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Susan R. Kahn - One of the best experts on this subject based on the ideXlab platform.
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Diagnostic scales for the Post-Thrombotic Syndrome.
Thrombosis research, 2017Co-Authors: Hilde Skuterud Wik, Susan R. Kahn, Tone Enden, Waleed Ghanima, Marit Engeseth, Per Morten SandsetAbstract:Abstract Post-Thrombotic Syndrome (PTS) is the most common long-term complication after deep vein thrombosis (DVT) developing in up to 70% of the patients. PTS is diagnosed on the basis of typical symptoms and signs of the lower limb with a previous DVT, but no objective diagnostic test exists. A number of diagnostic scales have been developed primarily for research purposes. An optimal diagnostic test for PTS should be reliable and easy to use, sensitive and specific, able to grade PTS severity, and to identify changes over time. We have identified reports on seven diagnostic scales that have been used for the diagnosis of PTS; the Widmer classification, the Clinical-Etiological-Anatomical-Pathological (CEAP) classification, the Venous Clinical Severity Score (VCSS), the Brandjes scale, the Ginsberg measure, the Villalta scale, and the Patient-reported Villalta scale. The aim of this paper was to review and present the existing diagnostic scales for PTS in adults and their utility in clinical studies.
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The importance of post thrombotic Syndrome as an outcome after deep venous thrombosis: A survey of Canadian thrombosis clinicians
Thrombosis research, 2017Co-Authors: Rick Ikesaka, Susan R. Kahn, Jean-philippe Galanaud, Marc A. Rodger, Fernando J. Vazquez, Graham Roche-nagle, Marc Carrier, Grégoire Le Gal, Esteban GandaraAbstract:Abstract Objectives The development of post thrombotic Syndrome (PTS) is a major source of morbidity and reduced quality of life. We sought to determine the value assigned by clinicians to post thrombotic Syndrome and whether clinicians believe that any post thrombotic Syndrome or severe post thrombotic Syndrome are important outcomes to assess after deep vein thrombosis (DVT) as compared to other outcomes. Design The design of the study was a self-responded electronic survey. Questions for the online survey were designed by two authors (R.I. and E.G.). Methods The survey was distributed to 233 members of Thrombosis Canada and the Canadian Society for Vascular Surgery between August 2014 and October 2014. Results There were 84 responses to the survey with complete responses were obtained from 71 respondents for a response rate of 36%. PTS was ranked as a significantly less important outcome after DVT than recurrent DVT, pulmonary embolism during treatment, major bleeding, death, quality of life, venous ulceration and severe post thrombotic Syndrome (all comparisons p Conclusions Our survey determined that “any post thrombotic Syndrome” is perceived by physicians as less important than other DVT outcomes. Thus, “Severe PTS” and not “Any PTS” should be included as an outcome measure in studies investigating acute DVT.
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Epidemiology of the Post-Thrombotic Syndrome.
Thrombosis research, 2017Co-Authors: Jean-philippe Galanaud, Manuel Monreal, Susan R. KahnAbstract:Abstract The post thrombotic Syndrome (PTS) refers to clinical manifestations of chronic venous insufficiency (CVI) following a deep-vein thrombosis (DVT). PTS is the most frequent complication of DVT, which develops in 20 to 50% of cases after proximal DVT and is severe in 5–10% of cases. The reported prevalence of PTS differs widely among studies because of differences in study populations, tools used to assess PTS, and time interval between acute DVT and PTS assessment. The two most important predictors of PTS are extensive proximal character of DVT and previous ipsilateral DVT. Other reported risk factors include pre-existing CVI, obesity, quality of anticoagulant treatment, older age and residual venous obstruction. Standardization of PTS assessment tools combined with the development of patient self-reported PTS scales are likely to constitute a breakthrough in research of the epidemiology of PTS, by allowing comparison between studies, meta-analyses and increasing the feasibility of longer follow-up of DVT patients. This should enable identification of patient populations at high risk of severe PTS, new predictors of PTS and targets for potential new treatments. In this perspective, identification of biomarkers that are predictive of PTS such as markers of inflammation is crucial in ongoing research.
