What are the symptoms of deep vein thrombosis. How is DVT diagnosed. What are the risk factors for developing DVT. What complications can arise from deep vein thrombosis. How is deep vein thrombosis treated.

Understanding Deep Vein Thrombosis: A Comprehensive Overview

Deep vein thrombosis (DVT) is a serious medical condition characterized by the formation of blood clots in the deep veins, typically in the lower legs. While it often goes unnoticed, DVT can lead to severe complications if left untreated. This article delves into the intricacies of DVT, exploring its symptoms, causes, risk factors, and potential consequences.

Recognizing the Signs: Common Symptoms of Deep Vein Thrombosis

Identifying DVT early is crucial for prompt treatment and prevention of complications. The most common symptoms include:

• Pain in the leg or hip
• Tenderness and tightness in the affected area
• Redness and warmth of the skin
• Swelling in the affected limb

Is DVT always symptomatic? No, in some cases, deep vein thrombosis may not cause any noticeable symptoms, making it challenging to detect without medical intervention.

The Root of the Problem: Causes and Risk Factors for DVT

Understanding the underlying causes and risk factors for DVT is essential for prevention and early intervention. Blood clots may form due to:

1. Slow blood flow in veins
2. Blood clotting disorders
3. Damage to blood vessel walls

Several factors can increase an individual’s risk of developing DVT:

• Extended periods of immobility (e.g., bed rest, long flights)
• Recent major surgery or injury
• Age (over 60 years)
• Family history of DVT
• Certain types of cancer
• Obesity
• Hormonal factors (e.g., contraceptive pill, hormone replacement therapy)
• Smoking
• Pregnancy

Do these risk factors guarantee the development of DVT? While these factors increase the likelihood of DVT, their presence alone does not necessarily lead to the condition. However, individuals with multiple risk factors should be particularly vigilant.

The Silent Threat: Prevalence and Demographics of Deep Vein Thrombosis

DVT affects a significant portion of the population, with studies estimating that approximately 1 in 1,000 people develop symptomatic deep vein thrombosis annually. The risk increases with age and is slightly more prevalent in men than in women.

Age-Related Risk

Why does the risk of DVT increase with age? As we grow older, our blood vessels become less elastic, and our circulation may slow down. Additionally, older individuals are more likely to have other health conditions or undergo surgeries that can increase the risk of blood clots.

Beyond the Clot: Potential Complications of DVT

While DVT itself is a serious condition, it can lead to further complications if left untreated. Two primary concerns are:

Post-Thrombotic Syndrome

This common complication can develop weeks or even years after the initial DVT. Symptoms include:

• Chronic leg swelling
• Pain and heaviness in the affected limb
• Skin discoloration and itching
• Rash development
• In severe cases, chronic wound formation

Pulmonary Embolism

A rarer but potentially life-threatening complication, pulmonary embolism occurs when a blood clot breaks free and travels to the lungs. Symptoms include:

• Sudden shortness of breath
• Chest pain, particularly when breathing or coughing
• Dizziness or lightheadedness
• Rapid heartbeat
• Coughing up blood (in rare cases)

Can pulmonary embolism be fatal? Yes, if left untreated, pulmonary embolism can lead to life-threatening heart failure due to the strain placed on the heart by blocked blood vessels in the lungs.

Diagnosing the Invisible: Methods for Detecting Deep Vein Thrombosis

Accurately diagnosing DVT is crucial for proper treatment and prevention of complications. The diagnostic process typically involves:

D-dimer Blood Test

This initial screening test detects substances released when blood clots break down. A normal result can often rule out DVT, while an abnormal result warrants further investigation.

Doppler Ultrasound

If the D-dimer test is abnormal, a specialized ultrasound is performed to visualize blood flow in the veins and confirm the presence of a clot.

Are these diagnostic methods always conclusive? While these tests are highly effective, in some cases, additional imaging studies such as venography or CT scans may be necessary for a definitive diagnosis.

Fighting the Clot: Treatment Options for Deep Vein Thrombosis

Once diagnosed, prompt treatment of DVT is essential to prevent complications and promote recovery. Treatment options include:

Anticoagulant Medications

Also known as blood thinners, these drugs help prevent existing clots from growing and new clots from forming. Common anticoagulants include:

• Heparin (initial treatment)
• Warfarin
• Direct oral anticoagulants (DOACs) such as rivaroxaban or apixaban

Thrombolytic Therapy

In severe cases, drugs that dissolve blood clots may be administered. This treatment is typically reserved for life-threatening situations due to its associated risks.

Compression Stockings

These specially designed stockings help improve blood flow and reduce swelling in the affected limb.

Lifestyle Modifications

Patients are often advised to make certain lifestyle changes to support recovery and prevent future clots, such as:

• Increasing physical activity
• Maintaining a healthy weight
• Quitting smoking
• Staying hydrated

How long does DVT treatment typically last? The duration of treatment varies depending on the individual case, but many patients require anticoagulant therapy for at least three to six months. Some may need long-term or even lifelong treatment to prevent recurrence.

Staying Ahead: Preventive Measures for Deep Vein Thrombosis

While not all cases of DVT can be prevented, there are several steps individuals can take to reduce their risk:

Regular Movement

Avoid prolonged periods of immobility, especially during long trips or hospital stays. Simple exercises like ankle rotations and leg stretches can help promote blood flow.

Compression Wear

For those at higher risk, wearing compression stockings during long flights or periods of inactivity can help maintain proper circulation.

Healthy Lifestyle Choices

Maintaining a healthy weight, staying physically active, and avoiding smoking can all contribute to reducing DVT risk.

Medication Management

Individuals undergoing major surgery or those with certain risk factors may be prescribed preventive anticoagulant medications.

Can these preventive measures guarantee protection against DVT? While these strategies significantly reduce the risk of developing deep vein thrombosis, they cannot provide absolute protection. It’s important to remain vigilant and seek medical attention if symptoms arise.

Living with DVT: Long-Term Management and Quality of Life

For many individuals, a DVT diagnosis can have long-lasting impacts on their lifestyle and health management. Long-term considerations include:

Ongoing Medical Care

Regular check-ups and monitoring of anticoagulant therapy are essential for those on long-term treatment.

Lifestyle Adaptations

Patients may need to make permanent changes to their daily routines, such as incorporating regular exercise, wearing compression stockings, and being mindful of long periods of immobility.

Mental Health Support

Coping with a chronic condition like DVT can be challenging. Some individuals may benefit from counseling or support groups to address anxiety or depression related to their diagnosis.

Travel Considerations

Those with a history of DVT need to take extra precautions when traveling, especially on long-haul flights. This may include wearing compression stockings, staying hydrated, and performing in-seat exercises.

How does DVT impact pregnancy and family planning? Women with a history of DVT need to work closely with their healthcare providers when planning pregnancy, as some anticoagulants are not safe during pregnancy. Special management strategies may be necessary to protect both mother and baby.

