Vascular Disease Foundation - Fighting Vascular Disease... Improving Vascular Health.

Interactive Learning : Ask the Doctor


Ask the Doctor Live Chat Transcript - Tuesday, April 6

Carmel Celestin, MD

Cleveland Clinic




Moderator- VDF: Thank you for joining us today!  I would like to introduce Dr. Celestin who is now ready to take your questions.

Boris: On Feb 6 I broke my left leg, both the Tibia and Fibula. On Feb. 7th, the doctor in the hospital placed me on a blood thinner to clear me for the surgery, because I have an irregular heartbeat. I am still taking warfarin every day. On Mar 31, I went for a DVT and abdominal aorta tests. Here are the results:

Findings on the LEFT:

The following deep vein(s) are not normally compressible: left posterior tibial and gastrochemius veins. In these veins, there is limited or no vein wall compressibility.

 The left posterior tibial and gastrocnemius veins are completely obstructed.

 The left posterior tibial and gastrocnemius veins have segments with no demonstrated flow.

 The left common femoral, deep femoral, femoral, popliteal and peroneal veins are normally compressible.

CONCLUSIONS - LEFT DEEP VEINS: There is ACUTE deep venous thrombosis of the left posterior tibial (1 of 2 ) and gastrocnemius veins. My questions are: 1. Should I continue to receive warfarin (for how long?) and exercise the leg to prevent more blood clots and dissolve current blood clots or 2. Should I be placed on a stronger blood thinner in the hospital to dissolve blood clots now? 3. I don’t like the idea of taking such a strong blood thinner like warfarin especially after having a bleeding ulcer two years ago, 4. I don’t like also continuously having blood clots, which could be fatal. What is the right answer? Who is the authority in such a situation?

Speaker- Dr. Celestin: Hello, Boris, you have raised very good questions here. First, the reason you have blood clots (deep vein thrombosis)is because of your injury-a very common cause of blood clots in the legs. Due to the fact that once you have a blood clot, you are at risk of developing new blood clots for a few months after the initial finding, you should remain on warfarin as directed by your physician. This usually is maintained for a few months. Although there are different types of blood thinners, warfarin is the most commonly used as it is in the oral form. There is no such thing as a stronger blood thinner. I understand you do not want to continually have blood clots, but this should not occur while on anticoagulation. I do recommend continuing to exercise.

Betty: Hi Dr. question is about clopidogrel and aspirin, what's the difference?

Speaker- Dr. Celestin: Both aspirin and clopidogrel are pretty much the same drug in that they inhibit platelets from sticking together. They do it biochemically in a different fashion.

Anne: Dr. Celestin, I know my father had some type of blood clot that went to his lungs. He is 80 now and has limited lung function. He knows he had blood clots but does not know if it was from DVT. Should I be checked to see if there is something in my family history? Is it worth the money it would cost? My doctor is ambivalent.

Speaker- Dr. Celestin: Hi, Anne. Many people ask this question when they have family members with blood clots. If you have no history of blood clots, it is generally not recommended to get checked, as it would not change management.

Anne: Thanks Dr. Celestin, you have set my mind at ease. I will just keep aware of my health, Anne

Sharon: Dear Doctor, I had been having some back of the calf pain, mostly in the right foot, now it's just localized to behind the heel (same foot) and it aches only when I walk, especially if I'm on my feet & doing a lot in a day.

Speaker- Dr. Celestin: Hi, Sharon. That is a good and common question. Although arterial disease is not typically in the heel, there are times when this can occur. Unfortunately, due to some overlap in your symptoms in that it can be arterial disease, vein disease, nerve pain, or muscle pain, it is difficult to determine the answer to your question without a full history and physical.

Elizabeth: I have had 14 surgeries on my legs, which has left me with a lot of nerve damage and 3 of my toes are not able to move them even after much therapy, I have learned to live with it but, I am wondering if there is an ointment that could help the burning on the bottom of my feet? I do take aspirin 81mg warfarin 2mg and clopidogrel to prevent further blood clots.

I also take omeprazole every morning to line the stomach because of aspirin, clopidogrel and warfarin has caused some stomach bleeding .I do have blood checks every month, sometimes twice, I have a problem keeping the reading stable. I do watch my diet, I weigh 105 pounds, and I am wondering how long I should be taking all three of the blood thinners?

Speaker- Dr. Celestin: Hi, Elizabeth, the answer to this question is very individualized and should be discussed with your physician.

Peggy: I was diagnosed with Fibromuscular Dysplasia (FMD) October 2007. After the fifth attempt to unclog right renal artery a dissection occurred & a stent installed. Should I be concerned about FMD conditions in other areas of my body? If so, what tests should be run? Do you believe based on current data that my stent will hold or will the FMD eventually clog my artery again? What is the likelihood other family members have this condition?

