DEEP VEIN THROMBOSIS DVT , PULMONARY EMBOLISM - CAPT AJIT VADAKAYIL

THIS POST IS IN RESPONSE TO A QUERY FROM A READER.

IT IS TOO LARGE FOR A COMMENT WINDOW.

PEOPLE WHO DO YOGA DO NOT SUFFER FROM DVT

I joined a ship in Egypt.  At the hotel, I met my second engineer—a handsome Punjabi. 

Later over dinner I asked him “ Something is eating you up—what is it ?”

Then he said that his engagement was canceled. He drove his family to the would be wife’s village. 

The drive was long.  His father was in the rear seat in this packed car.  

When they reached the destination, his father was half paralysed . The engagement was called off and he decided to join the ship.

Once I saw a woman wearing high heels, her right calf nearly double the size of her left calf, and red in colour, about to take a long flight.  She was NOT wearing stockings .

I asked her if her right calf is warm to touch. She cried “ It is HOT and has a dull ache ”

I advised her “  You have DVT , miss this flight – remove your shoes--go immediately to a hospital “

She did NOT check in her bags.

DVT AFFECTED MEN MORE BEFORE.

NOW WESTERN FEMALES HAVE OVERTAKEN MEN, TANKS TO HIGH HEELS, 

MINISKIRTS WHICH CAUSES THEM TO CROSS THEIR LEGS AND BIRTH CONTROL PILLS .

Below : God did NOT want human legs to be this way.   The human gait is meant to work the calf muscles which drives venous blood.  

Normally, blood flows through veins out of the legs and arms back to the heart. Small valves in the veins enable the blood to flow in the right direction and prevent blood from flowing backwards and pooling in the veins of the legs and arms. 

A clot (thrombosis) usually in the deep veins of legs (deep vein thrombosis, DVT) leads to an obstruction of blood outflow from the extremities back to the heart. Acute leg or arm swelling and pain, therefore, result. This is called an acute DVT. 

When the body tries to heal from these clots the valves in the veins are often damaged. The obstruction of the veins and the destruction of valves lead to impaired blood flow.

If a vein is completely blocked, neighboring smaller veins may enlarge to bypass the obstruction. These bypassing veins are called collaterals and can get quite large, particularly in the pelvis and abdomen in patients who have thrombosis of the big veins in the abdomen (vena cava) or pelvis (iliac veins).  

Such collaterals can sometimes be seen as prominent veins underneath the skin. If good collaterals have formed, symptoms of leg swelling and pain may not occur or may only be mild.

Collaterals often do not get very large and can, therefore, not carry all the blood needed to drain the legs or arms; this then leads to chronic leg or arm swelling, pressure and pain.

Arteries have thin muscles within their walls to be able to withstand the pressure of the heart pumping blood to the far reaches of the body. 

Veins don't have a significant muscle lining, and there is nothing pumping blood back to the heart except physiology. Blood returns to the heart because the body's large muscles squeeze the veins as they contract in their normal activity of moving the body. The normal activities of moving the body returns the blood back to the heart.

There are two types of veins; superficial veins and deep veins. 

Superficial veins lie just below the skin and are easily seen on the surface. 

Deep veins, as their name implies, are located deep within the muscles of the extremity. 

Blood flows from the superficial veins into the deep venous system through small perforator veins. Superficial and perforator veins have one-way valves within them that allow blood to flow only in the direction of the heart when the veins are squeezed.

A blood clot (thrombus) in the deep venous system of the leg or arm is not dangerous in itself. The situation becomes life-threatening when a piece of the blood clot breaks off (embolus, pleural- emboli), travels downstream through the hear, enters into the pulmonary circulation system, and becomes lodged in the lung.

Diagnosis and treatment of a deep venous thrombosis (DVT) is meant to prevent pulmonary embolism.

Clots in the superficial veins do not pose a danger of causing pulmonary emboli because the perforator vein valves act as a sieve to prevent clots from entering the deep venous system. They are usually not at risk of causing pulmonary embolism.  

Blood is meant to flow. If it becomes stagnant, there is a potential for it to clot. 

The blood in veins constantly forms microscopic clots that are routinely broken down by the body. If the balance of clot formation and resolution is altered, significant clotting can occur.

