What would you think if your doctor told you that you had a blood clot in your leg? Would you be confused, concerned, or afraid?
The word clot evokes anxiety in most people, but fewer know precisely what it means, or what can be done to prevent it.
First lets consider this scenario:
Kathy is a 36-year-old, otherwise healthy elementary school teacher who experiences severe pain in her right calf after a return flight from Seattle. Because of the intensity of her discomfort she is seen in a local emergency room. She undergoes an ultrasound and is told that she has a clot. Kathy is given a prescription for an oral blood thinner and advised to follow up with her primary care provider.
Kathy does as instructed, and after three months of treatment feels like she is almost back to normal. She admits to some swelling in her leg at the end of the day, but attributes that to having to stand all day because of her job. She also mentions that she has been experiencing frequent episodes of severe itching in that leg. It is recommended that she take Benadryl to relieve those symptoms and told, if she wishes, she may want to try wearing a compression stocking. No further studies are done. Her blood thinner is discontinued, and she is discharged with instructions to follow up if problems arise. This is how the vast majority of patients with DVT in this country are treated and would be considered good medical care.
Well get back to Kathy in a moment but first lets explain what we mean by the term clot. A venous clotlike the one Kathy hadis different from an arterial clot, which can result in a heart attack or a stroke. Arterial clots are often in the public eye, because they are such a major health concernbut theyre not the topic of todays article.
Venous clots are much less well-known, and often poorly understood. As a vascular surgeon, one of my primary jobs is to help patients with venous clots manage their condition. We work to prevent the kinds of acute and chronic issues that can lead to a lifetime of complications.
In 2008, I was present when the Surgeon General of the United States issued a Call to Action to physicians, urging us to do everything we could to prevent and minimize the complications of deep vein thrombosis (DVT) and pulmonary embolism (lung clot or PE). Im sad to say that very little has changed in the past ten years since that keynote address. While estimates vary, we believe that almost a million people in the US develop venous clots every yearand 60,000 to 100,000 people die as a result.
DVT most commonly occurs in leg veins, and so, unsurprisingly, when patients learn they have a clot in the leg, they are often afraid of the possibility of dying from a pulmonary embolism. But the truth is, DVT is far from a death sentence. If a patient gets diagnosed early, and is placed on a blood thinner, the risk of pulmonary embolism drops to less than one percent!
Thats the good news. The bad news is that even after clots are diagnosed and treated with blood thinners, there are other complications that can occur. The most notable of these is Post-Thrombotic Syndrome thats a mouthful, so Ill try to explain it as simply as I can.
When blood thinners fail to fully dissolve a clot, it can persist in the vein as hardened tissue. This may prevent blood from getting out of the leg and back to the heart. The backup of blood can damage the tissues in the leg, resulting in chronic leg pain, swelling, and even the development of leg sores (ulcers) that can significantly impede a patients ability to walk. Altogether, the combination of missed work, disability, hospitalizations, and wound care caused by venous leg ulcers (many due to PTS) costs the American economy 14.9 billion dollars each year!
In my opinion, PTS is a majorly overlooked problem, and its one area in which you, the patient, need to be knowledgeable about to help your provider best manage your care.
Right now, when you are diagnosed with DVT your doctor will probably try to determine whether the clot was what we call provoked or unprovoked.
As the name suggests, a provoked DVT results from an obvious cause, such as surgery or hospitalization. Anything that results in prolonged immobility, even a lengthy plane or car ride, can put a patient at risk for developing a clot. Patients diagnosed with provoked DVT are commonly treated with blood thinners for a relatively short durationon average, three months. On the other hand, patients with unprovoked DVT, where there is no obvious trigger, are assumed to be at significantly higher risk of developing another clot, and so are treated with blood thinners for much longerusually six months or a year.
Reading this, you might think that classifying blood clots in the way Ive described here is an exact sciencebut it isnt! Often, the diagnosis is based on not much more than educated guesswork. In addition, the guidelines are only useful for preventing PE and recurrent episodes of DVTthey do not address the possibility of developing PTS. Thats the problem.
Lets get back to Kathy.
A follow-up ultrasound done prior to stopping her blood thinner showed that her clot had actually gotten worse while on treatment?
There was significant clot obstructing flow in the leg but it was continuing to dissolve at the time her blood thinner was stopped?
The innocuous swelling and itching in her leg was actually the bodys signal that PTS was now taking holdand over time, might impact her mobility and even jeopardize her ability to work?
In these instances, should her blood thinner be stopped just because her DVT was considered provoked? Each of these scenarios is a common presentation in patients that I see in my vascular practice.
I believe that whenever patients are knowledgeable about their conditions, they can advocate for themselves and ask the kinds of questions that help them receive the best outcomes. Venous thrombosis should not be the exception!
Who is at risk for DVT and what can be done to help prevent it?
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Dr Roupenian is a vascular surgeon and certified vascular ultrasonographer with offices on campus at Alaska Regional Hospital and in the Valley. He is full time resident of Wasilla.
He specializes in the management of chronic venous problems including treatment of varicose veins and DVT. He has held leadership positions in several national venous organizations and lectures frequently on topics related to venous disease