Advancing the Field: Current Research and Future Directions in DVT Management

The medical community continues to make strides in understanding, diagnosing, and treating deep vein thrombosis. Current areas of research include:

Improved Diagnostic Tools

Scientists are working on developing more accurate and less invasive methods for detecting DVT, including advanced imaging techniques and blood-based biomarkers.

Novel Anticoagulants

Research is ongoing to develop new anticoagulant medications with improved safety profiles and more convenient dosing regimens.

Personalized Medicine Approaches

Genetic studies are exploring how individual genetic variations may influence DVT risk and treatment response, paving the way for more tailored prevention and treatment strategies.

Enhanced Prevention Strategies

Researchers are investigating new methods for preventing DVT in high-risk populations, including innovative mechanical devices and pharmacological interventions.

Will these advancements lead to a cure for DVT? While a complete cure may not be on the immediate horizon, these research efforts promise to significantly improve our ability to prevent, diagnose, and manage deep vein thrombosis, potentially reducing its impact on public health.

Global Impact: The Socioeconomic Burden of Deep Vein Thrombosis

Beyond its effects on individual health, DVT poses a significant socioeconomic burden on healthcare systems and societies worldwide. Consider the following aspects:

Healthcare Costs

The diagnosis, treatment, and long-term management of DVT and its complications contribute to substantial healthcare expenditures. This includes costs associated with hospitalization, medications, diagnostic tests, and follow-up care.

Lost Productivity

DVT can lead to prolonged periods of illness and disability, resulting in lost work days and reduced productivity. This not only affects individuals and their families but also has broader economic implications.

Quality of Life Impact

The chronic nature of DVT and its potential complications can significantly impact an individual’s quality of life, potentially leading to increased healthcare utilization and social support needs.

Public Health Initiatives

Recognizing the burden of DVT, many countries have implemented public health initiatives aimed at raising awareness, improving prevention strategies, and enhancing early detection and treatment.

How can society address the socioeconomic impact of DVT? A multi-faceted approach involving improved public education, enhanced preventive measures, and continued research into more cost-effective diagnostic and treatment options is crucial to mitigating the societal burden of deep vein thrombosis.

Empowering Patients: The Role of Education and Awareness in DVT Management

Education and awareness play pivotal roles in the prevention, early detection, and effective management of deep vein thrombosis. Key aspects include:

Public Awareness Campaigns

Initiatives aimed at educating the general public about DVT risk factors, symptoms, and prevention strategies can help individuals take proactive steps to protect their health.

Patient Education Programs

Comprehensive education for individuals diagnosed with DVT or those at high risk is essential for promoting adherence to treatment plans and lifestyle modifications.

Healthcare Provider Training

Ongoing education for healthcare professionals ensures they remain up-to-date on the latest diagnostic and treatment guidelines, leading to improved patient outcomes.

Support Groups and Online Resources

These platforms provide valuable information and emotional support for individuals affected by DVT, fostering a sense of community and shared experience.

Can improved education and awareness significantly reduce DVT incidence? While education alone cannot prevent all cases of DVT, increased awareness can lead to earlier detection, more effective prevention strategies, and better overall management of the condition, potentially reducing its impact on public health.

As our understanding of deep vein thrombosis continues to evolve, so too do our strategies for prevention, diagnosis, and treatment. By staying informed and proactive, individuals can take significant steps towards reducing their risk of DVT and its potentially life-threatening complications. Healthcare providers, researchers, and policymakers must continue to work collaboratively to address the challenges posed by this complex condition, ensuring that those affected receive the best possible care and support.

Deep vein thrombosis (DVT): Overview – InformedHealth.org

Introduction

Thrombosis is the medical term for the formation of a blood clot in a blood vessel. In deep vein thrombosis (DVT), the blood clot forms in one of the larger, deeper veins that run through the muscles. Deep vein thrombosis usually occurs in the lower leg.

It often goes unnoticed and dissolves on its own. But it may cause symptoms like pain and swelling. If someone is diagnosed with DVT, they will need treatment to avoid serious complications such as pulmonary embolism. This can occur if the blood clot breaks away from its original site and is carried to the lungs in the bloodstream.

The risk of deep vein thrombosis increases after more major operations such as knee or hip replacement surgery. Because of this, people who have had this kind of surgery are usually given medication to prevent blood clots from forming.

Symptoms

Typical symptoms of DVT include pain in a leg or hip, tenderness, tightness and red skin. The affected area may also swell and feel warm. But sometimes deep vein thrombosis doesn’t cause any symptoms.

Causes and risk factors

Blood clots may form if the blood flow in a vein is too slow, if there is a blood clotting disorder, or if the wall of a blood vessel is damaged. This can happen in the following cases:

• After longer periods of bed rest, for instance in hospital, after a bone fracture or injury. Staying in bed for a long time and not moving much can lead to poor blood circulation in your legs.

• Blood clotting disorders: Some people are born with a disease that makes their blood clot too much.

• More major operation: More major surgical procedures and serious injuries cause damage to blood vessels and activate the blood clotting (coagulation) system.

There are also various other factors that can increase someone’s risk of developing DVT:

• Previous DVT

• Being older than 60 years

• Family history (parents or siblings had a DVT)

• Certain types of cancer

• Heart failure

• Being severely overweight (obese)

• Taking the contraceptive pill

• Hormone therapy for menopause

• Very noticeable varicose veins

• Smoking

• Certain inflammatory diseases

• Pregnancy

• Regular long-haul journeys where you spend a lot of time sitting

Taken on their own, however, most of these risk factors only slightly increase the risk of DVT.

Prevalence

Studies have estimated that an average of about 1 out of 1,000 people develop noticeable (symptom-causing) deep vein thrombosis per year. The risk increases with age. It is somewhat more common in men than in women.

Effects

One common complication of DVT is known as post-thrombotic syndrome. People with this syndrome may have a swollen leg that feels heavy and hurts. The skin on their leg may also become discolored and itch, and a rash may develop. More severe cases of post-thrombotic syndrome can lead to the formation of chronic wounds.

Post-thrombotic syndrome occurs if the DVT has damaged the walls or valves of a vein, causing the blood to constantly build up in the vein. The syndrome often only develops several weeks or months after the DVT, sometimes even after one or two years.

Pulmonary embolism

A rarer but more serious complication of deep vein thrombosis is known as pulmonary embolism. This happens if the blood clot breaks away from its original site and is carried in the blood to the lungs, where it blocks a blood vessel. The symptoms of pulmonary embolism include:

• Sudden shortness of breath

• Chest pain (particularly when breathing in or coughing)

• Dizziness, lightheadedness or unconsciousness

• Rapid heartbeat

• Coughing up blood (rare)

Pulmonary embolism needs to be treated quickly because the blocked blood vessel causes blood to build up between the heart and lungs. This can put too much strain on the heart and eventually lead to life-threatening heart failure.

