air.  Mild pitting edema is noted on left lower extremity examination.  There are scattered dilated superficial veins, but no skin erythema or calf tenderness is present.  The right lower extremity has no abnormalities.  Lower extremity venous ultrasonography is negative for thrombus.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d0b7_1940_bc81_150d4405650c_MD0003_00 This patient had an acute left lower extremity deep venous thrombosis (DVT) a year ago and now has left leg pain, fatigue, and edema. Although these manifestations could indicate recurrent DVT, ultrasound examination is negative for lower extremity thrombus. Therefore, the most likely diagnosis is postthrombotic syndrome, a disorder characterized by chronic venous insufficiency following acute DVT. Approximately 50% of patients with acute DVT develop postthrombotic syndrome within 2 years due to venous hypertension distal to the site of previous thrombus. This is thought to arise due to venous valve damage from the release of inflammatory mediators and venous lumen stenosis due to wall remodeling. Increased venous pressure typically causes progressive lower extremity pain, fatigue, edema, superficial venous dilation, trophic skin changes, and/or ulcers. Patients with suspected postthrombotic syndrome often undergo Doppler ultrasonography to rule out acute DVT because the symptoms can overlap. Treatment of postthrombotic syndrome should be initiated to prevent the development of venous stasis ulcers; exercise (eg, daily walking, ankle flexion exercises) and compression (eg, stockings, bandages) help improve venous return and are the mainstays of therapy. (Choices A and F) Patients with peripheral artery disease often have leg pain that worsens with activity and improves with rest (claudication); nonhealing ulcers or gangrene can also occur. Medical management often includes smoking cessation and cilostazol, an arterial vasodilator (eg, for those with no improvement with supervised exercise therapy). This patient's leg pain, edema, and history of recent DVT make postthrombotic syndrome far more likely. (Choices C and D) Inferior vena cava (IVC) filter placement is usually indicated for those who have lower extremity thrombus and a contraindication to antithrombotic therapy (eg, gastrointestinal bleed, recent cranial hemorrhage). Long-term anticoagulation is often indicated for those with recurrent thrombus, thrombus in the setting of malignancy, or hypercoagulable state with thrombus. This patient has no evidence of lower extremity thrombus; additional anticoagulation and IVC filter are not indicated at this time. (Choice E) Salt restriction and diuretics can improve volume overload in cirrhosis or heart failure, which often causes bilateral lower extremity pitting edema. This patient's unilateral edema following DVT indicates localized venous hypertension, not excessive intravascular volume; exercise and compression treatment targeted to that limb are indicated. Educational objective: Postthrombotic syndrome occurs in >50% of patients with a history of acute deep venous thrombosis and is marked by the development of chronic venous insufficiency distal to the site of thrombus. It usually presents with leg pain, edema, fatigue, superficial venous dilation, and/or ulcer. Treatment includes exercise and compression.

A 56-Year-Old Woman Comes to the Office Due to Left