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

Interactive Learning : Ask the Doctor

 

Ask the Doctor Live Chat Transcript - Wednesday, March 26

 

Dr. Suresh Vedantham

Washington University School of Medicine

Vascular Disease Foundation Board of Directors

 

 

 

 

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


Jane: Why does DVT seem to be so common during pregnancy?

Speaker- Dr. Vedantham: Jane, there are a number of reasons why pregnancy increases the risk of DVT. First, female hormone levels change drastically during pregnancy, and these hormones can increase risk of clotting. Second, the weight of the baby often presses upon the veins in the pelvis, slowing blood flow and making them more prone to clot. Finally, after delivery and/or cesarean section, women are often at bed rest and immobility can promote clot formation.


Moderator- VDF: This next question was e-mailed to us ahead of time: What kind of a doctor handles DVT? Is it a hematologist?

Speaker- Dr. Vedantham: A number of different types of doctors have expertise that is helpful in treating DVT. Internists and surgeons commonly treat DVT using blood-thinning drugs. Hematologists are physicians who specialize in blood disorders - they will often manage patients who have been difficult to anticoagulant (thin the blood) properly. Interventional radiologists and vascular surgeons often perform clot removal treatments for DVT patients as well.


Moderator- VDF: This next question was also e-mailed to us ahead of time: I have several large clots in my left leg; they have been there for over 1 1/2 years due to two total knee replacements. My physician just took seven vials of blood to see if there is anything that could be causing the clots. My doctor did not explain this and I want to know what could possibly be the reason to take so much blood and what is he looking for? I'm a very young 59 year old woman, I'm active and not over weight, non-smoker and do not drink alcohol.

Speaker- Dr. Vedantham:
There are a number of inherited risk factors that can make blood more prone to clot. Some of these involve the formation of abnormal clotting factors or blood proteins, and some of these abnormalities are genetically-based. I suspect your physician plans to perform laboratory tests for these conditions. This may help to guide him/her on why you have clotted and how long you will need to take blood thinners.


Ben: I have varicose veins and have been thinking about getting them fixed. I have read some but am really confused as to the best treatments. I've read about laser and radio-frequency and micro-phlebectomy treatments. I find pressure stockings difficult to put on and hot, but would they fix the problem? What's best?

Speaker- Dr. Vedantham: Ben, compression stockings will often help to manage the symptoms of varicose veins, but they don't really address the underlying problem. Plus, most patients do find them uncomfortable to wear. The first step would be to be evaluated by a physician who specializes in vein treatment. That physician will probably do an ultrasound exam of the veins in your leg, which will help to determine exactly what the problem is. Most commonly, the problem is what we call reflux" or backwards blood blow in the major draining veins (the saphenous veins) - this occurs when the one-way valves in the vein do not function properly. Treatment of saphenous vein reflux previously involved open surgery but most patients nowadays prefer a less invasive option. Laser ablation and radiofrequency ablation are minimally invasive outpatient methods by which saphenous vein reflux can be eliminated. They take less than one hour to perform and can usually be done under local anesthesia. These treatments are very effective in eliminating the veins and relieving the leg symptoms.

Ben: Thanks. If I do one of the procedures you mentioned, will I still have to wear the stockings? Also, one leg is worse than the other. Should I just go ahead and do them both or wait for the other?

Speaker- Dr. Vedantham: Ben, that will depend upon how complete your response is to treatment.  It's important to wear the stockings for a few weeks after the procedure. After that, it entirely depends upon how your symptoms respond. I do have many patients who I successfully treated and who no longer need stockings.


Moderator- VDF: This next question was also e-mailed to us ahead of time: Can you recommend how to soften the skin of someone with varicose veins? The entire leg from the mid calf to the ankle is affected, the skin is very taut and extremely discolored and I have a fear of the vein rupturing. Are there ways to treat the varicose veins and the associated skin problem?