If pulmonary embolism develops, then it usually does so within two weeks of the DVT. The risk of pulmonary embolism is greater if the thrombosis is in the upper part of your leg or in your pelvis than if you have DVT in your lower leg. This is also true for thrombosis that causes very noticeable symptoms.

Diagnosis

Deep vein thrombosis can’t be diagnosed for sure based on typical symptoms alone. Symptoms such as pain, swelling and red skin can be caused by other things too, including an inflammation of superficial veins, varicose veins, erysipelas or narrow leg arteries (peripheral artery disease, or PAD).

To diagnose DVT, a blood test called a D-dimer test is usually done first. This test reacts to substances that are released when blood clots are broken down. The substances are called D-dimers. If the results of the test are normal, doctors can be quite sure that you don’t have DVT. If the results are abnormal, a special kind of ultrasound scan (a Doppler ultrasound) is done in order to confirm the diagnosis. Doppler ultrasounds provide information about the condition of the deep veins and blood flow in the veins.

If there’s good reason to believe that someone has a DVT, an ultrasound scan is usually done immediately. Examinations involving a small procedure are only rarely needed. One example is a special x-ray examination of the blood vessels which helps to see if there are any narrow areas (angiography). This involves injecting a contrast medium into the vein.

Prevention

There are different ways to try to prevent DVT. If someone has had surgery or was injured and has to stay in bed for a few days, it is important that they get up and start moving again as soon as possible. Even small movements like wiggling your feet are recommended in order to improve your circulation. If someone has an increased risk of DVT it can be a good idea for them to wear compression stockings or use medication too.

Compression stockings can lower the risk of deep vein thrombosis by applying pressure to the legs, which helps the blood flow back to the heart faster.

A third option is medication that reduces the clotting ability of the blood. This can be injected or swallowed. Medications that are injected into the skin or a vein already start working after a few hours. Examples include medications known as heparins and the drug fondaparinux.

There are two main kinds of oral medications, known as coumarins and direct oral anticoagulants (DOACs). DOACs are sometimes also called novel oral anticoagulants (NOACs). The best known coumarin is called phenprocoumon (known by many under the trade name Marcumar or Marcoumar). Examples of DOAC drugs include apixaban, dabigatran, edoxaban and rivaroxaban. Coumarins only start working after a few days, and direct oral anticoagulants already start working after a few hours.

Treatment

Deep vein thrombosis is usually treated in the hospital over several days, using the same medications that are used to prevent thrombosis. The treatment is started with a medication that works quickly, such as heparin.

To make sure that the blood clot dissolves completely, patients are advised to take anticoagulant (anti-clotting) tablets for three months after having acute treatment. Sometimes it’s a good idea to take them for even longer too.

For people who can’t take anticoagulants, an alternative option is having a small metal filter (known as an “inferior vena cava filter” or “IVC filter”) implanted in the large vein above the kidney. The filter is meant to catch any blood clots that could otherwise travel from the leg to the lungs. It is implanted using a venous catheter, in a procedure similar to cardiac (heart) catheterization.

The risk of post-thrombotic syndrome can be lowered by wearing compression stockings for up to two years.

Sources

• Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF). S3-Leitlinie Prophylaxe der venösen Thromboembolie (VTE). October 2015. (AWMF-Leitlinien; Volume 003 – 001).
• Deutsche Gesellschaft für Angiologie e.V. (DGA). Venenthrombose und Lungenembolie: Diagnostik und Therapie. S2k-Leitlinie. October 2015. (AWMF-Leitlinien; Volume 065 – 002).

• IQWiG health information is written with the aim of helping
  people understand the advantages and disadvantages of the main treatment options and health
  care services.

  Because IQWiG is a German institute, some of the information provided here is specific to the
  German health care system. The suitability of any of the described options in an individual
  case can be determined by talking to a doctor. We do not offer individual consultations.

  Our information is based on the results of good-quality studies. It is written by a
  team of
  health care professionals, scientists and editors, and reviewed by external experts. You can
  find a detailed description of how our health information is produced and updated in
  our methods.

Deep Vein Thrombosis | Vascular Center

What is deep vein thrombosis?

Deep vein thrombosis (DVT) occurs when a blood clot, or thrombus, develops in the large veins in the lower extremities or pelvis. A clot that forms in these areas can be life threatening. The clot may break free and travel through the vein. A traveling clot is called an embolus and it can become lodged in the heart or the lung. This is called a pulmonary embolism and it can be fatal if not diagnosed and treated immediately.

DVT, which occurs in 2 million Americans every year, is caused by reduced blood flow through the deep vein, the tendency of a person’s blood to clot too quickly and/or irritation or inflammation of the inner lining of the vein.

Symptoms of deep vein thrombosis

In about half the cases, there are no symptoms of deep vein thrombosis (DVT). When they are present, the most common symptoms are:

• Swelling or change in color (to purple or blue) of one leg
• Leg pain or tenderness in the calf muscle

These symptoms can develop suddenly or slowly over time. If you experience either of them, contact a doctor immediately.

Symptoms of a pulmonary embolism (PE) include:

• Chest pain
• Shortness of breath
• Rapid pulse
• Cough
• Feeling of apprehension
• Sweating
• Fainting

Symptoms of PE are similar to those for other medical conditions, such as heart attack. Whatever the underlying cause, these symptoms need to be medically evaluated immediately.

Risk factors of deep vein thrombosis

Deep vein thrombosis (DVT) affects men and women of all ethnic and socioeconomic groups equally. Factors that can contribute to this condition are:

• Smoking
• Later stages of pregnancy  
• Leg injury
• Recent surgery
• Inactivity
• Age

Diagnosis of deep vein thrombosis

A suspected deep vein thrombosis (DVT) is confirmed using:

• Duplex ultrasound: Duplex ultrasound is a type of ultrasound for assessing blood flow and structure of the leg veins.
• Magnetic resonance venography (MRV): A diagnostic procedure that produces detailed, three-dimensional images, magnetic resonance technology involves the use of magnets, radiofrequencies and computers to produce the images. MRV also includes the use of a contrast dye to help visualize the veins.

Treatment for deep vein thrombosis

Anyone with confirmed deep vein thrombosis (DVT) is treated immediately to prevent pulmonary embolism.  Anticoagulant medications are given to reduce clotting or thrombolytics are given to dissolve the clot.

Thrombolytics are usually used in only the most severe cases or those in which the clot occurs higher up in the thigh or in the pelvis. The drug is delivered directly to the clot through a catheter inserted in a vein. Sometimes the softened clot is removed by a tiny vacuum cleaner-like device. Once the clot is gone, balloon angioplasty and stent placement may be performed. These are analogous to those performed on arteries (see chronic limb ischemia ). If a person has a severe clot, but is not a good candidate for thrombolytics, the clot may be removed through an incision in the groin.