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Predictors of the Post-Thrombotic Syndrome and their effect on the therapeutic management of deep vein thrombosis
Journal of Vascular Surgery: Venous and Lymphatic Disorders, 2016Co-Authors: Jean-philippe Galanaud, Manuel Monreal, Susan R. KahnAbstract:The Post-Thrombotic Syndrome (PTS), which refers to chronic clinical manifestations of venous insufficiency after a deep vein thrombosis (DVT), is a frequent occurrence. Because treatment options for PTS are limited, its management mainly relies on the prevention of its occurrence after DVT. Among identified predictors of PTS, extensive proximal location of DVT directly modifies the treatment of DVT because of the possibility of performance of complementary endovascular techniques. The association between poor international normalized ratio control and subsequent PTS should encourage physicians to perform frequent and regular international normalized ratio monitoring of patients receiving vitamin K antagonists. Other identified PTS risk factors are ipsilateral DVT recurrence, older age, pre-existing primary venous insufficiency, obesity, and residual venous obstruction, but these are less amenable to therapy. Because of their potential therapeutic implications, identification of biomarkers that are predictive of PTS such as markers of inflammation is crucial and such research is ongoing.
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Guidance for the prevention and treatment of the Post-Thrombotic Syndrome
Journal of Thrombosis and Thrombolysis, 2016Co-Authors: Susan R. Kahn, Jean-philippe Galanaud, Suresh Vedantham, Jeffrey S. GinsbergAbstract:The Post-Thrombotic Syndrome (PTS) is a frequent, potentially disabling complication of deep vein thrombosis (DVT) that reduces quality of life and is costly. Clinical manifestations include symptoms and signs such as leg pain and heaviness, edema, redness, telangiectasia, new varicose veins, hyperpigmentation, skin thickening and in severe cases, leg ulcers. The best way to prevent PTS is to prevent DVT with pharmacologic or mechanical thromboprophylaxis used in high risk patients and settings. In patients whose DVT is treated with a vitamin K antagonist, subtherapeutic INRs should be avoided. We do not suggest routine use of elastic compression stockings (ECS) after DVT to prevent PTS, but in patients with acute DVT-related leg swelling that is bothersome, a trial of ECS is reasonable. We suggest that selecting patients for catheter-directed thrombolytic techniques be done on a case-by-case basis, with a focus on patients with extensive thrombosis, recent symptoms onset, and low bleeding risk, who are seen at experienced hospital centers. For patients with established PTS, we suggest prescribing 20–30 mm Hg knee-length ECS to be worn daily. If ineffective, a stronger pressure stocking can be tried. We suggest that intermittent compression devices or pneumatic compression sleeve units be tried in patients with moderate-to-severe PTS whose symptoms are inadequately controlled with ECS alone. We suggest that a supervised exercise training program for 6 months or more is reasonable for PTS patients who can tolerate it. We suggest that management of Post-Thrombotic ulcers should involve a multidisciplinary approach. We briefly discuss upper extremity PTS and PTS in children.
Grace Townshend - One of the best experts on this subject based on the ideXlab platform.
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Long-term Low-Molecular-Weight Heparin and the Post-Thrombotic Syndrome: A Systematic Review
The American journal of medicine, 2011Co-Authors: Russell D. Hull, Jane Liang, Grace TownshendAbstract:Abstract Objective Post-Thrombotic Syndrome causes considerable morbidity. The Home-LITE study showed a lower incidence of Post-Thrombotic Syndrome and venous ulcers after 3 months of treating deep vein thrombosis with the low-molecular-weight heparin tinzaparin versus oral anticoagulation. This systematic review examined whether long-term treatment of deep vein thrombosis using low-molecular-weight heparin, rather than oral anticoagulation, reduces development of Post-Thrombotic Syndrome. Methods We identified 9 articles comparing treatment of deep vein thrombosis using long-term low-molecular-weight heparin with any comparator, which reported outcomes relevant to the Post-Thrombotic Syndrome assessed ≥ 3 months post-deep vein thrombosis. Results Pooled analysis of 2 studies yielded an 87% risk reduction with low-molecular-weight heparin in the incidence of venous ulcers at ≥ 3 months ( P = .019). One study showed an overall odds ratio of 0.77 ( P = .001) favoring low-molecular-weight heparin for the presence of 8 patient-reported Post-Thrombotic Syndrome signs and symptoms. Pooled analysis of 5 studies showed a risk ratio for low-molecular-weight heparin versus oral anticoagulation of 0.66 ( P 0001) for complete recanalization of thrombosed veins. Conclusion These results support the lower incidence of Post-Thrombotic Syndrome and venous ulcers observed in Home-LITE. Long-term treatment with low-molecular-weight heparin rather than oral anticoagulation after a deep vein thrombosis may reduce or prevent development of signs and symptoms associated with Post-Thrombotic Syndrome. Post-Thrombotic Syndrome and associated acute ulcers may develop more rapidly after deep vein thrombosis than previously recognized.