The diagnosis of a superficial or deep thrombosis often relies on the clinical prognosis / diagnosis skill of the doctor. Swelling, redness, and pain may be indicators of a blood clot and should not be ignored

Standing for long periods of time in high heels can cause deep vein thrombosis. Deep vein thrombosis is condition in which blood clots form in deep veins, mainly in the legs.

When  women cross their legs, it causes the venous blood pressure in their legs to increase. Crossing your legs makes it harder for blood to get out of the legs because it interferes with the flow path and direction of blood from the legs to the heart. The resulting elevated venous pressure puts a strain on the valves inside the leg veins, which can affect valve function over time.

Wearing high heels contributes to vein disease. Less blood is pushed out of the leg when the calf muscles do not contract. This causes the venous blood pressure to increase and can stress the valves in the veins. Like crossing the legs, wearing heels can contribute to the overall venous reflux disease problem.

Most varicose veins start with some venous insufficiency – this happens when your vein valves don’t work properly or your vein walls are too weak. The blood can’t flow from the legs to the heart and it pools in the legs, which results in the formation of varicose veins or their enlargement.

Blood normally flows quickly through veins and does not usually become solid (clot). Blood flow in leg veins is helped along by leg movements, because muscle action squeezes the veins

Immobility which causes blood flow in the veins to be slow. Slow-flowing blood is more likely to clot than normal-flowing blood.

If you are on a plane on a long flight -- exercise your lower leg muscles to improve circulation in your legs. Point your toes up toward your head so that the calves of your legs are stretched, then relax. Repeat.  This exercise is especially important to do when you are sitting for long periods of time and don’t have a chance to walk up and down the aisles.

Blood flow through the leg veins generally requires some mechanical help, since it 'flows' up instead of down. Working calf muscles act as a pump. The contracting muscles compress the veins and force the blood in these veins upwards to the heart. This process is aided by valves in the veins, which direct the flow of blood and counteract the effects of gravity.

Anything that slows the flow of blood through the deep veins can cause DVT.

Venous means related to veins. A thrombosis is a blockage of a blood vessel by a blood clot (a thrombus). Embolism occurs when the thrombus dislodges from where it formed and travels in the blood. It then becomes stuck in a narrower blood vessel, elsewhere in the body. The thrombus is then called an embolus.

DVT mainly affects the large veins in the lower leg and thigh, almost always on one side of the body. 

The clot can block blood flow and cause:-

Changes in skin color (redness)

Leg pain

Leg swelling (edema)

Skin that feels warm to the touch

Blood that would normally go through the blocked vein is diverted to outer veins. The calf may then become warm and red.

A pulmonary embolus occurs when a thrombus has broken off from a DVT and become stuck in one of the blood vessels in the lung. Pulmonary emboli are also part of venous thromboembolism.

Damage to the inside lining of the vein increases the risk of a blood clot forming. For example, a DVT may damage the lining of the vein. So, if you have a DVT, then you have an increased risk of having another one in the future.

 Some conditions such as inflammation of the vein wall (vasculitis) and some medicines (for example, some chemotherapy medicines) can damage the vein and increase the risk of having a DVT.

When a blood clot forms in a leg vein it usually remains stuck to the vein wall. The symptoms tend to settle gradually. However, there are two main possible complications:--

A blood clot that travels to the lung (pulmonary embolus).

Persistent calf symptoms (post-thrombotic syndrome).

In a small number of people who have a DVT, a part of the blood clot breaks off. This travels in the bloodstream and is called an embolus. An embolus will travel in the bloodstream until it becomes stuck. 

An embolus that comes from a clot in a leg vein will be carried up the larger leg and body veins to the heart, through the large heart chambers, but will get stuck in a blood vessel going to a lung. This is called a pulmonary embolus.

DVTs and PEs are known collectively as venous thromboembolism.

A small PE may not cause any symptoms. A medium-sized PE can cause breathing problems and chest pain. A large PE can cause collapse and sudden death. It is estimated that if people with DVT are not treated, about half of them would develop a PE large enough to cause symptoms or death.

Blood contains platelets and compounds called clotting agents. Platelets are sticky and form the basis of the blood's ability to thicken (coagulate). 

If a blood vessel is cut, platelets collect at the site of the injury. In conjunction with clotting agents, the platelets produce a web or mesh, which traps platelets and creates a plug to seal off the wound. 

