clotting disorders

CALF VS. THIGH CLOTS

I recently experienced a skiing injury that tore my ACL. A few days later, I developed intense pain and swelling in my calf and sent immediately to the hospital. The ultrasound identify a clot in my perioneal vein and soleal. It has been nearly 30 days since the start of treatment. I had another ultrasound yesterday and the technician could not find my periotoneal clot. *good news* She also said my veins look fine. The clot in the soleal sinus is still there (she said it will likely remain there). My question is: if my clot is gone, do I need to continue treatment for the remaining five months and if so, how important is it that I do so?

Thank you!
Michelle

The vein that your clot was in is in the lower part of your leg, or the calf.

When we treat DVT, the goal is to prevent the clot from traveling to the lungs, a pulmonary embolism. The goal is NOT to dissolve the blood clot but to prevent more serious complications. The likelihood of a thigh clot going to the lung is very very high. Therefore, every thigh clot, or proximal DVT must be treated for the full duration of therapy to prevent adverse outcome. However, the likelihood of a distal, or calf clot, traveling to the lungs means that it must first travel or grow to involve the thigh. Then it must move to the lung. The likelihood of a calf clot moving is low or about 20% in some estimates.

Therefore, there are two different schools of thought. The first is that if the clot is in the calf, if it is going to move it probably will do so within the first month. So, every week an ultrasound can be done to see if the clot moves. If it does not, then blood thinning medication may not be needed. If it does, than medication is recommended. Some others, recommend it safer to give everyone with a blood clot blood thinning medication for the entire duration to prevent problems. Some studies only included patients with clots in the proximal region, therefore, we have better information on how those patients should be treated.

There is a significant risk of a blood clot with any knee injury, greater than 50% likelihood. So the clot you developed is not unexpected.

I would recommend that you discuss this further with your doctor and not make a premature decision that may affect you adversely in the future.

EXERCISE AND BLOOD CLOTS

Dear Sirs

I have recently turned 44, and in May this year started with swelling of my right leg. It took 4 doctors to get what I hope is the right diagnosis. When I was 18 I had three occurrences of Mild Vein Thrombosis within 6 months but wasn’t given any treatment and told to exercise and this would disperse the clot, which it did. But earlier this year I had some swelling and loss of sensation in the right leg when exercising which ceased on rest.

My question is can I exercise? My consultant says no, two doctors say yes and a physiotherapist said definitely not. I am hungry for information to completely understand my condition but I am finding it very difficult to source good help/advice. Can you help me? I was a very active person and I am finding this sitting around a little difficult to accept, I do work in a busy office where I am personal assistant to two directors. Please please please help

For many years we have thought that if you move around then the blood clot in your blood vessel may also move and if it moves to your lung it may cause serious problems. Therefore, we had previously always recommended best rest initially after being diagnosed and then for a period of time after. New information demonstrates that this is not the case and often times persons initially diagnosed with a blood clot are treated as an outpatient and go to work and walk around with some activity without adverse outcome.

New data demonstrates that exercise increases blood flow and also decreases edema by utilizing the muscles. Therefore, exercise in moderation that is not contact with risk of trauma is recommended. When you begin to exercise, you may note additional swelling in the affected leg. This is often bypassed with the use of compression hose and with rest and elevation of the leg after exercise. It is more cosmetic than dangerous and therefore safe.

PREGNANCY AND BLOOD CLOTS

I am 25 years old. I had my first baby in 2001. Two weeks after her birth I returned to the hospital because I could not breath properly and I had severe pains in the right side of my chest. Hours after test, waiting and more pain the doctors realized I had a blood clot in my right lung. (it was undetermined were it came from) I was on Coumadin for one year and then started the one 81mg of aspirin a day. Now it is 2003 and on April 23 I went to the my gyn and found out I was 3 weeks pregnant. Of course after being treated for a blood clot post-pregnancy I knew there was a possibility of having to take heparin. One of my doctors wanted to run test first. While he was trying to make up his mind rather or not I should take heparin with this pregnancy, I got a clot in my left leg behind my knee. (the pain was horrible and my leg felt heavy, no swelling occured until treatment was administered.) Now I am currently on Lovenox injection every 12 hours.

