Diagnosis of deep vein thrombosis, and prevention of deep vein thrombosis recurrence and the post-thrombotic syndrome in the primary care medicine setting anno 2014

Table 1 Scoring system according to Brandjes for mild-to moderate and severe postthrombotic syndrome[24]

Subjective criteria
Symptoms	Score	Signs	Score
For mild-to-moderate PTS: score > 3 of subjective and objective criteria
Spontaneous pain in calf	1	Calf circumference ↑ by 1 cm	1
Spontaneous pain in thigh	1	Ankle circumference ↑ by 1 cm	1
Calf pain on standing/ walking	1	Pigmentation	1
Thigh pain on standing/ walking	1	Venectasia	1
Edema of foot/calf	1	Newly formed varicosis	1
Heaviness of foot/leg	1	Phlebitis	1
For severe PTS score > 4 of symptoms and signs
Spontaneous pain	1	Calf circumference ↑ by 1 cm	1
Pain on standing/walking Edema calf	1	Pigmentation, discolouration, and venectasia	1
Impaiment of daily activities	4	Healed or active ulcer	1

Table 2 Scoring system according to Prandoni for the assessment of post-thrombotic syndrome in the early period 3 to 12 mo post-DVT known as the Vilalta score[29-31]

Subjective symptoms	Objective signs
Heaviness	Pretibial oedema
Pain	Induration of the skin
Cramps	Hyperpigmentation
Pruritus	New venous ectasia
Paraesthesia	Redness
Pain during calf compression
Ulceration of the skin (= severe)
Each sign or symptom is graded with a score as 0, 1, 2, or 3
0 = absent, 1 = mild, 2 = moderate or interference with daily life and work, 3 = severe or invalidating
The presence or absence of leg ulcer has to be noted
Definition of post-thrombotic syndrome according to Prandoni(Vilalta)
Absent	Score < 4
Mild-to-moderate	core between 5 and 14 at 2 consecutive visits
Severe	score > 15 at 2 consecutive occasions or ulcer at 1 occasion

Table 3 Clinical-etiology-anatomic-pathophysiologic classification for severity of chronic venous insufficiency[26]

Classification	Symptom
C0 (C = Clinical)	No visible varicose veins
C1	Spider or reticular veins
C2	Varicose veins
C3	Oedema
C4a	Pigmentetion or eczema
C4b	Lipodermatosclerosis or atrophie blanche
C5	Skin changes with healed ulceration
C6	Skin changes with active ulceration
S	Symptomatic, including aches, pain, tightness, skin irritation, heaviness, muscle cramps, and other complaints attributable to venous dysfunction
A	Asymptomatic
Clinical symptoms	Post-DVT
E = Etiology	Deep, perforator, or superficial vein, alone or in combination
A = Anatomic distribution	Reflux or obstruction, alone or in combination
P = Pathophysiologic dysfunction

Table 4 Widmer classification for assessment of chronic venous insufficiency[27]

Classification	Symptom
I	Corona phlebotatica paraplantaris (ankle flare), subclinical mild oedema
II	Hyperpigmentation, lipo- and dermatosclerosis, atrophie blanche (white skin atrophy), oedema, eczema
III	Healed or active ulcer

Table 5 Venous clinical severity score system of PTS or chronic venous insufficiency[28]

Attribute	Absent= 0	Mild= 1	Moderate= 2	Severe= 3
Pain	None	Occasional, not restricting activity or requiring analgesics	Daily, moderate activity limitation, occasional analgesics	Daily, severe limiting activities or requiring regular use of analgesics
Varicose veins	None	Few, scattered: branch varicous veins	Multiple: GS varicose veins confined to calf or thigh	Extensive: thigh and calf or GS and LS distribution
Venous oedema	None	Evening ankle oedema only	Afternoon oedema, above ankle	Morning oedema above ankle and requiring activity change, elevation
Skin pigmentation	Non or focal, low intensity	Diffuse, but limited in area and old (brown)	Diffuse over most of gaiter distribution (lower 1/3) or recent pigmentation (purple)	Wider distribution (above lower 1/3) and recent pigmentation
Inflammation	None	Mild cellulitis, limited to marginal area around ulcer	Moderate cellulitis, involves most of gaiter area (lower 1/3)	Entire lower third of leg or more
No. of active ulcers	0	1	> 2	> 2
Active ulceration, duration	None	< 3 mo	> 3 mo, < 1 yr	Not healed > 1 yr
Active ulcer, size	None	< 2 cm diameter	2 to 6 cm diameter	> 6 cm diameter
Compressive therapy	Not used or not compliant	Intermittent use of stockings	Wears stockings most days	Full compliance: stockings + elevation

GS: Greater saphenous; LS: Lesser saphenous.

Table 6 2008 Rotterdam objective scoring system for grading the severity of PTS during the first two years post-DVT based on prospective studies[18-25]: therapeutic implications

Objective score
Complete recanalization at 3 mo and no reflux	0
Incomplete recanalization at 3 mo	2
Complete recanalization after 6 mo and reflux	1
Incomplete recanalization after 6 mo and reflux	2
Obstruction after 1 year without or with reflux	3
Normal D-dimer after discontinuation of anticoagulant therapy	0
Increased D-dimer after discontinuation of anticoagulant thereapy	3
Clinical score
Brandjes Prandoni score for PTS: Absent	0
Mild	1
Moderate	2
Total Rotterdam score 12
Score	Therapeutic implication
Score 0 at 6 mo	No MECS and no ACT
Score 1 to 4 at 6 mo	MECS and discontinuation ACT
Score > 4 and normal D-dimer	MECS randomization ACT vs no ACT
Score > 4 and abnormal D-dimer	MECS and continuation of ACT according to the PROLONG
	Plus Study
Designed by Michiels

ACT: Anticoagulant treatment.