The ability of the blood to clot is essential for survival, but it can also lead to the formation of a thrombus.

It is estimated that 80 per cent of pulmonary embolisms are linked to DVT. Around one third of people who experience a major pulmonary embolism will die.

A pulmonary embolism (PE) usually happens when a blood clot called a deep vein thrombosis ( DVT), often in your leg, travels to your lungs and blocks a blood vessel. That leads to low oxygen levels in your blood. It can damage the lung and other organs and cause heart failure, too.

A blood clot is a clump of blood that is in a gelatinous, solid state. Deep vein blood clots typically form in your thigh or lower leg, but they can also develop in other areas of your body. Other names for this condition include thromboembolism, post-thrombotic syndrome, and post-phlebitic syndrome.

PE won't always cause symptoms. You might have:

Chest pain, which may get worse with a deep breath

Sudden shortness of breath or rapid breathing

Fast heartbeat

Sudden cough

Coughing up blood

Lightheadedness or fainting

Anxiety

The body has two sets of veins. The superficial veins found just below the skin surface and those that are found deeper within muscles. It is here that deep vein thrombosis can occur when a blood clot travels through the veins and arterial system including the heart and lodges itself in the lungs. It is then that such a condition called deep vein thrombosis can become life threatening.

If you have varicose veins, the veins just beneath your skin are elongated and dilated, potentially leading to pain, fatigue and muscle cramps.

Again, deep vein thrombosis is a serious condition because blood clots in your veins can break loose, travel through your bloodstream and lodge in your lungs

Pregnancy increases the pressure in the veins in your pelvis and legs. Women with an inherited clotting disorder are especially at risk. The risk of blood clots from pregnancy can continue for up to six weeks after you have your baby.

Birth control pills (oral contraceptives) and hormone replacement therapy both can increase your blood's ability to clot.

Being overweight increases the pressure in the veins in your pelvis and legs.

Smoking affects blood clotting and circulation, which can increase your risk of DVT.

Some forms of cancer increase the amount of substances in your blood that cause your blood to clot. Some forms of cancer treatment also increase the risk of blood clots.

People with heart failure have a greater risk of DVT and pulmonary embolism. Because people with heart failure already have limited heart and lung function, the symptoms caused by even a small pulmonary embolism are more noticeable.

Bowel diseases, such as Crohn's disease or ulcerative colitis, increase the risk of DVT.

Being over age 60 increases your risk of DVT, though it can occur at any age.

A common complication that can occur after deep vein thrombosis is a condition known as postphlebitic syndrome, also called postthrombotic syndrome. This syndrome is used to describe a collection of signs and symptoms, including:

Swelling of your legs (edema)

Leg pain

Skin discoloration

Skin sores

This syndrome is caused by damage to your veins from the blood clot. This damage reduces blood flow in the affected areas. The symptoms of postphlebitic syndrome may not occur until a few years after the DVT.

You'll also have a physical exam so that your doctor can check for any areas of swelling, tenderness or discoloration on your skin.

Sometimes a series of ultrasounds are done over several days to determine whether a blood clot is growing or to be sure a new one hasn't developed. 

Almost all people who develop severe deep vein thrombosis have an elevated blood level of a clot-dissolving substance called D dimer.

It can be difficult to diagnose DVT from symptoms alone, so your doctor  may advise that you have a specialised blood test called a D-dimer test.

This test detects pieces of blood clot that have been broken down and are loose in your bloodstream. The larger the number of fragments found, the more likely it is that you have a blood clot in your vein.

However, the D-dimer test isn't always reliable because blood clot fragments can increase after an operation, injury or during pregnancy. Additional tests, such as an ultrasound scan, will need to be carried out to confirm DVT.

D-dimer is a chemical that is produced when a blood clot in the body gradually dissolves. The test is used as a positive or negative indicator. If the result is negative, then in most cases no blood clot exists. 

If the D-dimer test is positive, it does not necessarily mean that a deep vein thrombosis is present since many situations will have an expected positive result (for example, from surgery, a fall, in cancer or in pregnancy). For that reason, D-dimer testing must be used selectively.

D-dimer blood test  detects fragments of breakdown products of a blood clot. The higher the level, the more likely you have a blood clot in a vein. 

