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American Journal of  Medical Science
and Innovation (AJMSI)

Challenges in The Management of  Post-Thrombotic Syndrome in a Low-Resource Setting  
Onyango C. Vonwicks1*, Malalu P. Collins1, Auma Nicholas2, Fryda C. William1

Volume 4 Issue 2, Year 2025
ISSN: 2836-8509 (Online)

DOI: https://doi.org/10.54536/ajmsi.v4i2.6278
https://journals.e-palli.com/home/index.php/ajmsi

Article Information ABSTRACT

Received: October 04, 2025

Accepted: November 08, 2025

Published: November 21, 2025

Post-thrombotic syndrome (PTS) is the most common long-term complication of  deep 
venous thrombosis (DVT) and occurs in up to 20-50% of  proximal DVTs. Patients 
with PTS present with pain and swelling of  the affected limb, edema with pruritus, 
skin hyperpigmentation, and venous ulcers. Risk factors for PTS include ineffective 
anticoagulation, obesity, and proximal DVT. The Villalta scale is validated for the diagnosis 
and severity scoring of  PTS. The American Heart Association recommends primary and 
secondary prevention of  PTS as the most effective management strategy since treatment of  
established PTS is very challenging, especially in resource-limited settings. The latter includes 
external compression devices, exercise, pharmacotherapy, venous ulcer management, and 
surgical endovascular procedures in selected patients. PTS leads to frequent hospital visits, 
reduced productivity, and a low quality of  life. In this study, we present the diagnostic and 
therapeutic challenges in managing a 30-year-old woman with PTS in a rural Kenyan setting. 
We propose a patient-centered multidisciplinary approach to managing PTS. 

Keywords
Kenya, Persistent DVT, Post-
Thrombotic Syndrome, PTS, 
Recurrent DVT, Villalta Scale

1 Department of  Medicine, St. Joseph Rift Valley Hospital, Gilgil, Nakuru County, Kenya
2 Department of  Endoscopy, St. Joseph Rift Valley Hospital, Gilgil, Nakuru County, Kenya
* Corresponding author’s e-mail: drvonczelo@gmail.com

INTRODUCTION
Post-thrombotic syndrome (PTS) is a common long-
term complication of  deep venous thrombosis (DVT) 
that occurs in up to 20-50% of  proximal DVT and may 
be severe in 5-10% of  the cases (Galanaud et al., 2018). 
It occurs primarily due to impaired and incomplete 
resolution of  the thrombus, persistent obstruction of  
venous outflow with ambulatory venous hypertension, 
and secondary valvular incompetence (Cosmi et al., 
2022). The main risk factors for PTS include previous 
and recurrent ipsilateral DVT, proximal DVT (especially 
iliofemoral), persistent symptoms ≥ 1 month after DVT 
diagnosis, obesity, and having subtherapeutic INRs while 
on warfarin for > 50% of  the duration of  treatment 
(Vazquez & Kahn, 2012). Table 1 below summarizes 
the risk fators for PTS (Wang et al., 2023). The typical 
symptoms of  PTS include heaviness of  the affected leg, 
pain, edema, and pruritus, which tend to worsen in the 
evenings, and trophic skin changes like hyperpigmentation 
and venous ulcers in severe cases (Makedonov et al., 
2020). There are many challenges in the management of  
PTS in low-resource settings. Difficulties in the diagnosis 
of  PTS arise from the widespread use of  point-of-
care diagnostic compression ultrasound (CUS) which 
is unable to distinguish between acute DVT and PTS. 
A lack of  confirmatory imaging modalities like CT and 
MRI scans in these clinical settings means that patients 
with PTS are repeatedly misdiagnosed as acute DVT and 
put on unnecessary prolonged anticoagulation with either 
warfarin or direct oral anticoagulants. This is especially 
true where patients seek treatment from different centers 
for “non-resolving” DVT symptoms. Though not lethal, 
PTS leads to a reduced quality of  life, increased use of  
healthcare services through frequent hospital visits, and 

decreased productivity (Wang et al., 2023). This case 
report from a rural Kenyan hospital highlights some of  
these challenges in the diagnosis and management of  
PTS and the resulting negative impact in the quality of  
life for the patient. We call for an increased awareness of  
the principles of  PTS diagnosis and management.

