What is the role of chronic venous insufficiency in the pathogenesis of deep venous thrombosis (DVT)?

Updated: Jun 05, 2019
  • Author: Kaushal (Kevin) Patel, MD; Chief Editor: Barry E Brenner, MD, PhD, FACEP  more...
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Answer

Over time, thrombus organization begins with the infiltration of inflammatory cells into the clot. This results in a fibroelastic intimal thickening at the site of thrombus attachment in most patients and a fibrous synechiae in up to 11%. [24] In many patients, this interaction between vessel wall and thrombus leads to valvular dysfunction and overall vein wall fibrosis. Histological examination of vein wall remodeling after venous thrombosis has demonstrated an imbalance in connective tissue matrix regulation and a loss of regulatory venous contractility that contributes to the development of chronic venous insufficiency. [25, 26] Some form of chronic venous insufficiency develops in 29-79% of patients with an acute DVT, while ulceration is noted in 4-6%. [27, 28] The risk has been reported to be 6 times greater in those patients with recurrent thrombosis. [29]

Over a few months, most acute DVTs evolve to complete or partial recanalization, and collaterals develop (see the images below). [30, 31, 32, 33, 34, 35] Although blood flow may be restored, residual evidence of thrombus or stenosis is observed in half the patients after 1 year. Furthermore, the damage to the underlying valves and those compromised by peripheral dilation and insufficiency usually persists and may progress. Venous stasis, venous reflux, and chronic edema are common in patients who have had a large DVT. [36]

Deep venous thrombosis (DVT). This lower-extremity Deep venous thrombosis (DVT). This lower-extremity venogram shows outlining of an DVT in the popliteal vein with contrast enhancement.
Deep venous thrombosis (DVT). The lower-extremity Deep venous thrombosis (DVT). The lower-extremity venogram reveals a nonocclusive chronic thrombus. The superficial femoral vein (lateral vein) has the appearance of two parallel veins, when in fact it is one lumen containing a chronic linear thrombus. Although the chronic clot is not obstructive after it recanalizes, it effectively causes the venous valves to adhere in an open position, predisposing the patient to reflux in the involved segment.

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