Again, a positive test does not, therefore, diagnose a DVT.   The test may, however, indicate how likely it is that you have a blood clot (the clot can be either a DVT or a PE) and can help decide if further tests are needed.

Both computerized tomography (CT) scan and magnetic resonance imaging (MRI) can provide visual images of your veins and may show if you have a clot.

Deep vein thrombosis treatment is aimed at preventing the clot from getting any bigger, as well as preventing the clot from breaking loose and causing a pulmonary embolism.

Medications used to treat deep vein thrombosis include the use of anticoagulants, also sometimes called blood thinners, whenever possible. These are drugs that decrease your blood's ability to clot.

While they don't break up existing blood clots, they can prevent clots from getting bigger or reduce your risk of developing additional clots.

Usually, you'll first be given a shot or infusion of the blood thinner heparin for a few days. After starting heparin injections, your treatment may be followed by another injectable blood thinner.. Other blood thinners can be given in pill form.

You may need to take blood thinners for three months or longer. Blood-thinning medications can have serious side effects if you take too much or too little.

You may need periodic blood tests to check how long it takes your blood to clot. Pregnant women shouldn't take certain blood-thinning medications.

Compression stockings help prevent swelling associated with deep vein thrombosis. These stockings are worn on your legs from your feet to about the level of your knees.

This pressure helps reduce the chances that your blood will pool and clot. You should wear these stockings during the day for at least two to three years if possible. Compression stockings can help prevent postphlebitic syndrome.

Heparin and warfarin are two types of anticoagulant often used to treat DVT.  Heparin is usually prescribed first because it works immediately to prevent further clotting. After initial treatment, you may also need to take warfarin to prevent another blood clot forming.

If left untreated, about one in 10 people with a DVT will develop a pulmonary embolism. A pulmonary embolism is a very serious condition which causes:

breathlessness – which may come on gradually or suddenly

chest pain – which may become worse when you breathe in

sudden collapse

Both DVT and pulmonary embolism require urgent investigation and treatment.

Seek immediate medical attention if you have pain, swelling and tenderness in your leg and you develop breathlessness and chest pain.

An ultrasound scan can be used to detect clots in your veins. A special type of ultrasound called a Doppler ultrasound can also be used to find out how fast the blood is flowing through a blood vessel. 

This helps doctors identify when blood flow is slowed or blocked, which could be caused by a blood clot.

Patients who take anticoagulation medications are at risk for bleeding. The decision to use these medications must balance the risk and rewards of the treatment.

Some patients may have contraindications to anticoagulation therapy, for example a patient with bleeding in the brain, major trauma, or recent significant surgery. 

An alternative may be to place a filter in the inferior vena cava (the major vein that collects blood from both legs) to prevent emboli, should they arise, from reaching the heart and lungs.

These filters may be effective but also may be the source of new clot formation. AN IVC filter is not recommended for patients who are taking anticoagulation medications urgery is a rare option in treating large deep venous thrombosis of the leg in patients who cannot take blood thinners or who have developed recurrent blood clots while on anti-coagulant medications.

The surgery is usually accompanied by placing an IVC (inferior vena cava) filter to prevent future clots from embolizing to the lung.

Vena cava filters are not a common treatment.   A vena cava filter is inserted into the vena cava, the large vein that returns blood to the heart from the abdomen and legs. This filter can prevent blood clots from traveling to the lungs (pulmonary embolism).

But the filter doesn't stop a clot from forming.

The recommended length of treatment for an uncomplicated DVT is three months.

The treatment for deep venous thrombosis is anticoagulation or "thinning the blood" with medications. Anticoagulation prevents further growth of the blood clot and prevents it from forming an embolus that can travel to the lung. 

The body has a complex mechanism to form blood clots to help repair blood vessel damage. There is a clotting cascade with numerous blood factors that have to be activated for a clot to form.

Phlegmasia Cerulea Dolens describes a situation in which a blood clot forms in the iliac vein of the pelvis and the femoral vein of the leg, obstructing almost all blood return and compromising blood supply to the leg. 

In this case surgery may be considered to remove the clot, but the patient will also require anti-coagulant medications. Stents may also be required to keep a vein open and prevent clotting. May Thurner Syndrome, also known as iliac vein compression syndrome, is a cause of phlegmasia, in which the iliac vein in the pelvis is compressed and a stent is also needed.