Table 1: Risk factors for development of  PTS (Wang et 
al., 2023).
Risk factors at baseline Risk factors 

during follow-up
Proximal DVT (especially 
iliofemoral)

Subtherapeutic 
INR 

Recurrent DVT history Ipsilateral recurrent 
DVT 

Obesity Residual thrombus 
Pre-existing venous insufficiency Venous reflux 
Higher severity of  symptoms at 
diagnosis 
Older age 

Key: PTS, post-thrombotic syndrome; DVT, deep vein thrombosis; 
INR, international normalized ratio.

LITERATURE REVIEW
The diagnosis of  PTS is based on the risk factor profile 
and clinical symptomatology. There is considerable 
overlap in the symptoms of  PTS, acute DVT, and primary 
venous insufficiency. Many low-resource clinical settings 
rely on compression ultrasound (CUS) for the diagnosis 
of  acute DVT. CUS may not distinguish acute DVT from 
a chronic thrombus (PTS), especially where previous 
imaging is unavailable for comparisons. This situation 



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is common in low-resource settings when patients seek 
treatment from different health centers that often lack 
central integrated electronic medical records (Gautam et 
al., 2020).  There are no biomarkers that are validated for 
diagnosing DVT or predicting acute DVT patients who 
will develop PTS later. Due to these diagnostic challenges, 
the Villalta scale has been validated for use in both clinical 
practice and research to standardize the diagnosis and 
estimate the severity of  PTS (Kahn et al., 2014). Table 2 
below, adapted from Guanella (Guanella & Kahn, 2012), 
shows the Villalta scale. 

The treatment of  established PTS is challenging. The 
American Heart Association (AHA) recommendations 
for treating established PTS include i) compression-
based therapies like graduated external compression 
stockings (ECS) and intermittent compression devices, 
ii) pharmacotherapy with rutosides, defibrotide, and 
hidrosmin, iii) exercise training programs, iv) venous 
ulcer management, and v) surgical and/or endovascular 
procedure interventions for selected patients, including 
bypass procedures, stents, and complex reconstruction 
surgeries (Kahn et al., 2014). Given these challenges in 
treating established PTS, the AHA recommends both 
primary and secondary prevention as the mainstay 
of  management. These strategies include i) primary 
prevention of  DVT using pharmacological and 
mechanical thromboprophylaxis in high-risk patients and 
ii) secondary prevention strategies such as optimal and 
effective anticoagulation for DVT treatment, use of  elastic 
compression stockings, and thrombolysis/endovascular 
therapies for selected patients (Kahn et al., 2014). There 
is no reported case of  PTS from a Kenyan hospital in 

Table 2: The Villalta Scale (Guanella & Kahn, 2012).
None Mild Moderate Severe

Symptoms
Pain 0 1 2 3
Cramps 0 1 2 3
Heaviness 0 1 2 3
Paresthesia 0 1 2 3
Pruritus 0 1 2 3
Clinical Signs
Pretibial edema 0 1 2 3
Skin induration 0 1 2 3
Redness 0 1 2 3
Hyperpigmentation 0 1 2 3
Venous stasis 0 1 2 3
Pain in calf  
compression

0 1 2 3

Venous ulcer Absent   Present

Key: Total score of  0 to 4 indicates no post-thrombotic syndrome 
(PTS); score of  ≥5 indicates PTS. PTS severity: total score of  5 
to 9, mild PTS; score of  10 to 14, moderate PTS; and score of  
≥15 or venous ulcer present, severe PTS.

the literature as at the writing of  this case study. The 
Kenya Ministry of  Health guidelines on the diagnosis 
and management of  venous thromboembolism does 
not include any information on PTS (Division of  Non-
Communicable Diseases, 2018). Therefore, this study 
aims to expose the presence of  PTS in a rural Kenyan 
setting and highlight the challenges in the diagnosis and 
management of  PTS in a low-resource clinical setting.

