Can a Large DVT Have no Symptoms?

A vascular surgeon addresses the issue of whether or not a large deep vein thrombosis can by asymptomatic.

For this article I consulted with Dr. Moji Gashti, Chief, Division of Vascular Surgery, Department of Surgery, Union Memorial Hospital, Baltimore, MD.

Perhaps you’ve read that half of DVTs don’t present with symptoms, but what about large DVTs?

“A large DVT in a proximal vein (popliteal, femoral, iliac veins) most often will be symptomatic with at least edema and perhaps pain,” says Dr. Gashti.

Popliteal = behind the knee

Femoral = main artery of thigh

Iliac = pelvic vein

“Some people can have duplicate femoropopliteal veins and even IVC [major vein that goes into the heart], and if they develop a large DVT in one of the two veins, they may not be symptomatic. Others may have developed significant collaterals in the past, perhaps from an old DVT, and again may not present with significant symptoms.”

Collaterals refer to development of additional veins to compensate for deficient veins.

“In one study, about 300 patients in the SICU, asymptomatic for DVT, were scanned and 7.5% had major proximal DVT. An orthopedic patient cohort was studied pre- and post-surgery. All were asymptomatic for DVT; 2.5% of patients pre-op had proximal DVT and over 16% post-op.”

Of course, it’s logical to wonder how many of these asymptomatic deep vein thromboses would have eventually began producing symptoms if they were not discovered, and therefore not treated.

Dr. Gashti continues, “So you can see that a significant number of even proximal DVTs can remain asymptomatic. The question is what is the significance of not treating these patients and should we study all of them?

“These are surgical patients; but to know the exact number of asymptomatic DVTs, a large number of people need to be randomly studied!

“The most common symptoms of large symptomatic DVTs in the acute setting are pain and swelling [edema]. Discoloration may occur later as the result of postphlebitic syndrome.

“Interestingly in another study where patients who had symptomatic, confirmed DVT in one limb, 5% had proximal DVT in the asymptomatic limb.”

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Retirement Better for Health than Work

Maybe you should retire at the first opportunity to avoid the health ravages of stress.

Your cardiovascular system and metabolic processes can be harmed by workplace stress. Ongoing stress creates inflammation throughout the body, which then can fire up disease processes in the cardiovascular system as well as other systems.

It’s nothing new that work can literally make a person sick, and that there’s a reason why you never hear about “retirement place stress.”

But yet a new study (from the Helmholtz Zentrum München) shows that work leads to stress that leads to cardiovascular disease. The full report is in the journals Brain, Behavior, and Immunity and Psychosomatic Medicine.

The investigation, led by Dr. Rebecca Emeny, shows that healthy workers who were subjected to workplace stress had highly elevated inflammatory parameters. They also had twice the risk of cardiovascular disease. Stress is a risk factor for heart disease.

Stress from work also leads to mental ailments like depression, and causes insomnia. Working also leads to unhealthy behaviors such as lack of exercise.

Here’s something to wonder about: Ever notice how unhealthy elderly people who still work look? Though many retired elderly people are quite frail and sickly, next time you’re out and about, take notice of elderly people who are bagging groceries, greeting people at stores or holding down some other form of employment.

Though in general, elderly people don’t exactly look like they can jump through hula hoops, it seems to be a general phenomenon that elderly people who still work appear to be in much poorer shape and health than they should be for their age.

Source:

http://www.sciencedaily.com/releases/2013/04/130423090940.htm

Abdominal Aortic Aneurysm: Surgery, Drugs, Watchful Waiting

ABDOMINAL AORTIC ANEURYSM INFORMATION

Visit the links below to find the answers to your questions about an abdominal aortic aneurysm:

-Is abdominal aortic aneurysm caused by genetics?

-Endovascular vs. surgical repair

-Are beta blockers effective at shrinkage?

-Endovascular repair for AAA near renal artery

-How often should small abdominal aortic aneurysms be followed?

-New research on a drug that may shrink an AAA

-Survival rates for endovascular repair vs. open surgery

Peripheral Neuropathy Misdiagnosis: Doctors Miss Disease

Just because doctors haven’t mentioned peripheral neuropathy as the cause of your pain, doesn’t mean you can’t have it.

“Peripheral neuropathy” means disease of the nerves of the peripheral nervous system, and I know at least one person who’s been recently diagnosed with this  --  after it was missed for the past four years by a steady stream of doctors: my father.

For about four years he’d been complaining of pain in his legs, and several doctors attributed this to problems with his low back, including spinal stenosis. Two endoscopic back surgeries didn’t help.

Another doctor said it was from osteoarthritis of the hip and recommended a hip replacement, which my father had; it did no good.

He’s had three knee replacement surgeries by two orthopedic surgeons who both said that the leg pain was caused by osteoarthritis in his knees. The second surgeon, who did the third knee surgery (a revision) said that the pain could very well be from a failed knee replacement.

