So even though you are not a vein specialist and vascular surgeon as I am, you now know the answer to the multiple-choice question posed in the first paragraph. Make sure you don't have something in your leg that can kill you or maim you: a blood clot. After you visit the emergency room and make sure everything is okay, go for a jog, have a drink, and take a nap, in that order. Now you'll feel better.
DVT (deep venous thrombosis) is a problem that is estimated to affect 300,000 people per year. Not everyone develops the life-threatening complication of blood clots traveling from their leg veins to their hearts or lungs (pulmonary embolus). Clots that remain in your leg vein can also cause long-term damage that affects the legs themselves over the course of your life, such as swelling, aching, throbbing, skin changes, and ulcers at the ankles. It's important to not only diagnose the problem early but also treat it early. Prompt treatment prevents life-threatening and leg-threatening problems.
How Do Veins Work?
Veins carry blood back to the heart and lungs, where it can then absorb oxygen and travel back to the rest of the body so that all organs can function. The leg veins have one-way valves. These valves direct the blood up the leg towards the heart. Every time you contract your leg muscles, they pump the blood up the veins in the direction of the heart.
If a vein is blocked with a clot, two problems develop. First of all, if the clot blocks the blood flow back to the heart, the leg can swell, ache, and throb. Secondly, the clot in the leg vein may break away and travel to the heart and lungs, causing significant damage and perhaps death.
What Causes Blood Clots?
If blood doesn't flow, it has a tendency to get "thick" and clot. So that seven-hour plane trip with your legs hanging down and the blood not flowing well didn't help. A blood clot could develop. Another cause of blood clots is inherited problems. There are about eight to 10 inherited clotting disorders called thrombophilias. They can easily be diagnosed with simple blood tests, but one needs a high index of suspicion. If you have had a blood clot already for no apparent reason such as a long plane or car trip, broken leg, recent surgery, cancer, etc., then you probably should be investigated for having thrombophilia. A family history of blood clots in veins, early heart attack in parents or siblings (under age 50), or early stroke are also reasons to investigate the possibility of an inherited clotting problem (thrombophilia).
How Can I Prevent Blood Clots?
The obvious answer is to minimize the risk factors listed above. It is very important to flex your leg muscles and move about during long trips. Dehydration, especially during plane trips, can cause the blood to be "thicker." Therefore, consciously drink more water, juice, soda, etc., before and during long trips. Most airlines now address the issue of DVT in their travel magazines. Over-the-counter or prescribed graduated compression knee-high stockings can also help maintain good blood flow in the veins. I feel it is important to wear these on long plane or car trips. The business traveler should be aware of these simple preventative measures.
How Do I Know I Have a Blood Clot?
You don't. Even the most experienced professionals (vascular surgeons) are only right 50% of the time by examining the patient alone. We may as well flip a coin. We need more information.
An ultrasound (Doppler) is the gold standard. This test utilizes sound waves to look at the leg veins and "see" if any blood clots are present. In experienced hands, the ultrasound test is almost 100% effective in identifying life-threatening blood clots. This examination gives us the information we need. The ultrasound exam is completely non-invasive, requires no preparation, and lasts approximately 20 minutes. There is no discomfort. It may also identify other reasons for the symptoms of calf tenderness and swelling.
What if I Have a Blood Clot?
The goal of treatment is to dissolve the blood clot so that it doesn't cause damage to the leg veins and doesn't travel to the heart or lungs. The most common form of treatment is "blood thinners." There are two types of blood thinners; one type works immediately but requires injections or intravenous treatment, and the other type is a pill that takes a few days to begin its effect.
Usually we begin with the immediate type (heparin, Lovenox) and give the oral type until it begins to take effect; then we stop the immediate type and continue oral blood thinner for at least six months. Most treatment can be undergone by an outpatient. The injections of the immediate-acting blood thinners can be self-administered at home. If a patient has significant risk factors, he or she may be hospitalized for a few days until the oral medication takes effect.
In some cases, the clot may be so extensive or the risk of blood thinners so great that patients need another type of protection. These patients may require the placement of a vena cava filter. The vena cava is the main vein in the abdomen. Both leg veins lead to the vena cava. A vena cava filter can be thought of as a "strainer" or "colander" that traps any blood clots that are traveling from the leg veins to the heart. Doing this prevents the life-threatening complication of leg vein blood clots, pulmonary embolus. This filter is designed in such a configuration that it is self-cleaning—i.e., once a clot is trapped, it is slowly dissolved over time.
The newest minimally invasive methods of clot dissolution are mechanical and chemical techniques. We are now able, with one small needle stick, to insert devices that utilize ways to dissolve clots by softening them and vacuuming them out of the body in a matter of hours. This removes the clots more quickly and reduces the risk of blood clots damaging the leg veins or traveling to the heart. Patients can get back to living their lives more quickly than with traditional methods of DVT management.
Summary
After that seven-hour flight, something dangerous may be brewing, or it may just be a sore muscle. Without a high index of suspicion, an easily treatable problem (DVT) may become a life-threatening one (pulmonary embolus). Travelers should be aware of the risks of travel, what they can do to prevent problems, where they should go to diagnose the problem, and what methods are available to treat a blood clot.
Travelers can reduce their risk by wearing support stockings, moving their legs, and keeping hydrated. Anyone with a family history of blood clots or unexplained blood clots of their own should seek the advice of vascular specialists. By being aware, travelers can be proactive and prevent problems.
If suspicion exists, the diagnosis is simple and painless—a non-invasive ultrasound study (Doppler). If a clot is found, early treatment is non-invasive (blood thinners) or minimally invasive (filters or clot removal). At most, a patient may require a small incision of a quarter inch.
The goal is to prevent complications and get people back to their lives in a safe, protected state. Awareness is key. The state of the art is such that we can prevent problems, we can diagnose problems, and we can quickly and safely treat problems in most cases without life-threatening complications.
About the Author
Steve Elias is the Director of The Center for Vein Disease at Englewood Hospital and Medical Center NJ. He lectures, publishes, and teaches extensively about minimally invasive vein care and procedures. As Course Director of the Annual Vascular Fellows Course in Venous Disease, he trains young vascular surgeons in the treatment of vein problems. His clinical interests encompass all aspects of vein care: spider veins, varicose veins, perforator and deep venous incompetence, and venous ulcers. He performs all minimally invasive vein procedures and his work at the Center for Vein Disease includes the prevention and treatment of deep venous thrombosis. Dr. Elias is a fellowship-trained vascular surgeon and member of the American Venous Forum, the American College of Phlebology, the Society for Clinical Vascular Surgery, and the International Society of Cardiovascular Surgery.