Long-term treatment may include the three E’s: exercise, elevation and elastic compression.

• Exercise: Exercise helps pump blood through the legs and builds muscle that can promote better circulation.
• Elevation: Elevating the legs can help to instantly relieve pain. A doctor may also instruct a patient to elevate the legs above the heart three or four time a day for about 15 minutes at a time. This can help to reduce swelling. If prolonged standing or sitting is necessary, bending the legs several times will help promote blood circulation.
• Elastic compression: Elastic compression stockings increase in tightness from the toes to the calves. They squeeze the leg veins, exerting additional pressure that helps to prevent blood from flowing backwards.

The dangers within: how blood clots affect your health

A healthy blood flow is something we take for granted – the assumption our veins will keep the vital fluid moving through our body at a healthy rate. But sometimes blood flow slows and clots form, wreaking havoc on our health.

A blood clot, or thrombus, can move through the blood stream until it gets stuck in a narrow passageway, becoming what is called an embolus. The blood can no longer pass through the veins and reach organs. An embolus in a coronary artery can cause a heart attack, in a cerebral artery, it can cause a stroke.

In the veins, a blood clot is called a venous thromboembolism (VTE), and it has two related conditions: deep vein thrombosis (DVT) and pulmonary embolism (PE). When they occur, they require immediate medical attention.

DVT and PE

Deep vein thrombosis affects over 1.2 million people in the U.S. It happens when a clot forms in a vein deep in the body, as opposed to a vein that runs close to the body’s surface.
DVT usually occurs in one leg, mainly affecting the large veins in the calf and thigh.

About half of people experiencing DVT don’t show outward signs or symptoms. When symptoms do occur, they show up in the leg that has a clot and may include:

• Changes in skin color (redness)
• Leg pain or tenderness, especially in the calf
• Leg swelling (edema)
• Skin that feels warm to the touch

Pulmonary embolism, or PE, occurs when a clot reaches the lung, causing a blockage that can cause permanent injury. This lowers the blood’s oxygen level and potentially damages other organs. Blood clots that travel to the lungs are more likely to have formed and broken away in the thigh rather than in the lower leg or other parts of the body.
Symptoms that arise for PE include:

• Unexplained shortness of breath
• Rapid breathing
• Chest pain (may be worse upon deep breath)
• Rapid heart rate
• Lightheadedness/fainting
• Coughing up blood.

DVT and PE are serious, potentially life-threatening conditions that require immediate medical attention to prevent further complications.

RISK FACTORS

VTE is an equal opportunity condition and can affect people of either gender, all ages, races and ethnicities. But some risk factors are stronger than others. Increasing age (from 40 on) means increased risk.

Experiencing surgery, major trauma, fractures of the hip or leg, also carries strong risk. Other independent risk factors include:

• Active cancers and chemotherapy
• Prior superficial vein thrombosis
• Infection
• Varicose veins
• Inherited thrombophilia (a condition that tends to make the blood clot more easily)
• Kidney disease
• Prolonged immobility such as hospital or nursing home confinement or leg paralysis

And among women:

• Use of oral contraceptives
• Pregnancy/postpartum period
• Hormone therapy

Any of the following factors alone may not justify preventive measures for VTE, but a combination of two or more may be cause for action and may affect the length and type of treatment someone receives:

Prior VTE — People who have had a previous episode of VTE have a high risk of recurrence. In one study, patients with a history of VTE were eight times more likely to develop a new episode during a high-risk period, such as surgery or serious illness, than patients without such a history.
Age — People over 40 are at higher risk, and that risk doubles with each subsequent decade.
Cardiac or respiratory failure
Immobility — Prolonged immobility like on very long flights, combined with other major risk factors, increases the chances of VTE.
Oral contraceptives — Women who use estrogens for contraception or menopause and men receiving
estrogen therapy for prostate cancer are at increased risk for VTE.
Some inherited or acquired blood conditions, such as antiphospholipid antibody syndrome.
Being pregnant or having had a baby recently puts a woman at greater risk of developing a blood clot.
Risks also increase when the following apply:

• Previous blood clots
• Genetic predisposition to blood clots
• Obesity
• Multiple births
• Other illness, such as cancer and serious infection

DIAGNOSIS

Diagnosis is done by assessment — a health care professional gathers information about a person’s medical history, age, medications and specific lifestyle factors.
A Doppler ultrasound may be performed on the legs and certain blood tests that detect a greater chance of blood clotting may be performed. Additional testing with CT angiography (a test used to see arteries and veins throughout the body) may be done if PE is suspected.

VTE TREATMENT

After a medical assessment, those at risk may receive treatment to prevent clots from forming, such as:

• Anti-clotting, blood-thinning medications
• Wearing compression stockings or using an intermittent compression device that helps keep blood from pooling in the deep veins
• Being instructed to move around or do foot/leg exercises when immobile for long periods.

DVT TREATMENT

• This potentially life-threatening condition requires immediate medical attention. A medical team will want to stop the clot from getting bigger, keep the clot from breaking off and travelling into the lungs, and prevent another clot from forming. Treatment includes: Anticoagulants to break up clots and prevent new ones. For example, injectables such as heparin or low-molecular-weight heparin, or tablets such as apixaban, dabigatran and rivaroxaban, edaxaban and warfarin.
• Equipment such as compression stockings and air compression cuffs and garments for the legs, calves, arms or chest that fill with compressed air and help increase blood flow.
• Thrombolytic therapy using drugs such as a tissue plasminogen activator, which is a clot-dissolving enzyme.

In rare cases, when medicines don’t work, surgery may be needed. It may involve placing a filter in the body’s largest vein to prevent blood clots from traveling to the lungs, removing a large blood clot from the vein or injecting clot-busting medicines.

Pulmonary embolism is the most common preventable cause of death among hospital patients. Data from randomized trials involving general surgical patients suggest prevention measures in high-risk patients can prevent VTE in 1 of 10 patients and save the life of about 1 of 200 patients.

The good news is hospitals are doing a better job of managing the condition. Recent research has focused on development of noninvasive diagnostics such as ultrasound enhanced techniques and molecular imaging methods.

Deep Vein Thrombosis (DVT) | Symptoms and Treatment

What is a deep vein thrombosis?

What is deep vein thrombosis?

Dr Sarah Jarvis MBE

A deep vein thrombosis (DVT) is a blood clot that develops in one of your deep veins. It usually occurs in your leg and makes that leg become very painful and swollen. The clot may travel up to your lungs to cause a pulmonary embolus.

Deep leg veins are the larger veins that go through the muscles of the calf and thighs. They are not the veins that you can see just below the skin; neither are they the same as varicose veins. When you have a DVT, the blood flow in the vein is partially or completely blocked by the blood clot.

A calf vein is the common site for a DVT. A thigh vein is less commonly affected. Rarely, other deep veins in the body can be blocked by blood clots.