Alun H. Davies - One of the best experts on this subject based on the ideXlab platform.
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Post thrombotic Syndrome following deep vein thrombosis in paediatric patients.
Phlebology, 2017Co-Authors: Klara Vosicka, Mahim I Qureshi, Susan Shapiro, Chung S. Lim, Alun H. DaviesAbstract:BackgroundAlthough well characterised in adults, less is known about Post-Thrombotic Syndrome in children. In this review, current knowledge regarding paediatric Post-Thrombotic Syndrome is summari...
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Handbook of Venous Thromboembolism - Post Thrombotic Syndrome.
Advances in experimental medicine and biology, 2016Co-Authors: Andrew Busuttil, C.s. Lim, Alun H. DaviesAbstract:Venous insufficiency following deep venous thrombosis is known as the post thrombotic Syndrome. Whilst its presentation and symptoms can vary slightly between individuals, it can have a profound effect on quality of life. Symptoms range from mild limb swelling to severe intractable ulceration. A number of scoring systems have been developed to help monitor the disease progression, response to treatment as well as to classify patients for research purposes.
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Post-Thrombotic Syndrome: a clinical review.
Journal of thrombosis and haemostasis : JTH, 2013Co-Authors: M. J. Baldwin, H. M. Moore, Manjit S. Gohel, Nung Rudarakanchana, Alun H. DaviesAbstract:Up to half of patients with proximal deep vein thrombosis (DVT) will develop Post-Thrombotic Syndrome (PTS) despite optimal anticoagulant therapy. PTS significantly impacts upon quality of life and has major health-economic implications. This narrative review describes the pathophysiology, risk factors, and diagnosis, prevention and treatment of PTS, to improve our understanding of the disease and guide treatment. Relevant articles were identified through systematic searches of the PubMed, EMBASE and Cochrane databases between 1966 and November 2011. Studies were included for detailed assessment if they met the following criteria: published in English, human study participants, study population aged > 18 years, and lower limb Post-Thrombotic Syndrome. All non-systematic reviews and single patient case reports were excluded. Recurrent thrombosis, thrombus location and obesity are major risk factors, whereas the importance of gender and age remain uncertain. The diagnosis of PTS is based on clinical findings in patients with a known history of DVT. Several clinical scales have been described, with the Villalta Score gaining increasing popularity. Adequate anticoagulation and use of elastic compression stockings (ECS) following DVT can reduce the incidence of PTS. Catheter-directed thrombolysis and mechanical thrombectomy of acute DVT may preserve valvular function. Studies to date of these techniques are encouraging, and have reported improved hemodynamics and a reduced incidence of PTS. The management of established PTS is challenging. Compression therapy, aimed at reducing the underling venous hypertension, remains the mainstay of treatment. This is despite a paucity of high-quality evidence to support its use. Pharmacologic and surgical treatments have also been described, with a number of studies citing symptomatic improvement.
