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

Interactive Learning : Ask the Doctor

 

Ask the Doctor Live Chat Transcript - Wednesday, October 24

Dr. Heather Gornik


Department of Cardiovascular MedicineThe Cleveland Clinic FoundationCleveland, OH

Vascular Disease FoundationBoard of Directors

 

 

Dr. Gornik generously donated her time to answer our patients general questions about vascular disease. The below transcript details all of the questions asked by our participants as well as her answers.

Moderator- VDF: Welcome and thank you for joining us today for VDF's Live Chat! I would like to introduce Dr. Heather Gornik from the Cleveland Clinic who will be taking your questions today. Please type in your questions and wait for Dr. Gornik's response.

Speaker- Dr. Gornik: Thank you, I am delighted to be here. Let's start the questions.


Chris: My father has DVT and when he goes on blood thinners he bleeds so much that he has to have a blood transfusion. I searched for an alternate solution and found the Angiojet by Possis. But apparently the hospitals locally will not accept him because he bleeds. He is on so many meds to heal his stomach lining but in the meantime he has gone from being very active to not being able to walk. Can you please help?

Speaker- Dr. Gornik: The AngioJet device also typically requires the use of blood thinners. This is a device that breaks up and removes clots used in combination with blood thinners typically. In some patients with DVT, blood thinners cannot be given at all due to bleeding, and other options, such as a vena cava filter must be considered. I would suggest that your father be seen by a vascular specialist to discuss treatment options for the blood clot.


Moderator- VDF: This next question was e-mail to us ahead of time: After starting anticoagulant drug treatments, under what circumstances does the body naturally break down a blood clot and are there statistics with regard to the success rate, how soon would you expect to see symptoms reduced or eliminated? Also, is it dependent on the location or size of the clot?

Speaker- Dr. Gornik: Very good question. In the setting of a blood clot, the most important job of blood thinners, such as heparin and coumadin, is to prevent new clots from forming on top of the existing clot. Over time, the body's own clot busting system will break down clots, but it is not uncommon to see some evidence of residual clot even months to years after the initial blood clot. In general, more extensive clots will require a longer time to resolve. There are some medications available which can dissolve clots more quickly. These are known as thrombolytic agents or "clot busters" and are given in special circumstances when the burden of clot is very high and the symptoms are very severe. There are also mechanical devices that are used in some cases to remove or break apart clot.


Moderator- VDF: This next question was also sent to us by e-mail ahead of time: My husband had an aneurysm on the back of his knee (avocado size) 13 months ago. TPA was used for 3 days to dissolve it and a bypass was done in his leg (used the vein in the back of his foot). It was a great success except that he still has pain when he walks about 100'. His vascular surgeon cannot figure out why he still has pain. He did not have PAD before the aneurysm. Why does he still have pain and can we do anything about it?

Dr. Heather Gornik: I am sorry your husband is having such difficulty. Unfortunately, I am unable to provide a diagnosis of specific medical information without evaluating your husband. I would discuss your concerns with your husband's surgeon, and also consider seeking a second opinion.


Moderator- VDF: This next question also came to us by e-mail: I experienced a PE about 2.5 months ago - multiple bilateral clots to the lungs. After flying, about 3 days later my left leg began to swell and became painful and red. I suspect something serious is going on. I had started birth control pills about 16 days prior at age 50 but decided to seek medical advice when back home. About 12 hours after flying back home I suffered another PE and was hospitalized for 10 days. I though it was worse with compression hose but don't know if it matters. Is this to be expected and ongoing?

Speaker- Dr. Gornik: I am having a bit of difficulty understanding the question. I think the question pertains to compression hose and risk of having another DVT or pulmonary embolism. In general, compression hose are actually very effective at PREVENTING DVTs, and there has been research that has shown the hose can prevent DVT during long-haul airline travel. Having another DVT or PE while already on coumadin is concerning, and you need to work with your doctor to figure out why this has happened.


Sheryl: Is sclerotherapy safe and effective for varicose veins?