A DVT is part of a group of problems together known as venous thromboembolism.

What is venous thromboembolism?

Venous means related to veins. A thrombosis is a blockage of a blood vessel by a blood clot (a thrombus). Embolism occurs when the thrombus dislodges from where it formed and travels in the blood. It then becomes stuck in a narrower blood vessel, elsewhere in the body. The thrombus is then called an embolus.

A pulmonary embolus occurs when a thrombus has broken off from a DVT and become stuck in one of the blood vessels in the lung. Pulmonary emboli (plural of ’embolus’) are also part of venous thromboembolism. See the separate leaflet called Pulmonary Embolism for more details.

Why do blood clots form in leg veins?

Blood normally flows quickly through veins and does not usually become solid (clot). Blood flow in leg veins is helped along by leg movements, because muscle action squeezes the veins. Sometimes a DVT occurs for no apparent reason. However, the following increase your risk of having a DVT:

• Immobility which causes blood flow in the veins to be slow. Slow-flowing blood is more likely to clot than normal-flowing blood:
  • A surgical operation where you are asleep (under general anaesthetic) is the most common cause of a DVT. Your legs are still when you are under anaesthetic, because the muscles in your body are temporarily paralysed. Blood flow in the leg veins can become very slow, making a clot more likely to occur. Certain types of surgery (particularly operations on the pelvis or legs) increase the risk of DVT even more.
  • Any illness or injury that causes immobility increases the risk. This includes having a leg in a hard plaster cast after a fracture. People who are admitted to intensive care units are at an increased risk of DVT. This is due to a number of reasons but partly because they are very ill and also because they are immobile (they may even be kept asleep by anaesthetic medications).
  • Long journeys by plane, train or coach/car may cause a slightly increased risk. This is because you are mostly sitting still and not moving around very much.
• Damage to the inside lining of the vein increases the risk of a blood clot forming. For example, a DVT may damage the lining of the vein. So, if you have a DVT then you have an increased risk of having another one in the future. Some conditions, such as inflammation of the vein wall (vasculitis) and some medicines (for example, some chemotherapy medicines), can damage the vein and increase the risk of having a DVT. Damage to the vein can also happen with injury to the vein caused by a needle. This might occur after treatment with a drip in hospital (where a tube is inserted into a vein to get fluids into you). Drug users who inject drugs, such as heroin, can also damage their veins, making DVTs more common. This is especially the case if they inject illegal drugs into their leg or groin.
• Conditions that cause the blood to clot more easily than normal (thrombophilia) can increase the risk. Some conditions can cause the blood to clot more easily than usual. Examples include nephrotic syndrome and antiphospholipid syndrome. See the separate leaflets called Nephrotic Syndrome, Antiphospholipid Syndrome and Thrombophilia for more details. Some rare inherited conditions can also cause the blood to clot more easily than normal. An example of an inherited blood disorder which can cause DVTs is factor V Leiden mutation. You are more at risk of a DVT if you have a family history of DVTs – that is, a close relative who has had one.
• Contraceptive pills, patches and rings and hormone replacement therapy (HRT) which contain oestrogen can cause the blood to clot slightly more easily. Women taking the combined oral contraceptive (COC) pill or HRT have a small increased risk of DVT.
• People with cancer or heart failure have an increased risk. Sometimes a DVT happens in a person who has not yet been diagnosed with cancer. Investigations looking for the cause of a DVT may show cancer to be the underlying cause.
• Older people (over 60 years of age) are more likely to have a DVT, particularly if they have poor mobility or have a serious illness such as cancer.
• Pregnancy increases the risk. About 1 in 1,000 pregnant women have a DVT while they are pregnant, or within about six months after they give birth.
• Obesity also increases the risk. If your body mass index (BMI) is more than 30 kg/m², you are more at risk of DVT.
• Lack of fluid in the body (dehydration) can make a DVT more likely to happen. Effectively, the blood becomes stickier and more liable to clot.

How common is a deep vein thrombosis?

It is estimated that about 1 in 1,000 people have a DVT each year in the UK.

What are the symptoms of a deep vein thrombosis?

A DVT most commonly develops in a deep vein below the knee in the calf. Typical DVT symptoms include:

• Pain and tenderness of the calf.
• Swelling of the calf.
• Colour and temperature changes of the calf. Blood that would normally go through the blocked vein is diverted to outer veins. The calf may then become warm and red.

Sometimes there are no symptoms and a DVT is only diagnosed if a complication occurs, such as a pulmonary embolus (PE) – see below.

Do I need any tests?

Sometimes it is difficult for a doctor to be sure of the diagnosis from just your symptoms, as there are other causes of a painful and swollen calf. Examples of conditions that can cause similar symptoms are muscle strains or skin infections (cellulitis). Your doctor might calculate something called a Wells’ score to work out the likelihood of you having a DVT. It involves looking at your symptoms and risk factors for a DVT.

If you have a suspected DVT, you will normally be advised to have tests done urgently to confirm or rule out the diagnosis. Two commonly used tests are:

• D-dimer blood test. This detects fragments of breakdown products of a blood clot. The higher the level, the more likely you are to have a blood clot in a vein. Unfortunately, the test can be positive in a number of other situations, such as if you have had recent surgery or if you are pregnant. A positive test does not, therefore, diagnose a DVT. The test may, however, indicate how likely it is that you have a blood clot (the clot can be either a DVT or a PE) and can help decide if further tests are needed.
• A special type of ultrasound called a duplex Doppler is used to show blood flow in the leg veins and any blockage to blood flow. Ultrasound is useful because it is an easy, non-invasive test.

Sometimes these tests are not conclusive and more detailed tests are necessary. Contrast venography is another test that can be done. In this test a dye is injected into the leg veins. X-ray tests can then detect the dye which is shown not to be flowing if a vein is blocked by a clot. Computerised tomography (CT) scans and magnetic resonance imaging (MRI) scans are also very occasionally needed.

Sometimes, especially if there is a delay in getting a scan, you may be given daily injections to thin your blood. This is, in effect, treating you as if you do have a DVT, even though it has not been proven. This is safer than doing nothing whilst waiting for a scan.

Editor’s note

Dr Sarah Jarvis, 17th September 2021

Quality standards for DVT

The National Institute for Health and Care Excellence (NICE) has issued new guidance on what people with a possible DVT can expect on the NHS. They recommend:

1. If you’re over 16 years old and have an assessment which suggests you need medication to prevent a DVT, this should be started as soon as possible (maximum 14 hours after hospital admission).
2. If you’re over 16 and have been in hospital for a problem that prevents you moving your legs much, you should have an assessment to see if you need medication to prevent a DVT.
3. If you’re over 18 and your doctor’s assessment suggests you may have DVT in your upper leg, you should have an ultrasound scan within four hours.
4. If you’re over 18 and taking medicine to treat a DVT, you should be reviewed after three months (and at least every year if your doctor advises you to take it long-term).
5. You should have an agreed follow-up plan in place if you have, or are suspected to have, a clot on the lung (pulmonary embolus) and aren’t admitted to hospital.