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Scoring systems for the Post-Thrombotic Syndrome
Journal of vascular surgery, 2012Co-Authors: Arany Soosainathan, H. M. Moore, Manjit S. Gohel, Alun H. DaviesAbstract:Objective To assess each of the scoring systems used to diagnose and classify Post-Thrombotic Syndrome, a common chronic complication of deep vein thrombosis. The design of the study was a systematic review of the literature pertaining to Post-Thrombotic Syndrome. Methods A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines by a search of PubMed (1948 to September 2011) using the search terms "Post-Thrombotic Syndrome," "postthrombotic Syndrome," "post-phlebitic Syndrome," and "postphlebitic Syndrome." A manual reference list search was also carried out to identify further studies that would be appropriate for inclusion. The various scoring systems in use were identified and assessed against a list of criteria to determine their validity for use. For outcome measures, each scoring system was assessed for specific criteria, including interobserver reliability, association with ambulatory venous pressures, ability to assess severity of Post-Thrombotic Syndrome, ability to assess change in condition over time, and association with patient-reported symptom severity. Results The Villalta, Ginsberg, Brandjes, Widmer, CEAP, and Venous Clinical Severity Score systems all were assessed for the stated outcome measures. From their use in the literature, only the Villalta score was able to fulfill all the criteria described. The main criticism of the Villalta score in the literature appears to be its use of subjective measures. To that end, we propose that use of a venous disease-specific quality-of-life questionnaire in combination with the Villalta score may help standardize the subjective criteria. Conclusions The Villalta score, combined with a venous disease-specific quality-of-life questionnaire, should be considered the "gold standard" for the diagnosis and classification of Post-Thrombotic Syndrome.
Marilyn J. Manco-johnson - One of the best experts on this subject based on the ideXlab platform.
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Validation of Upper Extremity Post-Thrombotic Syndrome Outcome Measurement in Children
The Journal of pediatrics, 2010Co-Authors: Neil A. Goldenberg, Elizabeth Pounder, R. Knapp-clevenger, Marilyn J. Manco-johnsonAbstract:Using the Manco-Johnson instrument in a derivation cohort of 107 children with or without a central venous catheter, upper extremity physical findings of Post-Thrombotic Syndrome were absent, and the pain score was 0 in all but one child. Interrater reliability in an independent validation cohort (n = 38) of children with or without upper extremity deep venous thrombosis was 97%-100%.
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Post-Thrombotic Syndrome in children: a systematic review of frequency of occurrence, validity of outcome measures, and prognostic factors
Haematologica, 2010Co-Authors: Neil A. Goldenberg, Susan R. Kahn, Mark Crowther, Marco P. Donadini, Gili Kenet, Ulrike Nowak-göttl, Marilyn J. Manco-johnsonAbstract:Background Post-Thrombotic Syndrome is a manifestation of chronic venous insufficiency following deep venous thrombosis. This systematic review was conducted to critically evaluate pediatric evidence on frequency of occurrence, validity of outcome measures, and prognostic indicators of Post-Thrombotic Syndrome. Design and Methods A comprehensive literature search of original reports revealed 19 eligible studies, totaling 977 patients with upper/lower extremity deep venous thrombosis. Calculated weighted mean frequency of Post-Thrombotic Syndrome was 26% (95% confidence interval: 23–28%) overall, and differed significantly by prospective/non-prospective analysis and use/non-use of a standardized outcome measure. Results Standardized Post-Thrombotic Syndrome outcome measures included an adaptation of the Villalta scale, the Clinical-Etiologic-Anatomic-Pathologic classification, and the Manco-Johnson instrument. Data on validity were reported only for the Manco-Johnson instrument. No publications on Post-Thrombotic Syndrome-related quality of life outcomes were identified. Candidate prognostic factors for Post-Thrombotic Syndrome in prospective studies included use/non-use of thrombolysis and plasma levels of factor VIII activity and D-dimer. Conclusions Given that affected children must endure chronic sequelae for many decades, it is imperative that future collaborative pediatric prospective cohort studies and trials assess as key objectives and outcomes the incidence, severity, prognostic indicators, and health impact of Post-Thrombotic Syndrome, using validated measures.
Jean-philippe Galanaud - One of the best experts on this subject based on the ideXlab platform.