Speaker- Dr. Gornik:
Sclerotherapy is an effective treatment for varicose veins, ranging from the tiny spider veins (or reticular veins) to the larger veins. There are a number of types of sclerotherapy procedures that can be performed for varicose veins. There are also a number of newer technologies available for treating varicose veins, particularly large varicose veins, such as laser ablation and radiofrequency ablation. A vascular specialist should be able to discuss the full range of treatment options for varicose veins. As always, though, for varicose veins, wearing graduated elastic compression stockings (prescription strength) and elevating the legs is the most basic component of therapy.


Moderator- VDF: This next question was also e-mailed to us ahead of time: I am experiencing marginal pain in my toes. I take medicine for gout. This may be pain from gout or decreasing circulation. How can I know which and what can I do about it?

Speaker- Dr. Gornik: A very good question. Sometimes pain due to abnormal circulation can mimic or be confused with pain due to other causes. A doctor's physical examination and a simple test called the ankle-brachial index are important to rule out a circulation problem, such as peripheral arterial disease, or PAD. Ask your doctor if your foot pain could be due to PAD, rather than gout, and if you should be tested.


Chris: How do you know if you should consult with a vascular specialist or a vascular doctor (is there difference?) and how would I find one in my area?

Speaker- Dr. Gornik: A number of the vascular professional societies maintain listings of qualified vascular specialists, including vascular surgeons, vascular medicine, and vascular radiology physicians. Go to the VDF Web site, www.vdf.org, click on the resources tab, and then click on the find a vascular specialist page to direct you to these society Web sites. Good luck!


Moderator- VDF: This next question as also e-mail to us ahead of time: My father has been diagnosed with AAA. His doctor has been following it by ultrasound. One of my concerns is that if it ruptures, my 86 year old father will not be able to relate to emergency personnel what he has. His memory is not very good. My question is, what about a medical alert tag? Do they make them for AAA and do you think it would be a good idea?

Speaker- Dr. Gornik: I think a medic alert bracelet for abdominal aortic aneurysm is an excellent idea. Make sure it spells out abdominal aortic aneurysm" and not just AAA. 


Moderator- VDF: This next question also comes to us by e-mail: I exercise regularly (kickboxing 2-3 times per week). I have never had a problem with my leg until one day I kicked a sandbag and hurt my vein. It got bruised and then this pain started that I still have. Now the bruise is gone, but the pain is still there!

Speaker- Dr. Gornik:
You should make sure there is not a blood clot within this vein or phlebitis. Please contact your physician and let him or her know about what happened.


Michelle: What should I do if I have a swollen and painful leg?

Speaker- Dr. Gornik: Important question. First of all, it is key to make sure that this is not a blood clot, or DVT. This is a medical emergency that requires evaluation by your doctor right away. Once a DVT has been ruled out, other causes of leg swelling can be considered, such as varicose veins, venous insufficiency, medications, lymphedema, or other medical conditions.


Kathy: My ankles get swollen by the end of the day and during hot summer days. What can be done?

Speaker- Dr. Gornik: It sounds like you may be having benign mild ankle swelling that is common, especially for people on their feet for a long period of time.  I would discuss this with your doctor. The first step is ruling out blood clots and other medical conditions such as heart failure. Once these things are ruled out and this is determined to be mild edema, the first treatment is generally graduated elastic compression stockings.


Cathie: I was having intermittent claudication and was sent in to have a doppler ultrasound. It showed I have blockages behind both knees and in the left femoral artery. I have an appointment with a vascular surgeon at the end of next month. How will they determine if I need bypass surgery? I am a 34 year old female and an insulin dependant diabetic.

Speaker- Dr. Gornik:
Thanks for your question Cathie --- You have just been diagnosed with peripheral arterial disease or PAD. Blockages in the femoral arteries and behind the knees are a very common location. There are many treatment options available, ranging from a trial of one of the available medications for claudication, supervised exercise rehabilitation training, open surgery, and catheter-based procedures (balloon angioplasty with or without stenting). A vascular specialist should be able to discuss the full spectrum of options with you. Also, it is very important for patients with PAD to be treated for all cardiovascular risk factors, such as blood sugar, cholesterol, and high blood pressure.  I am glad you are getting help. Good luck.


Moderator- VDF: This next question came to us by e-mail: Is it possible to get a DVT from having an accident?