Editor’s note

Dr Sarah Jarvis, 3rd February 2021

New guidance on possible complication of DVT

When you see your doctor with symptoms of a possible DVT, they will check to see if there is any evidence that you have a clot on the lung (a pulmonary embolus, or PE). NICE has updated its guidance on treatment for people with suspected DVT or PE.

It now recommends that if your doctor suspects you might have a PE, and it is likely to take at least four hours to have tests to check, you should be given a dose of anticoagulant (see below) while you wait to have tests.

Is a deep vein thrombosis serious?

It can be. When a blood clot forms in a leg vein it usually remains stuck to the vein wall. The symptoms tend to settle gradually. However, there are two main possible complications:

• A blood clot that travels to the lung (pulmonary embolus).
• Persistent calf symptoms (post-thrombotic syndrome).

Pulmonary embolus (PE)

In a small number of people who have a DVT, a part of the blood clot breaks off. This travels in the bloodstream and is called an embolus. An embolus will travel in the bloodstream until it becomes stuck. An embolus that comes from a clot in a leg vein will be carried up the larger leg and body veins to the heart, through the large heart chambers, but will get stuck in a blood vessel going to a lung. This is called a pulmonary embolus.

DVTs and PEs are known collectively as venous thromboembolism
A small PE may not cause any symptoms. A medium-sized PE can cause breathing problems and chest pain. A large PE can cause collapse and sudden death. It is estimated that if people with DVT are not treated, about half of them would develop a PE large enough to cause symptoms or death.

Post-thrombotic syndrome

Without treatment, up to 4 in 10 people who have a DVT develop long-term symptoms in the calf. This is called post-thrombotic syndrome. Symptoms occur because the increased flow and pressure of the diverted blood into other veins can affect the tissues of the calf. Symptoms can range from mild to severe and include calf pain, discomfort, swelling and rashes. An ulcer on the skin of the calf may develop in severe cases.

Post-thrombotic syndrome is more likely to occur if the DVT occurs in a thigh vein or extends up into a thigh vein from a calf vein. It is also more common in people who are overweight and in those who have had more than one DVT in the same leg.

What are the aims of treatment for a deep vein thrombosis?

The aims of treatment are:

• To prevent the clot spreading up the vein and getting larger. This may prevent a large embolus breaking off and travelling to the lungs (a PE).
• To reduce the risk of post-thrombotic syndrome developing.
• To reduce the risk of venous ulcers in the leg in future. This can happen to people who have developed post-thrombotic syndrome.
• To reduce the risk of a further DVT in the future. 

What are the treatments for a deep vein thrombosis?

Anticoagulation – preventing the clot from becoming larger

Anticoagulation is often called thinning the blood. Medicines which work in this way are called anticoagulants. However, they do not actually thin the blood. They alter certain chemicals in the blood to stop clots forming so easily. Anticoagulants do not dissolve the clot. Anticoagulation prevents a DVT from getting larger and prevents any new clots from forming. The body’s own healing mechanisms can then get to work to break up the clot.

If you have a DVT, you will usually need an anticoagulant medicine for at least three months. There are a number of options:

• Warfarin has been the usual anticoagulant for many years. The aim is to get the dose of warfarin just right so the blood will not clot easily, but not too much, which may cause bleeding problems. You will need regular blood tests (called INRs) whilst you take warfarin. The INR (which stands for International Normalised Ratio) is a blood test that measures your blood clotting ability. You need the tests quite often at first but then less frequently once the correct dose is found. An INR of 2.5 is the aim if you have warfarin for a DVT, although anywhere in the range 2-3 is OK. If you have had recurrent DVTs, or have had a PE whilst on warfarin, you might need a higher INR (even ‘thinner’ blood). Recently, some alternatives to warfarin have become available, which do not need regular blood tests.
• Rivaroxaban, apixaban, edoxaban and dabigatran are newer anticoagulant medicines. You do not have to have regular blood tests to monitor your blood clotting. This is an advantage over warfarin. However, there is no antidote (as there is with warfarin) to stop you bleeding too easily. These newer tablets are not suitable for everybody.

NICE recommends:

• Apixaban or rivaroxaban for confirmed DVT or PE.
• If neither apixaban nor rivaroxaban is suitable, then either:
• Low molecular weight heparin (LMWH) injections for at least 5 days followed by dabigatran or edoxaban, or
• LMWH injections with Warfarin for at least 5 days, followed by Warfarin on its own.

A serious embolus is rare if you start anticoagulation treatment early after a DVT.

If you are pregnant, regular heparin injections rather than anticoagulant tablets may be used. This is because anticoagulant medicines can potentially cause harm (birth defects) to the unborn child.

The length of time you will be advised to take anticoagulation depends on various factors. If you have a DVT during pregnancy or after an operation, then after the birth, or when you are fit again, the increased risk is much reduced. So, anticoagulation may be only for a few months. On the other hand, some people continue to have an increased risk of having a DVT. In this case, the anticoagulation may be long-term.

As a guide, for a DVT that happens below the knee, you will need at least six weeks of anticoagulant treatment. You will need at least three months of treatment if the DVT is above the knee. Some people at higher risk of another DVT may need longer than this. The length of time of anticoagulation varies from person to person. Your doctor or anticoagulant clinic will advise you how long your treatment will be for.

Compression stockings

Most people who develop a DVT are advised to wear compression stockings. Compression stockings are also known as compression hosiery or thromboembolic deterrent stockings (‘TEDs’). This treatment has been shown to reduce the risk of developing another DVT and can also reduce the risk of developing post-thrombotic syndrome. You should wear the stockings each day, for at least two years. If you do develop post-thrombotic syndrome, you may be advised to wear the stockings for more than two years.

The stockings work by applying pressure from outside the veins. This helps squeeze the blood in the veins back up the legs. This then makes the pressure inside the veins less. In turn this prevents leakage of blood into the surrounding tissues.

Before compression stockings are advised you will need to have a test to check that the circulation through the arteries of your legs is normal. This is usually done by a nurse, with a handheld machine called a Doppler. This measures the pressure in your arteries.

Compression stockings come in light, medium or strong material (class 1, 2 or 3) and are worn below the knee. Most people can tolerate class 2. If class 2 is too uncomfortable or difficult, class 1 is prescribed. If class 2 stockings do not work it may be necessary to try class 3, although many people find these difficult to wear for any length of time. These can be prescribed by your doctor, and obtained at the chemist. People often do not like wearing these stockings, because they are uncomfortable, or difficult to put on, or don’t look very nice. But they really help your circulation, and can prevent serious problems such as ulcers.

