Deep vein thrombosis (DVT) is a clot that forms in a large, deep vein of the legs, pelvis or arms. The primary concern with DVT is that the clot or parts of it can break free and travel along the veins through the heart and into the arteries leading to the lung. This is called a “pulmonary embolus” or PE, and can be fatal. In fact, it is a significant cause of sudden death, particularly among hospitalized patients and others at risk for developing DVT. The mainstay of treating DVT is anti-clotting drugs or “blood thinners” in order to prevent more clot from forming. Vascular surgeons are commonly called upon in certain instances when the clots are large and extensive enough to cause severe symptoms in the limbs or when protection from a PE is needed.
Common Risk Factors
- Recent surgery or trauma
- Prolonged bedridden or immobile status
- Past history of DVT
- Family history of DVT (congenital hypercoagulable state)
- Estrogen therapy (birth control or replacement therapies)
- Congenital anatomical abnormalities
- Lengthy travel
Most of the time symptoms are rather acute or sudden in onset:
- Leg or arm swelling
- Bluish hue to the leg or arm
- Pain or tenderness in the muscles of the leg or arm
- Sharp chest pain made worse with deep breathing
- Shortness of breath
The first line test is a thorough history and physical exam to ascertain a DVT or PE from other more or less life-threatening conditions. Initial tests include:
- Ultrasound of the legs or arms
- Chest x-ray
- Blood work
If a DVT is discovered it is important to identify the cause and initiate prompt treatment. As mentioned above, this usually involves medications that are “blood-thinners” that prevent further clot formation – they do not break down established clot. Your body’s own natural system will do that over time. However, as the clot is broken down it can cause unintended damage to the lining of the veins and the valves that control venous blood flow. If this occurs the veins will not work properly later and patients can develop a condition known as the “post-thrombotic syndrome.” This is a condition when damaged veins cause chronic, severe limb swelling, pain, discoloration, varicose veins and skin damage to the affected limb. Patients who have DVT that involve the very large veins of the thigh extending up into the pelvis seem to be at highest risk of developing this complication. To prevent this vascular surgeons may recommend and perform the following:
These stockings are used to help control the swelling and pain from swelling by preventing blood pooling in the limb. This forces blood back into circulation and aids in clot breakdown. These are usually started after appropriate medications have been started and there is no concern for spreading of the clot.
Venous Thrombolysis and Stenting
This is a catheter-based, minimally invasive method of accelerating clot removal. It requires insertion of a catheter into a vein “below” the clot (i.e. behind the knee) and the use of specialty catheters that can either inject powerful clot-busting drugs into the clot itself, break up the clot with wires, ultrasound waves or small jets of saline, or use suction to extract the clot. The goal is to clear the large veins of the thigh and pelvis of clot that can lead to post-thrombotic syndrome. Occasionally an obstruction within the vein or compressing the vein is discovered that caused, or contributed, to the clot that can’t be removed. In these case stents are commonly used to reopen the vein and keep that area from causing further problems.
Vena Cava Filter Placement
In some instances your surgeon may recommend placement of a filter, which acts like a “trap,” to block clots from travelling up to your lungs (a PE). This is a minimally invasive procedure that can be done under a local anesthetic. Your surgeon places a catheter in a vein that then is advanced into the vena cava – the large vein in your abdomen that both of your leg veins drain into on their way to the heart and lungs. The filter looks a lot like an umbrella with no fabric, so normal blood can flow by, but large clots will be trapped there and then broken down by the body. Many times these filters are removable and can be taken out when the concern for a PE has lessened. The decision to place and/or remove a filter depends on several factors that your surgeon will discuss with you.
1. How long will I be on blood thinners after Deep Vein Thrombosis?
Typically, you will take coumadin for six months for the first event.
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