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VASCULAR DISEASE
Deep Vein Thrombosis (DVT)
What is Deep Vein Thrombosis (DVT)?
Deep Vein Thrombosis, commonly referred to as "DVT", occurs when a blood clot, or thrombus, develops in a deep vein. Most of the time, DVT presents itself in the legs or pelvis, but occasionally DVT can occur in the upper extremities. The deep veins differ from the superficial veins in that they are located deep in the body and can not be seen, and more importantly, because they have a direct connection to the heart and lungs. DVT affects approximately 2 million Americans per year. Back to top
What are the Risk Factors for DVT?
Generally, a DVT is caused by a combination of 2 or 3 of the following underlying conditions:
- Slow or sluggish flow through the veins
- A tendency for a person's blood to clot quickly
- Irritation or inflammation of the inner lining of the vein
There are a variety of situations in which these conditions can occur:
- During or after major surgery
- Prolonged travel
- Trauma to the legs
- A family history of blood clots or blood disorders
- Cancer
- Obesity
- Pregnancy
- Smoking
- Varicose veins
To assess your risk for DVT, click on this link and complete the Risk Assessment Tool. You can print it out and bring it to our office to discuss your risk and what it means to your overall health. Back to top
https://www.preventdvt.org/docs/pdf/DVTRiskAssessmentTool.pdf
What are the Symptoms of DVT?
Approximately 50% of patients with DVT have no symptoms. When symptoms are present they include:
- Calf pain and tenderness
- Leg swelling
- Leg discoloration (blue or red)
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How is DVT Diagnosed?
 A suspicion of DVT is raised after a physician performs a detailed history and physical, and identifies associated risk factors. The most important test is a venous ultrasound. This test is quick, painless, and very accurate in making the diagnosis. It can identify thrombus within the deep veins, and is also used to follow the patient's response to  therapy. Usually, this is the only test that is needed. Occasionally, for more complex cases, a venogram may be needed. This test involves injecting dye into the veins to visualize them more precisely. Back to top
Is DVT Dangerous?
DVT in and of itself is not usually life threatening unless it completely blocks flow out of the legs. When this happens, a condition called "venous gangrene" can develop and this requires immediate medical attention. Luckily, it is very rare for this condition to occur. However, the real danger of DVT is that the clot can become dislodged and move ("embolize") to the heart and lungs. This condition, called a pulmonary embolism (PE), is a very serious condition and is often fatal. For this reason, it is very important to diagnose DVT early and begin treatment to minimize the risk of PE. Back to top
Do I need treatment?
All patients with DVT require treatment. The treatment goals are:
- Relieve symptoms
- Prevent extension of DVT
- Minimize risk of pulmonary embolism (PE)
- Minimize risk of recurrence
- Minimize the late effects of DVT
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How is DVT treated?
MEDICAL THERAPY
Medical therapy consists of:
- Bed rest for 24-48 hours
- Leg elevation
- Compression stockings
- Anticoagulation
Anticoagulation involves taking medicine that thins the blood. Thinning the blood prevents further growth of the blood clot, but does not dissolve the clot. Your body has natural chemicals in the blood that will dissolve the clot slowly over time, usually within 3 months.
Coumadin is the oral blood thinner that you will take. Unfortunately, Coumadin does not work right away, and can take a few days to reach a desired level in your blood. Therefore, a fast acting blood thinner is also given initially. Traditionally, an intravenous medication called Heparin was the only option, and the patient would have to be admitted to the hospital for several days until the Coumadin level was therapeutic. This is still done in many cases. In some uncomplicated cases of DVT, however, a medication called Lovenox can be used as an outpatient. The patient gives themselves a subcutaneous injection (similar to taking insulin) twice a day at home. Blood work will be done every few days until the Coumadin level is adequate. Once it is, the Heparin or Lovenox can be discontinued, and the patient is maintained on Coumadin for a minimum of 3 months.
Lifestyle Modifications:
- Quit smoking
- Control high blood pressure and diabetes
- Achieve and maintain a desirable weight
- Regular exercise
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VENOUS INTERVENTION
 In severe cases, your doctor may recommend thrombolysis, which is the use of intravenous medication to dissolve the clot. This procedure is done at Milford Hospital, in the Specials Radiology unit, under light sedation and local anesthesia. A plastic tube, called a catheter, is threaded through a vein in the back  of the leg and into the clot. The clot dissolving drug is then infused into the clot through the catheter's many side holes, like a soaker hose. Sometimes a special instrument that works like a vacuum cleaner is used to suck out the softened clot. Once the clot is removed, sometimes a balloon or stent may be needed to treat an underlying narrowing of the vein. This procedure immediately relieves the patient's symptoms and swelling, and can dramatically reduce the long term consequences of severe DVT, such as chronic leg swelling and ulcers.
Inferior Vena Caval (IVC) Filters
Some people are at such a high risk of DVT and subsequent embolism that anticoagulation alone is not considered sufficient protection. In addition, some people can not tolerate anticoagulation due to other underlying medical conditions.  In these cases, the doctor may recommend placement of an inferior venal caval (IVC) filter. The inferior vena cava (IVC) is the large single vein that connects both legs to the heart and lungs. All blood from the legs must travel through the IVC to get back to the heart, and therefore it is the only way that a blood clot can get from the legs to the heart and lungs. A filter, which is like a mesh cage, can be placed in the IVC. It allows blood to pass easily, but blood clots will be caught in the filter before they can get to the heart and lungs and cause damage. Once in the filter, your body dissolves the clot naturally over time. These filters are placed during a simple procedure in the Specials radiology Department at Milford Hospital. The procedure is done with local anesthesia and light sedation, and takes less than 10 minutes. A small catheter is placed in the groin, and under X-ray guidance, the filter is placed into its position. The patient can go home immediately after the procedure without limitations. Most of the time, the filters remain in place for life. If necessary, they can be removed in a separate procedure through a vein in the neck. Back to top
What are the long term effects of DVT?
 The long term consequences of DVT can persist even when short term therapy has been "successful". This is because the presence of a blood clot can cause damage to the inner lining of the vein, resulting in chronic scar tissue that constricts the veins and valves that do not function properly. Over time, this leads to chronic venous insufficiency (CVI) and venous hypertension. The result is chronic leg swelling, skin discoloration with brown pigment, leg heaviness, varicose veins, and ulcerations. This condition is called post thrombotic syndrome (PTS) and can result in significant disability. Once PTS develops, there are few options for treatment, and lifelong compression therapy is needed. Therefore, it is of utmost importance to prevent PTS from developing in the first place. This is best accomplished by prompt diagnosis and treatment, early thrombolysis for larger DVT, and the early use of compression therapy. Therefore, if you have any concern that you may be developing a DVT, consult your vascular surgeon as soon as possible. Back to top
Can DVT be prevented?
Some risk factors for DVT can not be changed. There are some things, however, that can reduce the risk of developing a DVT:
- Regular exercise
- Stop smoking
- Early activity after surgery
- Low dose blood thinners, elastic stockings, and compression pumps may be used during long hospitalizations or after major surgery
- Regular stretching and walking for people who sit all day
- If traveling by car, stop regularly to stretch your legs
- If traveling by plane, get up and stretch in the aisle every hour when possible
- Stay well hydrated
- If you feel you are at high risk, talk to your vascular surgeon about other ways to reduce your risk of DVT
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