Further tips on support stockings

• They are available in different colours, so do ask for the one that suits you best. That way, you are more likely to use them.
• They should be removed at bedtime and put on first thing in the morning. It is important to put them on before your legs start to swell in the mornings.
• There are open or closed toe options. Open toe stockings may be useful if:
• You have painful toes due to arthritis or infection.
• You have large feet.
• You want to wear socks over your support stockings.
• You prefer them.
• Stockings should be replaced every 3-6 months. Each time you should be measured again, just in case the size needs to be changed.
• You should always have at least two pairs prescribed so that one pair can be washed and dried while the other is worn.
• Do not tumble dry support stockings, as this may damage the elastic.
• They can be made to measure if none of the standard sizes fit you. This can still be done with a prescription.
• Support stocking applicator aids are available if you are unable to get them on. You can discuss this with your pharmacist or nurse.

Walking regularly but raising your leg whilst resting

• Unless your doctor advises against this, you should walk regularly after you are discharged from hospital. Walking is thought to improve circulation in the affected leg and may help to reduce your risk of further DVT.
• When you are resting, as much as possible – raise your leg. This reduces the pressure in the calf veins and helps to prevent blood and fluid from pooling in the calves. Raised means that your foot is higher than your hip so gravity helps with blood flow returning from the calf. The easiest way to raise your leg is to recline on a sofa with your leg up on a cushion. Sitting on the sofa or in a chair, with your feet on a footstool or pouffe, is not keeping your feet up – the feet are well below your hips in this position.
• Raise the foot of the bed a few inches if it is comfortable to sleep like this. This is so your foot and calf are slightly higher than your hip when you are asleep.

Other treatments

Sometimes other treatments may be considered – for example:

• Clot-busting (thrombolytic) therapy with medicines such as streptokinase or urokinase. These may help to dissolve a blood clot. The medicine is given directly into the vein and sometimes directly to the clot by a tube (catheter). Studies report this treatment results in fewer people developing post-thrombotic syndrome. It is not yet known if it makes people less likely to have a PE, or another DVT.
• Sometimes an operation (called an embolectomy) is done to remove a blood clot from the leg vein or pulmonary artery. These operations are not routine and it is not clear if they are an effective treatment in most cases.
• Occasionally, an operation is done to place a filter in the large vein above the blocked leg vein. The aim is to stop any blood clots from travelling up to the lungs. This may be considered if anticoagulation cannot be given (for various reasons), or if anticoagulation fails to prevent clots breaking off and travelling up into the larger veins and up to the lungs.

Preventing a first, or recurrence of, deep vein thrombosis

A DVT is often just a one-off event after a major operation.

However, some people who develop a DVT have an ongoing risk of a further DVT – for example, if you have a blood clotting problem, or continued immobility. As mentioned above, you may be advised to take anticoagulation medicine long-term. Your doctor will advise you about this.

Other things that may help to prevent a first or recurrent DVT include the following:

• If possible, avoid long periods of immobility, such as sitting in a chair for many hours. If you are able to, get up and walk around now and then. A daily brisk walk for 30-60 minutes is even better if you can do this. The aim is to stop the blood pooling and to get the circulation in the legs moving. Regular exercise of the calf muscles also helps. You can do some calf exercises even when you are sitting.
• Major operations are a risk for a DVT – particularly operations to the hip, lower tummy (abdomen) and leg. There are a number of methods to help reduce this risk:
• To help prevent a DVT, you may be given an anticoagulant such as a heparin injection just before an operation. This is called prophylaxis. Enoxaparin and dalteparin are the most common types of heparin given for prophylaxis against blood clots. The new medicine, fondaparinux sodium, can also be given by injection in some circumstances to prevent DVT in surgical patients or immobile medical patients in hospital.
• The newer anticoagulant medicines discussed above can be used to prevent DVT or PE after hip or knee replacement surgery. Rivaroxaban, apixaban and dabigatran are used in these situations, and can be given by mouth as a tablet, rather than injection.
• An inflatable sleeve connected to a pump to compress the legs during a long operation may also be used.
• You may also be given compression stockings to wear whilst you are in hospital.
• It is now common practice to get you up and walking as soon as possible after an operation.
• When you travel on long plane, train, car or coach journeys, you should have little walks up and down the aisle every now and then. Try to exercise your calf muscles whilst sitting in your seat. (You can do this by circling your ankles, getting into a ‘tiptoe’ position and lifting your toes off the floor whilst keeping your heels on the ground.) You should aim to stay well-hydrated and avoid alcohol and sleeping medications. See the separate leaflet called Preventing DVT When You Travel for more details. If you have had a previous DVT, you should see your doctor for advice before you travel on a long journey or fly.
• People who are overweight have an increased risk of DVT. Therefore, to reduce your risk, you should try to lose weight. 

Reducing the risk of having a DVT in hospital 

There has been increased awareness of patients in hospital being at risk of a DVT. This has led to National Institute for Health and Care Excellence (NICE) recommendations on reducing the risk of having a DVT in hospital – see Further Reading below. The purpose of the guideline is to protect people in hospital from blood clots by making sure that:

• Everyone has their risk of blood clots checked when they are admitted to hospital (including mental health units), whatever type of treatment they are having.
• Each person’s risk check is used to decide whether they need treatment to prevent clots – for example, blood-thinning medicines, compression stockings or foot pumps.
• If people need blood-thinning medicines to stop clots, they have their risk of bleeding checked first.
• Staff explain how important it is for people to stick to their treatments after leaving hospital, because a blood clot can develop weeks later.

In summary

• The main cause of DVT is immobility – especially during or after surgery.
• If you are having major surgery, you will usually be given medication with injections and/or tablets, to prevent blood clots forming. This is called thromboprophylaxis.
• The most serious complication of DVT is a PE, where part of the blood clot breaks off and travels to the lung. PEs can cause death.
• Persistent calf symptoms may occur after a DVT.
• With treatment, the risk of the above two complications is much reduced.
• Treatment includes anticoagulation medicines, compression stockings, leg elevation when sitting, and keeping active.
• Prevention is important if you have an increased risk of DVT – for example, during long operations or when you travel on long journeys.

Deep vein thrombosis – causes, symptoms, prevention

A deep vein thrombosis (DVT) is a blood clot that forms in the major veins of the body – usually the legs. It is estimated one in every 1200 New Zealanders will develop a DVT each year.

Life-threatening complications can arise from DVT when blood clots dislodge, travel in the bloodstream, and then lodge in other veins or arteries causing a blockage (this blockage is called an embolism). This can be life threatening, especially when the embolism occurs in the lungs, heart, or brain. Pulmonary embolism (a blood clot in the lung) is the most common of these serious DVT complications.

Causes

Veins are blood vessels that carry blood from the tissues of the body back to the heart. Veins that lie just beneath the skin surface are referred to as “superficial veins” while veins found deep inside the muscles are referred to as “deep veins”. Other veins connect the superficial and deep veins, allowing blood to flow between them.