What seems to make it easy for doctors to miss peripheral neuropathy is when the patient actually has these other conditions, which are easily proven with X-rays and MRIs. My father has had more than one primary care physician over this time period, who named back and knee problems, as well as old age, as probable causes of the leg pain.

Other proposed explanations for the leg pain was a knee infection, and allergic reaction to the knee replacement device. Early on, an adverse side effect to my father’s use of a statin drug was suspected, but ruled out after he went off the statin but the leg pain continued.

Strangely, none of these many doctors came up with, “You know, this very well could be peripheral neuropathy. Let’s aggressively pursue this possibility.”

Peripheral Neuropathy Doesn’t Necessarily Work Alone

If you have degenerated knees or lumbar discs, this doesn’t mean you can’t also have peripheral neuropathy adding to your lower body pain, burning and tingling.

Peripheral neuropathy is associated with diabetes; diabetes is the most common cause. A doctor may rule out peripheral neuropathy if you don’t have diabetes (my father doesn’t), and especially if you have other “differentials” that can explain the leg pain, such as degeneration of the lumbar spine as shown on imaging tests.

How did my father finally get diagnosed with peripheral neuropathy? His assortment of doctors would have continued to miss this had he himself not decided one day to review his medical records over the past four years.

He’d had an EMG about three years ago and the doctor said he had “nerve damage.” However, that doctor, plus his primary care doctor at the time, didn’t further pursue this “nerve damage,” and thus, my father had thought nothing of it.

My father found the words “peripheral neuropathy” in the paper work as a diagnosis, and was floored that nothing ever came of this; no further workups or recommended drugs. He immediately contacted his newest PCP, who in turn ordered blood tests to rule everything else out.

Within 24 hours of the blood tests, my father was prescribed Nortriptyline, a tricyclic antidepressant that’s also used to suppress the pain of peripheral neuropathy. At the time of this writing, he has not yet gotten the prescription because it was ordered late Friday afternoon.

Why, after four years, did so many doctors not think of peripheral neuropathy? And why didn’t the EMG neurologist pursue it? It’s because sometimes, the patient knows more than their physician.

Abdominal Aortic Aneurysm Repair: Short Term Mortality

Find out why the short-term mortality rate is high for an abdominal aortic aneurysm repair.

For this article I consulted with Dr. Moji Gashti, Chief, Division of Vascular Surgery, Department of Surgery, Union Memorial Hospital, Baltimore, MD.

Dr. Gashti explains, “Most randomized control trials indicate the 30-day perioperative mortality for elective repair of abdominal aortic aneurysm is about 5%. This is major surgery and presence of a AAA is a marker for other significant cardiovascular disease. As a matter of fact, beyond the 30-day, most people die from other cardiovascular causes, such as MI, CVA, etc.”

MI = myocardial infarction (heart attack).

CVA = cerebral vascular accident (stroke).

Time it Takes DVT to Become PE Once It Dislodges

When a DVT breaks off, how long does it take to embolize in the lung?

For this article I consulted with Dr. Moji Gashti, Chief, Division of Vascular Surgery, Department of Surgery, Union Memorial Hospital, Baltimore, MD.

Dr. Gashti explains, ‘Generally it is immediate (do not know the exact time period), but by far the majority remain clinically silent since they can be very small.”

Imagine that you have a DVT anywhere in your leg, and suddenly, a part of it breaks off or dislodges. This clot material then gets swept up by the venous flow that returns de-oxygenated blood to the lungs.

This is akin to tossing stuff in a river, and the flow of the river carries it downstream. Of course, veins in the legs pump blood “upstream,” but the principle is the same: The bits of DVT immediately get carried away with this blood circulation and, like Dr. Gashti says, the time lapse is immediate from when the clot dislodges to when it arrives in the lung (pulmonary artery).

Though most don’t produce symptoms due to being very small, this doesn’t negate the estimated 300,000 U.S. deaths every year to a pulmonary embolus. A pulmonary embolus is a common event in the population.

If you suspect a DVT, and knowing that if it dislodges, the occurrence of a pulmonary embolism will be literally within seconds, don’t delay getting yourself checked out in the emergency room. Better safe than sorry.

Related Reading

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Can You Get a Pulmonary Embolus without a DVT?

Find out the interesting answer to the question: Can a pulmonary embolus form in the absence of a DVT?

For this article I consulted with Dr. Moji Gashti, Chief, Division of Vascular Surgery, Department of Surgery, Union Memorial Hospital, Baltimore, MD.

Dr. Gashti explains, “By definition a PE is an ‘embolus’ that has traveled to the lungs. An embolus is a thrombus (blood clot) that is dislodged from one place and ends up in another. It can be both venous and arterial. Of course a pulmonary embolus must have a venous source.”

In other words, in order for a blood clot to end up in a pulmonary artery, it has to travel there somehow, and the only way is via veins (venous pertains to veins).

“I assume that one can form a thrombus de novo [originating from] in a pulmonary artery, but that would not be considered a PE.” Remember, embolus refers to a blood clot that has dislodged. So if the clot originates in the lungs, it’s not a “pulmonary embolus.”