MATERIALS AND METHODS
Patient History and Physical Examination
A 30-year-old married mother of  7, a business lady 
from Tanzania but living in Nakuru, Kenya, first 
presented to us at the medical clinic in April 2022, with 
persistent left leg pain, swelling, and numbness over 
the preceding 18 months. She had been first diagnosed 
with left leg common femoral vein (CFV) deep venous 
thrombosis (DVT) on Doppler ultrasound in February 
2021, following a cesarean section. She was treated with 
warfarin for 8 months (by the 6th month, she reportedly 
still had significant pain and swelling of  the left leg, hence 
the decision to continue warfarin beyond 6 months). 
Notably, her INR remained subtherapeutic between 1.2 
and 1.8 during the 8 months of  treatment. She stopped 
breastfeeding after 8 months. The next month, she was 
put on 20 mg of  rivaroxaban daily for another month 
in another facility when a repeat Doppler ultrasound 
showed DVT in the left CFV. In the 10th month, she 
was switched back to warfarin plus aspirin for another 
month in yet a different facility in which the left CFV 
still had DVT. From the 11th month, she was put on 
rivaroxaban in a different facility following a Doppler 
scan showing left CFV DVT. She was on rivaroxaban 
(20 mg daily) when she came to us. She was visibly 
frustrated with the diagnosis of  persistent left CFV DVT 
by multiple doctors who “failed to listen to her and were 
in a hurry to prescribe anticoagulants” and the possibility 
of  lifelong anticoagulation without much symptomatic 
improvement.
She was hemodynamically stable, obese with a weight 
of  98 kg and a BMI of  32.4 kg/m2, and limping on 
the left leg. The left leg was swollen and moderately 
hyperpigmented from the mid-leg to the foot and tender 
on the entire medial aspect from the foot to the groin, 
with no lymphadenopathy, no venous ulcers, and no 
features of  varicose veins. See figure 1 below. The rest 
of  the systemic examination was unremarkable. A repeat 
Doppler scan showed DVT in the left CFV. Her baseline 
metabolic workup was unremarkable. 

RESULTS AND DISCUSSION
Diagnosis, Management, and Follow-up
We made a diagnosis of  severe post-thrombotic syndrome 
(given the fact that the DVT in the left CFV had not 
changed since 2021) based on the Villalta scale with a 
score of  27. We proposed to stop the anticoagulation, 
manage pain with non-steroidal anti-inflammatory drugs, 
elevate the left leg while in bed, use external compression 



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Figure 1: Swollen left leg with hyperpigmented skin from 
the mid-leg to the foot. There were no venous ulcers or 
varicose veins.

stockings, undergo physiotherapy, and that she actively 
lose weight in a structured nutritional support system. 
We also referred her for psychological counseling. Two 
physiotherapy centers near her home declined her 
physiotherapy following their evaluation of  the left leg 
over fears of  possibly dislodging the clot and precipitating 
a pulmonary embolism. The surgical team added Daflon 
(diosmin and hesperidin) to her treatment and requested 
a CT venogram, which confirmed an organized clot in 
the left CFV with resultant significant luminal narrowing. 
She was referred to vascular surgeons at the national 
teaching and referral hospitals for a possible endovascular 
recanalization procedure. At 2 vascular surgical clinics in 
different towns, she was seen by different doctors who 
restarted the rivaroxaban 20 mg daily at different times 
for left CFV DVT based on repeat Doppler scans in each 
of  these clinics. She returned to us 20 months after the 
referral and has had multiple clinic visits with us due to 
persistent pain and left leg swelling, with frustrations 
about the persistent symptoms. She has since cut down 
weight to 92 kg (lost 6 kg over 3 years). We stopped 
the rivaroxaban again and have been implementing the 
original management plan, including physiotherapy at 
our hospital. She went into depression and was seen by a 
psychiatrist and put on antidepressants. Notwithstanding 
these interventions, she reports minimal improvement 
related to better pain control. We consulted a vascular 
surgeon in a private hospital, who will do a stenting 
procedure in December 2025. Presently, she is under a 
multidisciplinary care team while the family is seeking 
financial resources to actualize the planned surgery.