Speaker- Dr. Vedantham: When there is either reflux (backwards blood flow due to valve failure) or obstruction (blockage of the vein by blood clots) in the leg veins, the blood pressure in the veins increases dramatically, particularly when a person is standing upright. This results in several consequences. First, varicose veins typically bulge out. The patient often develops symptoms of heaviness or aching in the leg. Over time, the skin becomes thicker, hardened, can change color, and can develop open sores called ulcers. If you have skin changes, then you probably have fairly advanced venous disease and should seek care for it. Depending on whether the problem is valve failure or clotting, this can often be treated. Valve reflux can be treated with laser or radiofrequency ablation.


Jane: Does being on Birth Control give you the same risk factors for DVT as pregnancy?

Speaker- Dr. Vedantham: Most estrogen-containing birth control pills do increase DVT risk, although there are now preparations that are less risky - ask your gynecologist. The basic mechanism is similar to pregnancy - elevated hormone levels increase clotting risk. It's important to understand that only a very small minority of women will develop a blood clotting episode while on birth control pills. So you will want to have a careful discussion of the good and bad of different options for contraception with your physician.  


Moderator- VDF: This next question was also e-mailed to us ahead of time: Is air travel safe for those with DVT?

Speaker- Dr. Vedantham: Long air flights probably do slightly increase the risk of DVT, although there are many unanswered questions in this area of study. If you have had a DVT before, then it may be prudent to discuss options for preventing travel-related DVT with your physician if you are contemplating a long flight. At a minimum, you will want to get up and walk every 30-60 minutes, and it's probably worth discussing whether it's best to also take an injectable blood-thinner for several days. That would depend upon the original reason for your DVT, and what additional risk factors you may have.


Roger: Hello, I am concerned about my wife's varicose veins. She's just over 40 and in good general health (doesn't drink or smoke, good diet, etc.). She has one varicose vein in her left leg and many smaller I guess they're called spider veins in both of her legs and feet. She also has MS, and has problems with both of her legs (numbness/weakness), mainly her left one where the varicose vein is. Should I be concerned about this and if so should we seek treatment with her neurologist or a vein doctor? Thanks-

Speaker- Dr. Vedantham: The varicose veins are not dangerous but can be treated if they are causing symptoms. However, the physician who treats the veins should first discuss his/her plans with her neurologist.

Roger: Thank you Dr. Vedantham, is my wife more at risk for varicose veins because of the MS and what kind of symptoms would they cause? She already has numbness and tingling and some pain. Thanks again-

Speaker- Dr. Vedantham: No, the MS should not increase the risk of varicose veins.  Varicose veins are extremely common (perhaps 20% of the U.S. population). Common symptoms of venous disease are swelling and aching in the legs that worsen when she is upright - however, these symptoms can also occur in other conditions so a careful exam is needed to sort through this.

Roger: What is the difference between a varicose and a spider vein and do they have the same cause for concern?

Speaker- Dr. Vedantham: Spider veins are just very small varicose veins. However, depending upon where they are located, they may be treated very differently. A careful physical exam by a venous doctor will help to determine what treatment to pursue. Patients with varicose veins are more likely to have underlying saphenous vein reflux (valve failure), and may benefit from treatments to address this. Patients with spider veins alone may often just be treated with injections into the veins (sclerotherapy"). But there is a lot of overlap. Keep in mind neither condition is dangerous to you - treatment is undertaken to relieve symptoms and/or appearance.


Barry: Hi Doctor, I'm going in for a knee replacement in a few days and the doctor said that DVT might be one of the complications. Why is that and how can I keep that from happening?

Speaker- Dr. Vedantham: The primary ways to avoid DVT are a) get walking as soon as you are able - this may not be entirely within your control; b) use blood thinning drugs - they work very well to prevent DVT, but sometimes cannot be used around the time of surgery; and c) use a device which compresses the legs to move blood around (all hospitals have these). Definitely re-address this issue with hospital staff when you arrive at the hospital. In terms of why, any time you experience trauma (and surgery is one form of trauma), your body revs up its clotting system to counter it. Sometimes it just goes too far and forms a blood clot.


Moderator- VDF: This next question was e-mailed to us ahead of time by Julie: Last June I had a cardiac arrest. As a result of the efforts to restore my life, I developed a DVT in my right arm between my elbow and my shoulder. It is not clearing with blood thinners and I have taken Lovenox injections. Do you have any info on DVTs of the arm? Everything I can find is about the legs. My right arm is swollen, cooler and a slightly different from my left.

