ABSTRACT
Most post-thrombotic diseases are now known to be associated with a combination of obstruction and reux.16 e obstruction is a result of inadequate resolution of thrombus which quickly organizes into brotic tissue evolving into obstructive trabeculae. e term ‘chronic thrombus’ is a misnomer – the initial thrombus has turned into non-dissolvable brous tissue in a few weeks aer onset. Post-thrombotic reux results from entrapment or varying degrees of damage to the valve cusps; in some cases, the valve may survive thrombus resolution, but the intense mural and perivenous post-thrombotic brosis may result in valve station restriction resulting in relative valve cusp redundancy and reux (Figure 46.2).17 e inammatory cascade that involves the venous segment aer a thrombotic insult has not been fully appreciated.18,19
It is now clear that most patients (≥80%) with advanced CVD whether primary or secondary in origin have a combination of obstruction and reux in the deep system. An
unsolved problem is the relative importance of obstruction and reux in these subsets with combined pathologies. Success with anti-reux procedures such as valve reconstruction is now well documented in large series of primary as well as post-thrombotic disease.20,21 Because of the high prevalence of obstruction in these subsets, it is certain that a signicant proportion of patients in the reported series had undiagnosed underlying obstruction. Similarly, excellent symptom remission has been reported with stent correction of iliac vein stenosis in patients with known associated severe reux that remained uncorrected.22 It appears that partial correction of venous pathology in advanced CVD can lead to symptom remission even though residual obstruction or reux remains uncorrected.
