Top Things to Know: Revisiting the Open Vein Hypothesis to Reduce the Post-thrombotic Syndrome — Implications for Multidisciplinary Care and Research

Published: May 13, 2025

Post-thrombotic syndrome (PTS) is a frequent complication after proximal deep vein thrombosis (DVT), affecting up to 50% of patients despite anticoagulation, with 5–10% developing severe cases, including venous ulcers.
Standard treatments such as compression therapy, leg elevation, exercise, venoactive drugs, and wound care provide symptom relief but do not cure PTS, making prevention a key priority.
The open vein hypothesis (OVH) suggests early thrombus clearance reduces PTS by preventing residual obstruction and valvular reflux. Clinical trials support catheter-directed thrombolysis for select patients with acute iliofemoral DVT (IFDVT) and low bleeding risk. However, these interventions are not optimal for proximal DVT that is limited to the femoral and popliteal veins.
Since OVH was first proposed, research has revealed additional contributors to PTS, including genetic predisposition, thrombophilia, inflammation, fibrinolysis, and treatment timing, prompting a refined approach.
Initially focused on rapid thrombus removal, OVH now emphasizes maintaining long-term vein health, addressing PTS drivers, and incorporating multidisciplinary care for better outcomes.
A two-stage care model for IFDVT includes early anticoagulation, symptom monitoring, and risk stratification at diagnosis, followed by ongoing follow-up, recurrence prevention, and venous patency maintenance.
IFDVT, defined as a thrombus in the iliac or common femoral vein, is often identified via duplex ultrasound, with cross-sectional imaging considered for suspected iliocaval DVT when ultrasound is inconclusive.
Key research priorities include improving preclinical models, refining PTS assessment tools, developing multidisciplinary care strategies, identifying predictive biomarkers, and evaluating interventions such as antithrombotics, anti-inflammatories, obesity management, and exercise.
Future advancements in basic science, omics, AI, telehealth, and implementation science may refine OVH into a broader venous health paradigm with personalized care strategies.
Collaboration among clinicians, researchers, policymakers, industry, and communities is essential to increasing thrombosis awareness, enhancing DVT prevention, and improving PTS management.

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Citation

Li W, Vedantham S, Jaffer FA, Kakkos SK, Galanaud J-P, Dobesh PP, Fukaya E, Whipple MO, Alabi O, Rosovsky RP, Henke PK; on behalf of the American Heart Association Council on Peripheral Vascular Disease; Council on Cardiovascular and Stroke Nursing; Council on Clinical Cardiology; and Council on Cardiovascular Radiology and Intervention. Revisiting the open vein hypothesis to reduce the postthrombotic syndrome: implications for multidisciplinary care and research: a scientific statement from the American Heart Association. Circulation. Published online May 13, 2025. doi: 10.1161/CIR.0000000000001330