Speaker- Dr. Vedantham: About 10-15% of DVT cases occur in the arm. The treatment is very similar to leg DVT. If you are in reasonably good health, sometimes clot-dissolving treatments can be performed to eliminate the clot and relieve symptoms - however, they are generally most useful soon after the clot has formed. If it has really been many months, then I'm afraid blood-thinners are the best we've got.  But if your symptoms have recently worsened significantly, you might have some new clots that could be dissolved in this way.


KC: I had surgery to repair an Achilles tendon rupture. Within a month I was in the hospital diagnosed with blood clots. Was give heparin while in the hospital, then continued warfarin for 6months thereafter. At the end of the 6months I had another ultrasound to confirm that I had not developed more clots. I did not and was able to stop the coumadin therapy. I do have continuous swelling in the same leg. Randomly I have a twinge" of pain (not much pain) in my thigh (there was a clot there when I was admitted to the hospital). Is there something that can remove the clot for good and restore the valve to work right? What happens to an old clot just left there?

Speaker- Dr. Vedantham: KC, old blood clots are a difficult problem. The body can usually remove part of the clot on its own, but usually doesn't succeed in getting it all. This has two consequences: blockage of blood flow in the vein, and damage to the venous valves. Unfortunately, the valve damage is usually permanent. However, there are two treatable" components to this problem: a) if you have blockage of the vein in the groin or pelvis an interventional radiologist can sometimes place stents in the vein to open it; and b) if reflux in the saphenous veins is contributing to the problem those veins can be eliminated with laser or radiofrequency ablation. So it's worth seeing a specialist such as an interventional radiologist to see if you are likely to be eligible for one for these new treatments.


Barry: Are there procedures for DVT that will in essence 'roter rooter' the clot out like there is for arteries?  It seems like I've only been presented with things that will remove the clot over time (drugs, etc) instead of a procedure to just open up the vein. Is that really difficult or dangerous?

Speaker- Dr. Vedantham: Barry, as you have pointed out, blood thinners prevent new clots from forming but don't actually eliminate the ones that are already there. During the first few weeks after a blood clot forms, interventional radiologists (physicians who specialize in image-guided procedures) can use clot-busting drugs and new devices (roter rooter" in some form) to remove the clot and prevent long-term problems. The downside is that the clot-busting drugs can cause bleeding and there is no large-scale study that proves that this will work in the long run. For these reason although there are many smaller studies that suggest that this would work most physicians do not routinely offer clot-removal treatments to their DVT patients. It's also important for you to know that in some patients with old blockages of the vein we can open up the vein using stents. So it's worth re-addressing with a physician who specializes in this form of treatment.


Moderator- VDF:This next question was also e-mailed to us ahead of time: I had a DVT in my right leg and was told that I will have scar tissue there though the DVT is gone. Is there any procedure or medicine that will clear out the DVT scar tissue and restore my veins to their proper functioning?

Speaker- Dr. Vedantham: If the scar tissue is in the veins of the groin and/or pelvis, an interventional radiologist can sometimes place stents in the vein to open it up and relieve symptoms.  Other than that, there are no drugs that can eliminate the scar at this point, I'm afraid.  Sometimes, though, long-term symptoms in DVT patients are partly due to saphenous reflux and this can sometimes be treated if the anatomy is right.


Lois: Hi, I'm currently undergoing cancer treatment and would like to know if I need to be worried about DVT while taking chemo?

Speaker- Dr. Vedantham: Patients with cancer are certainly at higher risk of DVT. You should definitely receive DVT-prevention measures (mainly blood thinner injections and/or compression devices) while you are in the hospital. If you are at home and walk several times a day at least, most physicians would not take special measures to prevent DVT.

Lois: What is it about cancer that causes DVT?

Speaker- Dr. Vedantham: Cancer cells produce proteins that increase clotting.


Moderator- VDF: Thanks to everyone for joining us today! That's all the time we have for your questions. Thanks to Dr. Vedantham for his time and we wish you a healthy day!

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