DISCUSSION
Our patient had severe PTS based on a Villalta score 
of  27 (Guanella & Kahn, 2012). Her risk factors for 
PTS included obesity, proximal DVT (left common 
femoral vein), subtherapeutic INR during the index 
anticoagulation, persistent symptoms at 6 months of  
anticoagulation, and residual thrombus (Wang et al., 
2023). Achieving and maintaining a target INR of  2 to 

3 with warfarin effectively prevents PTS by stopping 
thrombus propagation and promoting early thrombus 
resolution (Makedonov et al., 2022). Use of  direct oral 
anticoagulants (DOACs) has been shown to be superior 
to warfarin in many studies to prevent PTS (Kahn et al., 
2014). Our patient has been seen in several different health 
facilities in which she was repeatedly (mis)diagnosed 
with persistent/new/recurrent DVT by means of  
compression Doppler ultrasound (CUS). The symptoms 
of  PTS closely mimic those of  acute DVT, and CUS may 
not distinguish acute from chronic thrombus, especially 
where previous imaging is unavailable for comparisons 
(Gautam et al., 2020). This sort of  mistake is common 
where patients are seen in different health institutions, as 
was with our patient. It is therefore understandable that 
the various facilities she visited opted to treat her as a 
case of  acute DVT with anticoagulation. At our hospital, 
we determined from at least 9 different CUS reports that 
the left CFV was involved in all the reports, making it 
more likely that the index left CFV DVT had persisted 
and become organized all this time rather than being a 
new clot. This finding was confirmed by a CT venogram. 
Magnetic resonance imaging (MRI) is more accurate than 
CUS and CT scans in diagnosing recurrent DVT but 
obviously more expensive (Müller et al., 2023). Ideally, 
the vascular clinics she was referred to should have put 
her on management strategies for established PTS since 
the referral letter had the diagnosis of  PTS established 
clinically and with the attached CT venogram report. The 
AHA guidelines for the management of  established PTS 
are both class I and II recommendations, with mixed 
outcomes in several studies due to the heterogeneity 
of  the study participants (Kahn et al., 2014). There is 
no therapeutic value in prolonged anticoagulation of  
patients with PTS.
Our patient has responded, albeit suboptimally, to 
the management strategy, including weight reduction, 
external compression stockings, physiotherapy and 
exercise, analgesics, and psychological counselling. The 
diagnosis of  PTS has markedly affected her quality of  life 
negatively due to frustrations about the non-resolution of  
the PTS despite multiple clinic visits with the attendant 
financial expenditures. Our multidisciplinary approach has 
alleviated most of  her pain and psychosocial aspects of  
the PTS diagnosis. Based on the AHA recommendations, 
she is a potential candidate for a combined operative and 
endovenous procedure (Kahn et al., 2014), which she is 
scheduled for in December 2025.
 
CONCLUSIONS
PTS is a common complication of  proximal DVT 
due to incomplete resolution of  the index thrombus 
resulting in venous obstruction and secondary valvular 
incompetence. The main risk factors for PTS include 
proximal DVT, obesity, ineffective anticoagulation, and 
persistent DVT symptoms. The Villalta scale is validated 
for the diagnosis and severity of  PTS. The AHA 
recommends both primary and secondary prevention of  



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PTS as the most effective management. Established PTS 
may respond to ECS, pharmacotherapy, exercise, venous 
ulcer management, and surgical endovascular procedures 
in selected cases. Clinicians ought to have a high index 
of  suspicion for the diagnosis of  PTS in patients 
with a compatible risk factor profile who present with 
“persistent” DVT in the same leg. These patients should 
be managed in a patient-centered multidisciplinary team 
that includes psychosocial care. There is no therapeutic 
value to prolonged anticoagulation in patients with PTS.

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