“Not infrequently a patient has a pulmonary embolus, but a source cannot be found,” continues Dr. Gashti. “In these cases the possibilities include: thrombus completely broke off from the original vein and therefore none can be found now; thrombus was in a vein in the upper extremity which normally is not studied in a patient with a PE unless clinically indicated, or that it came directly from the right heart (after open heart surgery), after having a heart attack, or from a tumor, i.e., myxoma.”

Can DVT Cause Swelling only in the Ankle?

A physician answers the question: Can a DVT cause only the ankle to become swollen?

For this article I consulted with Dr. Moji Gashti, Chief, Division of Vascular Surgery, Department of Surgery, Union Memorial Hospital, Baltimore, MD.

When I asked if a deep vein thrombosis can cause swelling only in a person’s ankle, Dr. Gashti explained, “That would be unusual, unless the very distal tibial veins are thrombosed, in which case it would not be of great significance, again because these emboli would be very tiny.”

The distal tibial veins are the veins in the front or anterior of the lower leg where the tibia bone is. The tibia is the larger of the two lower leg bones. Distal means distant from the center of the body, so in this case, the location would be near the ankle.

Thus, if a DVT forms near the front of the lower leg near the ankle, the clots would be, as Dr. Gashti says, “very tiny,” and thus not potent enough to cause swelling going up the leg, but rather, more likely confining it to only the ankle.

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Why So Many DVTs Are Missed after Surgery

A doctor explains why so many DVTs get missed post-op.

For this article I consulted with Dr. Moji Gashti, Chief, Division of Vascular Surgery, Department of Surgery, Union Memorial Hospital, Baltimore, MD.

I wondered if this had anything to do with the fact that many DVTs produce no symptoms. After all, nurses check a patient’s legs after surgery on a regular basis. After my father’s four joint replacements, nurses were always inspecting his legs for signs of a deep vein thrombosis.

“Yes, a significant number of DVTs remain asymptomatic, particularly if they involve the smaller (tibial) veins,” says Dr. Gashti. “Even a venous Doppler has a high false negative rate when it comes to these veins.” False negative means that a procedure missed what it was looking for.

“A lot of patients after knee or hip surgery would have pain and swelling related to their surgery anyways; it can be difficult to know if their symptoms are related to their surgery or DVT. It may not be practical or cost effective to study all of these patients.”

“Most of these DVTs would be labeled as provoked, most often secondary to central venous catheters,” says Dr. Gashti. “Generally these are focal and limited to the site of the catheter (most often in the internal jugular vein). These can be watched.

“But if the thrombus extends to the subclavian/innominate veins, then most physicians would consider anticoagulation if there are no contraindications.” Following CABG, a patient can bleed to death from anticoagulant drugs.

“If anticoagulation is contraindicated, then an SVC filter would be indicated,” says Dr. Gashti. SVC stands for superior vena cava, a large vein that transports de-oxygenated blood from the upper body to the heart.

“The SVC is much shorter than the IVC [inferior vena cava], and therefore placement of a filter in the SVC is technically more challenging. You have to make sure the length is adequate. Currently there are no filters in the market indicated for SVC and if you place one, it would be off label. I have only placed a handful of these in 14 years of practice.”

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DVT in Neck after CABG: Shouldn’t Patient Get SVC Filter?

What should be done when a patient gets a DVT in the neck after coronary bypass surgery? Seems like an SVC filter should be placed, no?

For this article I consulted with Dr. Moji Gashti, Chief, Division of Vascular Surgery, Department of Surgery, Union Memorial Hospital, Baltimore, MD.

Following coronary bypass surgery (a.k.a. CABG), it’s possible for a patient to develop a DVT in the neck. This happened to my mother following her CABG. “She has a big DVT,” I was told by the nurse after results of the ultrasound came in.

But nothing was done. At the time, I didn’t know about the SVC filter, which is designed to prevent a dislodged portion of a DVT from entering the lungs and becoming a pulmonary embolus. 

After learning about the SVC filter, I’ve always wondered what the doctors’ responses would have been had I insisted on an SVC filter placement for my mother.

“Most of these DVTs would be labeled as provoked, most often secondary to central venous catheters,” says Dr. Gashti. “Generally these are focal and limited to the site of the catheter (most often in the internal jugular vein). These can be watched.

“But if the thrombus extends to the subclavian/innominate veins, then most physicians would consider anticoagulation if there are no contraindications.” Following CABG, a patient can bleed to death from anticoagulant drugs.

“If anticoagulation is contraindicated, then an SVC filter would be indicated,” says Dr. Gashti. SVC stands for superior vena cava, a large vein that transports de-oxygenated blood from the upper body to the heart.

“The SVC is much shorter than the IVC [inferior vena cava], and therefore placement of a filter in the SVC is technically more challenging. You have to make sure the length is adequate. Currently there are no filters in the market indicated for SVC and if you place one, it would be off label. I have only placed a handful of these in 14 years of practice.”

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