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The importance of post thrombotic Syndrome as an outcome after deep venous thrombosis: A survey of Canadian thrombosis clinicians
Thrombosis research, 2017Co-Authors: Rick Ikesaka, Susan R. Kahn, Jean-philippe Galanaud, Marc A. Rodger, Fernando J. Vazquez, Graham Roche-nagle, Marc Carrier, Grégoire Le Gal, Esteban GandaraAbstract:Abstract Objectives The development of post thrombotic Syndrome (PTS) is a major source of morbidity and reduced quality of life. We sought to determine the value assigned by clinicians to post thrombotic Syndrome and whether clinicians believe that any post thrombotic Syndrome or severe post thrombotic Syndrome are important outcomes to assess after deep vein thrombosis (DVT) as compared to other outcomes. Design The design of the study was a self-responded electronic survey. Questions for the online survey were designed by two authors (R.I. and E.G.). Methods The survey was distributed to 233 members of Thrombosis Canada and the Canadian Society for Vascular Surgery between August 2014 and October 2014. Results There were 84 responses to the survey with complete responses were obtained from 71 respondents for a response rate of 36%. PTS was ranked as a significantly less important outcome after DVT than recurrent DVT, pulmonary embolism during treatment, major bleeding, death, quality of life, venous ulceration and severe post thrombotic Syndrome (all comparisons p Conclusions Our survey determined that “any post thrombotic Syndrome” is perceived by physicians as less important than other DVT outcomes. Thus, “Severe PTS” and not “Any PTS” should be included as an outcome measure in studies investigating acute DVT.
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Epidemiology of the Post-Thrombotic Syndrome.
Thrombosis research, 2017Co-Authors: Jean-philippe Galanaud, Manuel Monreal, Susan R. KahnAbstract:Abstract The post thrombotic Syndrome (PTS) refers to clinical manifestations of chronic venous insufficiency (CVI) following a deep-vein thrombosis (DVT). PTS is the most frequent complication of DVT, which develops in 20 to 50% of cases after proximal DVT and is severe in 5–10% of cases. The reported prevalence of PTS differs widely among studies because of differences in study populations, tools used to assess PTS, and time interval between acute DVT and PTS assessment. The two most important predictors of PTS are extensive proximal character of DVT and previous ipsilateral DVT. Other reported risk factors include pre-existing CVI, obesity, quality of anticoagulant treatment, older age and residual venous obstruction. Standardization of PTS assessment tools combined with the development of patient self-reported PTS scales are likely to constitute a breakthrough in research of the epidemiology of PTS, by allowing comparison between studies, meta-analyses and increasing the feasibility of longer follow-up of DVT patients. This should enable identification of patient populations at high risk of severe PTS, new predictors of PTS and targets for potential new treatments. In this perspective, identification of biomarkers that are predictive of PTS such as markers of inflammation is crucial in ongoing research.
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Predictors of the Post-Thrombotic Syndrome and their effect on the therapeutic management of deep vein thrombosis
Journal of Vascular Surgery: Venous and Lymphatic Disorders, 2016Co-Authors: Jean-philippe Galanaud, Manuel Monreal, Susan R. KahnAbstract:The Post-Thrombotic Syndrome (PTS), which refers to chronic clinical manifestations of venous insufficiency after a deep vein thrombosis (DVT), is a frequent occurrence. Because treatment options for PTS are limited, its management mainly relies on the prevention of its occurrence after DVT. Among identified predictors of PTS, extensive proximal location of DVT directly modifies the treatment of DVT because of the possibility of performance of complementary endovascular techniques. The association between poor international normalized ratio control and subsequent PTS should encourage physicians to perform frequent and regular international normalized ratio monitoring of patients receiving vitamin K antagonists. Other identified PTS risk factors are ipsilateral DVT recurrence, older age, pre-existing primary venous insufficiency, obesity, and residual venous obstruction, but these are less amenable to therapy. Because of their potential therapeutic implications, identification of biomarkers that are predictive of PTS such as markers of inflammation is crucial and such research is ongoing.