Speaker- Dr. Gornik:
It is absolutely possible to have a DVT following trauma. Immobility, being on bed rest, or having a cast on the leg are all risk factors for DVT.


Chris: How can you prevent PAD?

Speaker- Dr. Gornik:
The most important thing you can do to prevent PAD is NOT SMOKE or QUIT SMOKING IF YOU DO SMOKE. Diabetes is also a very strong risk factor for PAD. High blood pressure and high cholesterol also contribute. Regular exercise, maintaining normal blood pressure and cholesterol, and maintaining a healthy body weight can also help. I believe next month's CHAT will focus on PAD prevention. Is this true Christa?

Moderator- VDF: Yes, next month Dr. Kerry Stewart will be discussing PAD management on Wednesday, November 21 at 1pm EST.


Sue: What about chelation therapy? Does it work?

Speaker- Dr. Gornik: There is little scientific evidence to support the use of chelation therapy for leg symptoms in PAD, and this treatment is not recommended by a consensus of vascular specialists. A recent large study of chelation for angina due to heart disease demonstrated that this treatment was not beneficial.


Sheryl: How long do stents last?  What about bypass surgery?

Speaker- Dr. Gornik: With regard to leg stents for PAD, it depends on the location of the stent.  For stents in the abdomen and pelvis, there are good long term outcomes, up to 80% or so at 5-years. Surgical outcomes for blockages in the aorta or iliac (abdominal/pelvis) vessel are even better, with ~ 75-80% patency rates at 10 years. For blockages in the thigh and knees (femoral/popliteal vessels), the outcomes depend on the type of material used for the bypass procedure. In general, for disease in the thigh or calf muscle, long term outcomes are better with surgery than with angioplasty/stenting, but surgery carries a higher risk of a complication, such as a heart attack or bleeding.


Moderator- VDF: This next question was e-mailed to us: I am a 36 year old female and since the birth of my 4th child I have this feeling like there is cold running down the inside of my leg. The first time I experienced this I had to check and make sure I didn't wet my pants. I have no clue as to why this happens. Could is be nerve damage or something else?

Speaker- Dr. Gornik: I would be concerned about the possibility of a nerve-related problem or an orthopedic problem. Vascular disorders, such as a blood clot, are less likely, but are not impossible. I would strongly recommend that the e-mailer contact her obstetrician, internist, or family medicine doctor to be evaluated soon.


Robin: I am having problems keeping my feet, hands, face, neck right below the chin, butt and thighs warm. Even after being in a warm room of 75 degrees. I am still cold in those areas for hours. My toenails are getting thick and a couple of them have callous looking sores on them. Its takes several hours to rewarm. I am also fatigued much of the time and it takes me a long time to wake up. Any idea what this could be?

Speaker- Dr. Gornik:
There are certain cold-related vascular disorders, such as Raynaud's, that come to mind. I would be worried about a more systemic problem, such as an endocrine problem. I do think you need to see your physician soon to look into this.


Sheryl: If I've had a DVT before, are there any precautions I should take before going on an air flight? Should I wear support hose?

Speaker- Dr. Gornik: With regard to DVT and airplane travel. I would be concerned about risk of another DVT with airline travel. You should discuss this with your doctor. At minimum, you may be prescribed a pair of graduated elastic compression stockings, which have been shown to prevent DVT. In some cases, a physician may also consider given a low dose of a blood thinner for patients at highest risk for another DVT, such as those with a clotting disorder. Again, this should be discussed with your physician.


Moderator- VDF: We had several questions from the audience wondering if vascular disease can cause depression.

Speaker- Dr. Gornik: I think any chronic medical condition can cause depression. In addition, recent research has shown that patients with PAD are more likely to have poor quality of life and evidence of depression using screening questionnaires, than patients without PAD.


Moderator- VDF: Thanks to everyone for joining us today, we appreciate your time! Thank you Dr. Gornik for taking the time to answer everyone's questions. We wish you a great day!

Disclaimer

The material provided on VDF's Web site and Live Ask the Doctor chat are for educational purposes only and are not to be used as a substitute for professional medical services or advice. For more information, please read VDF's important disclaimer.