My worries are "What is expected of my baby" and "Because this is my second clot will I be on blood thinners for the rest of my life?"

thanks

fran

There are certain inherited abnormalities that make one prone to blood clots especially during pregnancy or hormone use. This includes the Factor V Leiden mutation, Antithrombin III deficiency, and Anticardiolipin Antibody. Therefore, screening for these abnormalities should be done and will help to identify your future risks. This may be the test your doctor was looking to run. Lovenox is the standard of care for treatment during pregnancy as it is easy to administer at home and safe for both you and the baby. (see page on low molecular weight heparin for more information). Usually the children are fine, the only problem will be as to whether you plan the delivery so that you can stop the heparin in time to receive epidural anesthesia. Some obstetricians induce the baby so that you can plan the birth date and know when to stop the heparin. The medication and the clot affect you and will not affect your child.

As to the second question, the usual recommendation is that with two blood clots life long treatment with anticoagulants are needed. However, no one has studies this just in pregnancy induced clots. I would begin with determining if there is another explanation for the clot, ie blood testing, as this may help to determine whether you need therapy for life or not.

BLOOD CLOTS, INFERIOR VENA CAVA FILTERS, AND HEAD TRAUMA

In November my nephew was in a terrible car accident. Resulted in severe head trauma. He had emergency surgery and has been doing much better until recently when it was discovered that there is a blood clot in his left thigh and calf. On Friday we found out the a piece of the clot had broken off and traveled to his lung. We have received conflicting treatment recommendations from the hematologist and the vascular team. One says he should have a surgical procedure in which a "basket" is to be inserted to catch any other pieces that might break off. The one says we should do nothing and keep watching the clot. Obviously, my family is very torn as to which direction is the best for my nephew. At this point we would like to get a second opinion. However, we aren't quite sure how to go about this. Do you have any advice.

Patients with blood clots in their legs or lung are usually treated with blood thinners. However, in patients with serious risk of bleeding complications, blood thinners are dangerous and cannot be used. Therefore, in order to prevent the blood clot from moving to the lung which may result in death, a wire basket may be placed through the groin. This does nothing to help prevent additional blood clots, it only acts as a barrier to prevent the blood clot in the leg from travelling to the lung. It is effective in 90% of patients, but not 100%. In addition, there may be complications with the placement of this basket and also it may become ineffective after a period of time.

The basket, called an inferior vena cava filter, may be placed by a radiologist or a vascular surgeon. There are several different types available and have been readily used for many years. Some types may be removed within a period of time if no longer needed.

The concern in your nephews case is probably that the head trauma may not have healed and that additional bleeding into the brain may occur with blood thinners. I assume you were given reasons by both specialists as to why the basket should or should not be placed. First, I would ask you to meet with both of them and have them explain their reasoning in terms that you can understand in order to make a decision. Also, it is important that the two of them discuss the medical case and come up with the best option for your family member. While differences of opinion often occur among specialists, they usually are able to come up with a solution that best fits the situation. As for obtaining a second opinion, if discussing this further with the doctors involved does not help in coming up with an acceptable answer, I would ask the physician in charge of your nephews case if there is someone else that comes to that hospital that may have expertise in this area to help give an opinion. Depending upon the hospital size, this may already have been done, or may be difficult if you are in a small hospital. In specialty practices where there is more than one physician in the group, the associates commonly discuss cases to come up with an answer. Your physicians may have already done this, therefore a formal second opinion may not be necessary.

TREATMENT OF DVT:

If diagnosed with DVT and the lovenox and coumadin does not work is their
any other procedures to open the vein or help it? I have been taking these
medications for seven weeks. My doctor has stated there is nothing else to
do for it. Is this true?

A majority of patients treated with appropriate doses of anticoagulants
achieve results. A minority of patients present with a clot that is so
large, or becomes so large, that it threatens the blood flow to the limb.
This is called phelgmasia and is an emergency. Without treatment to dissolve or remove the clot, the limb will die from lack of blood flow. This is
accompanied by severe pain and infection with high likelihood of death. If
you had this complications, you would not be writing this e mail today.
More likely, you have postphlebitic syndrome causing persistent swelling.
If you do ultrasound examinations on all patients with a DVT, almost all will
have persistent defects associated with the DVT. This does not mean that
they have failed therapy. Response to treatment is a clinical one with
gradual decline in the swelling, pain, and discoloration.

Send mail to rshtcn@aol.com with questions or comments about this web site. Last modified: May 17, 2010

Send mail to rshtcn@aol.com with questions or comments about this web site.
Last modified: May 17, 2010