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Guidance for the prevention and treatment of the Post-Thrombotic Syndrome
Journal of Thrombosis and Thrombolysis, 2016Co-Authors: Susan R. Kahn, Jean-philippe Galanaud, Suresh Vedantham, Jeffrey S. GinsbergAbstract:The Post-Thrombotic Syndrome (PTS) is a frequent, potentially disabling complication of deep vein thrombosis (DVT) that reduces quality of life and is costly. Clinical manifestations include symptoms and signs such as leg pain and heaviness, edema, redness, telangiectasia, new varicose veins, hyperpigmentation, skin thickening and in severe cases, leg ulcers. The best way to prevent PTS is to prevent DVT with pharmacologic or mechanical thromboprophylaxis used in high risk patients and settings. In patients whose DVT is treated with a vitamin K antagonist, subtherapeutic INRs should be avoided. We do not suggest routine use of elastic compression stockings (ECS) after DVT to prevent PTS, but in patients with acute DVT-related leg swelling that is bothersome, a trial of ECS is reasonable. We suggest that selecting patients for catheter-directed thrombolytic techniques be done on a case-by-case basis, with a focus on patients with extensive thrombosis, recent symptoms onset, and low bleeding risk, who are seen at experienced hospital centers. For patients with established PTS, we suggest prescribing 20–30 mm Hg knee-length ECS to be worn daily. If ineffective, a stronger pressure stocking can be tried. We suggest that intermittent compression devices or pneumatic compression sleeve units be tried in patients with moderate-to-severe PTS whose symptoms are inadequately controlled with ECS alone. We suggest that a supervised exercise training program for 6 months or more is reasonable for PTS patients who can tolerate it. We suggest that management of Post-Thrombotic ulcers should involve a multidisciplinary approach. We briefly discuss upper extremity PTS and PTS in children.
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Compression stockings to prevent Post-Thrombotic Syndrome
Lancet (London England), 2014Co-Authors: Jean-philippe Galanaud, Marc Philip Righini, Isabelle QuéréAbstract:www.thelancet.com Vol 384 July 12, 2014 129 left to the discretion of the observer with no quantitative measurement or use of CEAP (Clinical, Etiological, Anatomical, and Pathophysiological) classification. The results were not reported at 2 years as planned, but rather were a cumulative incidence of Post-Thrombotic Syndrome from 6 to 24 months. There was no diff erence for both endpoints, with 2-year data for the primary outcome available in only 45·5% of patients, and for the secondary endpoint in 27% of patients. This study contradicts previous fi ndings. The design and execution of this trial, including the timing of application of elastic compression stockings, the application itself, and defi nition and evaluation of compliance, seem inappropriate. Patients were randomised at a mean of 4·7 days from the time of deep venous thrombosis, and elastic compression stockings were applied within the first 2 weeks of diagnosis. What was the mean time from diagnosis to elastic compression stockings application? Optimum management in this acute phase is crucial for early symptom relief, recurrence, and late outcome. This has clearly been shown for adequate anticoagulation treatment, but also for compression and immediate mobilisation. Compression and walking exercises reduce pain and swelling immediately, and symptoms diminish after 1 week. The aim of continuing wearing elastic compression stockings is to maintain this effect—this could be crucial because the patient might recognise the immediate benefit from using elastic compression stockings and therefore overall compliance would be improved. Sizing was based on leg measurements and elastic compression stockings were sent to patients without provision of proper training. Most patients are unable to apply stockings without specific instruments or training, especially Post-Thrombotic Syndrome: heparin, a drug discovered a century ago by Jay McLean (in 1916), which revolutionised deep-vein thrombosis prognosis. Moreover, a well-conducted anticoagulation treatment has also been associated with a decreased rate of Post-Thrombotic Syndrome. Therefore, the results of the SOX trial should not be “leaving doctors empty handed”, but should rather reinforce their role in off ering a high-quality anticoagulant treatment to their patients. An ongoing international placebocontrolled trial should assess more precisely the eff ect of heparin on the natural history of Post-Thrombotic Syndrome after a distal deep-vein thrombosis (NCT00539058). The eff ect of new oral anticoagulants on the prevention of Post-Thrombotic Syndrome is another important issue.