Diseases

Surgery 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.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.

• Minimize risk factors for DVT, for example, quit smoking (especially if the person also is taking birth control pills or hormone therapy).
• In the hospital setting, the staff works hard to provide DVT prophylaxis to minimize the potential for clot formation in immobilized patients. Surgery patients are out of bed walking (ambulatory) earlier and low dose heparin or enoxaparin is being used for deep vein thrombosis prophylaxis (measures taken to prevent DVT).
• When traveling it is recommended that you get up and walk every couple of hours during a long trip.

Pulmonary embolism is the major complication of deep vein thrombosis. With signs and symptoms such as chest pain and shortness of breath, it is a life-threatening condition. Most often pulmonary emboli arise from the legs.Post-phlebitic syndrome can occur after a deep vein thrombosis. The affected leg or arm can become chronically swollen and painful with skin color changes and ulcer formation around the foot and ankle.

The treatment for deep venous thrombosis is anticoagulation or "thinning the blood" with medications.The recommended length of treatment for an uncomplicated DVT is three months. Depending upon the patient's situation, underlying medical conditions and the reason for developing a blood clot, a longer duration of anticoagulation may be required. At three months, the doctor or other health care professional should evaluate the patient in regard to the potential for future blood clot formation. If the decision is made to continue anticoagulation over the long term, the risk/reward decision of preventing clots versus bleeding risk should occur every year to decide if anticoagulation is still a reasonable treatment.There are times when anticoagulation may have increased bleeding risk, for example, if the patient has had recent major surgery (anticoagulation thins all of the blood in the body not just the DVT). Other bleeding risks occur in patients with liver disease and those who take medications that can interact with the anticoagulation medicines.

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 clot breakdown is altered, significant clotting may occur. A thrombus can form if one or a combination of the following situations.Immobility

• Prolonged travel and sitting, such as long airplane flights ("economy class syndrome"), car, or train travel
• Hospitalization
• Surgery
• Trauma to the lower leg with or without surgery or casting
• Pregnancy, including 6-8 weeks post-partum after delivery of the baby
• Obesity

Coagulation of the blood faster than usual (hypercoaguability)

• Medications such as birth control pills (oral contraceptives), for example, Ortho-Novum, Yaz, Yasmin, Microgestin, Kelnor, and other estrogens
• Smoking
• Genetic or hereditary predisposition to clot formation
• Increased number of red blood cells (Polycythemia)
• Cancer
• Trauma to the vein
• Fracture to the leg or arm
• Bruised leg or arm
• Complication of an invasive procedure of the vein

Picture of how red blood cells and platelets form a blood clot

A deep vein thrombosis, or DVT describes a blood clot (thrombosis) that forms in the deep veins located in the arm or leg. It is important to know the body's anatomy and function to understand why clots form in veins and why they can be dangerous.

• 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. Being mobile causes this blood return system to fail, and the resulting stagnated blood may clot.
• There are two types of veins in the arm or leg; 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, in itself, is not dangerous. It becomes potentially life-threatening when a piece of the blood clot breaks off and embolizes, travels through the circulation system through the heart, and enters into one of the pulmonary arteries and becomes lodged. This can prevent blood from flowing properly through the lung and decreasing the amount of oxygen absorbed and distributed back to the body.
• Diagnosis and treatment of a DVT is meant to prevent pulmonary embolism.
• Blood 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.

Treatment for superficial thrombophlebitis treating the symptoms with:

• Warm compresses
• Leg compression
• Anti-inflammatory medications such as ibuprofen (Mortin) or naproxen (Naprocen).

If the thrombophlebitis occurs near the groin where the superficial and deep systems join together, there is potential that the thrombus could extend into the deep venous system. These patients may require anticoagulation or blood thinning therapy.

The diagnosis of superficial thrombophlebitis usually is made by the doctor at the bedside of the patient, based upon history, potential risk factors present, and findings from the physical examination. Further risk stratification tools may include scoring systems that can help decide whether a DVT is likely.If the probability of a leg thrombosis is low, a D-dimer blood test may be ordered.

• If the D-dimer is negative, then it is unlikely that a DVT is the diagnosis.
• If the D-dimer is elevated, then the possibility of a DVT exists and an imaging study, usually ultrasound, is required to look for the DVT

Ultrasound

• Ultrasound is the standard method of diagnosing the presence of a deep vein thrombosis.
• The ultrasound technician may be able to determine whether a clot exists, where it is located in the leg or arm, and how large it is. It also may be possible to know whether the blood clot is new or chronic. If necessary, ultrasounds may be compared over time to see whether a clot has grown or resolved.
• Ultrasound is better at "seeing" the veins above the knee as compared to the small veins below the knee joint.
• Clots in the chest or pelvis may not be identified on ultrasound.

D-dimerD-dimer is a blood test that may be used as a screening test to determine if a blood clot exists. 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. Any bruise or blood clot will result in a positive D-dimer result (for example, from surgery, a fall, in cancer or in pregnancy). For that reason, D-dimer testing must be used selectively.Other tests

• Venography, injecting dye into the veins to look for a thrombus, is not usually performed anymore and has become more of a historical footnote.
• Other blood testing may be considered based on the potential cause for the deep vein thrombosis.

People with a swollen extremity or concern that a DVT exists may be cared for by a variety of health-care professionals. Both the primary care provider (including internal medicine and family medicine specialists) and a health care professional at in an urgent care (walk in) clinic or emergency department are able to recognize and diagnose the condition. Some people go to the hospital and the diagnosis is made there.Treatment is usually started by the doctor who makes the diagnosis, but long-term treatment decisions, risk stratification, and follow-up usually is be done by the person's primary care doctor. Depending upon the situation, a hematologist (specialist in blood disorders) may be consulted. If there is need for the clot to be removed or dissolved, an interventional radiologist may also be involved.Depending upon the medication used to anticoagulate the blood, pharmacists and anticoagulation nurses may also be involved on your treatment team.

There are a wide variety of people who are at risk for developing blood clots. Some risk factors include:

• Immobility, including prolonged bed rest due to illness or injury and long travel in a car or airplane
• Pregnancy
• Birth control pills or hormone therapy
• Smoking
• Cancer
• Surgery that damages the veins in an arm or leg
• Family history or genetic predisposition to forming blood clots
• Obesity