Speaker- Dr. Celestin: Hi, Peggy. FMD can occur in other areas in the body, most commonly the carotid arteries. Patients with FMD can also have aneurysms in the brain, therefore screening for this with an MRI will help detect this. Regarding stenting, there is variable data on this. It is not known fully if FMD runs in families or not, but typically not.

Evelyn: Hello Dr. Celestin. I am 73 going to have knee surgery repair on my left knew for the third time in two years. I took the risk quiz online and have three risk factors: 1) Recent planned surgery for April 28, 2010; 2) Major trauma or injury (to my left leg); and 3) Obesity (I am only 5'4" and 200lbs) my question is how should I treat this surgery? Do I need any special medications? Thank you so much for answering all our questions today!

Speaker- Dr. Celestin: Hi, Evelyn. Joint surgeries, particularly hip and knee surgeries are associated with blood clots. Therefore, these patients are typically placed on some type of blood thinner for a time period after their surgery to decrease this risk. This should be discussed in detail with your physician.

Evelyn: Oh thank you so much! I will be sure to talk with him about it! I remembered something my daughter wanted me to ask. She has that Raynaud’s Disease where her hands and feet turn white when it is cold. Is that something she could grow out of? Or will it just get worse as she gets older. She has been very slim her whole life and I was also wondering if her low weight may have something to do with it as well. Thank you.

Speaker Dr. Celestin: Hi, Evelyn. Raynaud's can be primary or secondary. Primary Raynaud's is usually benign where it would not cause any problems and typically will not progress. It is typically seen in young females. Secondary Raynaud's is usually due to an underlying inflammatory condition or other conditions. Usually the difference is determined by a good physical examination and blood tests.

Arlene: The last seven years I have had PAD in my left leg. My treatment started with angioplasties. I have now had two bypass operations and several more angiograms to unblock these, nothing seems to help, is there anything out there that you know of that might change this outcome.

Speaker- Dr. Celestin: Hi, Arlene. Typically, what needs to be assessed when someone has to have repeat procedures is if they are still smoking, if their diabetes is under control, if their cholesterol is under control, and if their blood pressure is under control. If there is anything medically going on that is not controlled, this can affect the outcome of procedures done.

Arlene: I have not smoked in 5 years (I am 66) do not have diabetes, blood pressure problems or high cholesterol. The doctors say there is a lot of scar tissue because I have had so much done to me.

Speaker- Dr. Celestin: Arlene, that is good that you do not have these common risk factors. If this is the case, one can look into more unusual causes of arterial disease, such as inflammation and others, but this is something that requires detailed investigation. There are times, that scarring will result in the need for repeat procedures also.

Maria: Have there ever been arterial or vein transplants done? In the USA? I have popliteal entrapment syndrome and have had a popliteal/bypass done and another one with sapphenous veins in the same leg. My veins and arteries are extremely small congenitally, leading to these problems. Thanks.

Speaker- Dr. Celestin: Maria that is a very interesting question. I have not heard of any arterial or vein transplants being done, at least not here in the US.

David: Hi there. Are you aware of the recent availability of desirudin - a SC direct thrombin inhibitor? Do you have any experience with this?

Speaker- Dr. Celestin: Hi, David. I am familiar with the other direct thrombin inhibitors. Although I do know about desirudin, I am not familiar with its availability at this time.

Connie: Due to a DVT, I am currently on warfarin therapy for 6 months. I initially started on 2 mg of warfarin and my INR levels ranged between 2.0 to 3. which was good. After 3 weeks, my INR levels dropped and ranged from 1.8 to 1.4. The doctor increased my dose to 5 mg and my level went up to 2.1 and 2 this past week. I am worried about the drop in level. The doctor thinks it was my diet or vitamin K intake. and will have me stay on the 5 mg. should I have more cause for concern for the drop in the INR levels? and that I will not go back to taking only the 2 mg?

Speaker Dr. Celestin: Hi, Connie. It is not uncommon to have fluctuations in the INR level. This can occur from a variety of causes. If it is now at the therapeutic level., there should be no cause for concern.

VDF Moderator: This next question was e-mailed to us ahead of time: Can ones calf be stented?  I know that legs have been stented for a long time. I am asking about my calf. If so, where is this event performed and what doctors are comfortable stenting calves?

Speaker Dr. Celestin: Regarding the calves being stented. Although it can be done in some cases, it is typically avoided given the small nature of the vessels and the muscular contractions of the calves may result in the stent to close.

VDF Moderator: This next question was e-mailed to us ahead of time: Can I use my home blood pressure monitor to measure the blood pressure in my ankle?

Speaker Dr. Celestin: That is a great question. You can check the blood pressure in your ankles, but the appropriate way to perform this is to have the arm blood pressures and the leg blood pressures, detected by Doppler in the supine position, done in a short period of time. This is how we determine if you have peripheral arterial disease.

VDF Moderator: Thank you all for joining us today and thanks to Dr. Celestin for her time. We wish you a healthy day!

Thanks again for joining us, we wish you all a health day and hope to see you on May 4th for our next chat with Dr. Gornik!


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