Phlegmasia cerulea dolens (literally: painful blue edema) is an uncommon severe form of deep venous thrombosis which results from extensive thrombotic occlusion (blockage by a thrombus) of the major and the collateral veins of an extremity.

 It is characterized by sudden severe pain, swelling, cyanosis and edema of the affected limb. There is a high risk of massive pulmonary embolism, even under anticoagulation

Most often pulmonary emboli arise from the legs.

Post-phlebitic syndrome can occur after a deep vein thrombosis. The affected leg can become chronically swollen and painful with skin color changes and ulcer formation around the foot and ankle.

It mainly affects the large veins in the lower leg and thigh, but can occur in the deep veins in the arms.

 An embolism can get stuck in the brain, lungs, heart, or other area, leading to severe damage.

Blood tests may be done to check if you have an increased chance of blood clotting, including:

Activated protein C resistance (checks for the Factor V Leiden mutation)

Antithrombin levels

Antiphospholipid antibodies

Complete blood count (CBC)

Again, DVT is usually treated with anticoagulant medicines. These medicines are often called blood thinners, but they do not actually thin the blood. They prevent blood clots by increasing the time it takes a blood clot to form. Also, anticoagulants help prevent existing blood clots from becoming larger.

Intermittent pneumatic compression (IPC) devices are also used to prevent DVT. These devices inflate and deflate knee-high boots, which reduces pooling of blood in the legs. IPC pumps are often used when people stay in a hospital.

The contraceptive pill and hormone replacement therapy (HRT) which contain oestrogen can cause the blood to clot slightly more easily.

Lack of fluid in the body (dehydration) can make a DVT more likely to happen. Effectively, the blood becomes more sticky and liable to clot.

A DVT most commonly develops in a deep vein below the knee in the calf.

Compression stockings work  by applying pressure from outside the veins. This helps squeeze the blood in the veins back up the legs. This then makes the pressure inside the veins less. In turn this prevents leakage of blood into the surrounding tissues.

Before compression stockings are advised you will need to have a test to check that the circulation through the arteries of your legs is normal. This is usually done  with a handheld machine called a Doppler. This measures the pressure in your arteries.

Compression stockings come in light, medium or strong material (class 1, 2 or 3) and are worn below the knee. Most people can tolerate class 2. If class 2 is too uncomfortable or difficult, class 1 is prescribed. If class 2 stockings do not work it may be necessary to try class 3, although many people find these difficult to wear for any length of time

Being pregnant increases your risk of DVT. Increased hormone levels, and a slower blood flow as your uterus expands and restricts blood flowing back from your lower extremities, contribute to this risk. This elevated risk continues until about six weeks after giving birth. 

Being on bed rest or having a C-section also increases your risk of having DVT. If you are pregnant, regular heparin injections rather than anticoagulant tablets may be used. This is because anticoagulant medicines can potentially cause harm (birth defects) to the unborn child.

Varicosities can predispose to superficial thrombophlebitis and varicose veins. This occurs when the valves of the larger veins in the superficial system fail (the greater and lesser saphenous veins), allowing blood to back up and cause the veins to swell and become distorted or tortuous. 

The valves fail when veins lose their elasticity and stretch. This can be due to age, prolonged standing, obesity, pregnancy, and genetic factors.

A surgical operation where you are asleep for over 1-1.5 hours is the most common cause of a DVT. Your legs are still when you are under anaesthetic, because the muscles in your body are temporarily paralysed. 

Blood flow in the leg veins can become very slow, making a clot more likely to occur. Any illness or injury that causes immobility increases the risk. This includes having a leg in a hard plaster cast after a fracture. People who are admitted to intensive care units are at an increased risk of DVT.

When you are resting, as much as possible - raise your leg. This reduces the pressure in the calf veins and helps to prevent blood and fluid from pooling in the calves. Raised means that your foot is higher than your hip so gravity helps with blood flow returning from the calf. 

The easiest way to raise your leg is to recline on a sofa with your leg up on a cushion. - the feet are well below your hips in this position.

Raise the foot of the bed a few inches if it is comfortable to sleep like this. This is so your foot and calf are slightly higher than your hip when you are asleep.

CAPT AJIT VADAKAYIL
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