When a blood clot occurs in a vein it is referred to as a venous thrombosis. A DVT is a blood clot that occurs in the deep veins. DVTs can occur in any of the deep veins but most commonly occur in the leg veins. The clot will either partially or completely block the flow of blood through the affected vein.

A DVT is usually more serious than a blood clot in one of the superficial veins, as there is a much greater risk with a DVT that part of the clot may dislodge and circulate through the body.

Risk factors

General factors that indicate an increased risk of developing a DVT include:

• Obesity
• Smoking
• Being older than 40 years (although DVT can occur at any age)
• Having previously had a DVT
• Having a family member who has had a DVT.

A DVT is also more likely to occur when the blood flow through the deep veins is slowed.
Immobility is one such factor; blood flow is slowed when a person remains immobile for long periods of time as a result of such things as:

• Paralysis, eg: following a stroke or injury
• Being bedridden, eg: following surgery or due to illness
• Having a leg in a plaster cast or splint
• Sitting for long periods of time while travelling, eg: in a bus, train, plane, or car.

Other factors that can slow blood flow include:

• Injury to a vein, eg: as a result of a broken bone or severe muscle injury
• Surgery – particularly orthopaedic and cancer surgery
• Heart disease – particularly heart failure (where a weakened heart doesn’t pump blood as well as it should)
• Varicose veins
• Phlebitis (inflammation of the walls of the vein).

A DVT is also more likely to occur where there is some factor that makes the blood more likely to clot, including:

Signs and symptoms

A DVT does not always cause symptoms. If symptoms do occur, the first symptom is usually a cramp-like aching pain in the affected muscle. This pain might worsen when exercising but does not subside with rest. Symptoms of a DVT in the calf muscle may include:

• Swelling of the lower leg
• Tenderness of the calf muscle
• Localised redness and warmth
• A mild fever
• Lower leg veins may become more prominent (darker and raised) and sometimes the skin becomes darker.   

A DVT can also occur in the upper leg, arms or neck and cause similar symptoms in those areas of the body.

If a pulmonary embolism occurs as a result of a DVT it may produce barely noticeable symptoms such as chest discomfort and mild breathlessness, or more noticeable symptoms such as sharp chest pain, a rapid heart rate, breathlessness, and coughing-up blood.

Diagnosis

If a DVT is suspected – even if symptoms are mild – it is important to seek medical attention promptly. Accurate diagnosis and appropriate treatment of a DVT are necessary to reduce the risk of potentially life-threatening complications, such as pulmonary embolism.

Because a DVT can occur without any obvious symptoms, diagnosis can sometimes be difficult. Initially, the doctor will examine the affected area and take a full medical history. The doctor may recommend a blood test called a D-Dimer, which measures a protein essential for blood clotting. If the D-Dimer test is positive, further tests to confirm the diagnosis are likely to be ordered.

The most common diagnostic test for DVT is an ultrasound scan. The specific type of scan used is called a doppler ultrasound, which determines how fast blood is flowing through a blood vessel.  

If there is doubt about the diagnosis, venography may be recommended. This diagnostic test involves injecting a specialised dye that can be seen by x-ray as it flows through the veins, allowing them to be easily visualised.   

Blood tests may be done to check for irregularities in the blood clotting system or for inherited disorders

If a pulmonary embolism is suspected a range of additional tests may be used.

Treatment

The immediate goal of treatment for a DVT is to limit the size and movement of the clot, and to prevent complications. Treatment will depend on the location and severity of the clot. Some small clots may resolve spontaneously without treatment but a DVT is generally treated intensively. Admission to hospital for treatment and observation for signs of complications may be required.
Treatment may include:
    

Medications

Anticoagulants:

These medications “thin” the blood, reducing its ability to clot. They prevent an existing clot from getting bigger and reduce the risk of developing more clots.

Anticoagulant medications such as heparin may be administered initially as a continuous infusion into a vein (intravenously) because it acts quickly to prevent further clotting. After initial treatment, anticogulant medication may be given in tablet form (e.g. warfarin) or as an injection under the skin.

Regular blood tests will usually be required to monitor the effectiveness of the medication and to adjust dosage. Anticoagulant treatment is usually maintained for at least three months to be fully effective in treating a DVT. In some cases, it may be required on a long-term basis.

Thrombolytic agents:

In some cases, these medications are given by intravenous injection to help dissolve the clot. However, they can cause side effects, such as severe bleeding, so are usually used only in life-threatening situations, eg: the presence of a large pulmonary embolus.

Compression stockings

Elasticised compression stockings give support to the lower legs and encourage the return of blood to the heart and helps to reduce swelling. It is generally recommended that compression stockings are worn in situations where immobility is likely.

Surgery

In high-risk cases, where there have been recurrent or severe DVTs, or where anticoagulant medication is not appropriate or has not worked, surgery to insert a small filter or sieve into the main vein leading to the heart (the vena cava) may be recommended. This traps any blood clots travelling through the blood stream thus preventing the clot travelling to the heart and lungs.

Prevention

General measures to help lower the risk of developing a DVT are to quit smoking, maintain a healthy body weight, and take regular exercise. When certain medical conditions or inherited disorders are present, long-term anticoagulant treatment to minimise the risk of DVT may be recommended.

Measures that can reduce the risk of DVT associated with long-distance travel include:

• Compression stockings
• Drinking plenty of non-alcoholic fluids to avoid dehydration
• Leg and ankle exercises to encourage blood flow in the legs
• People at high risk of DVT may be prescribed aspirin or anticoagulant tablets or injections whilst travelling.   

Anyone at risk of DVT is advised to see their doctor prior to travelling to discuss preventative measures. Measures that can reduce the risk of DVT associated with being bedridden as a result of surgery or illness include:

• Compression stockings
• Anticoagulant medications
• Specific leg and breathing exercises to promote blood flow.   
    

Long-term complications

After a DVT some people may develop a long-term condition called “chronic venous insufficiency” or “post-phlebotic syndrome”. This is due to damage and scarring to the veins and is characterised by swelling, discomfort, and skin pigmentation in the affected area. It can increase the likelihood of subsequent DVT.

Repeated pulmonary emboli can lead to a condition called pulmonary hypertension, which is where the blood pressure within the lungs is increased. This can cause serious problems with the functioning of the heart. Certain medications, compression stockings, and, in rare cases, surgery, may be recommended to help treat these long-term complications.

References

Douketis, J.D. (2018). Deep vein thrombosis (DVT) [Web Page]. MSD Manual Consumer Version. Kenilworth, NJ: Merck and Co., Inc. https://www.merckmanuals.com/home/heart-and-blood-vessel-disorders/venous-disorders/deep-vein-thrombosis-dvt [Accessed 22/08/19] 
Liao, S. et al. (2014). Incidence of venous thromboembolism in different ethnic groups: a regional direct comparison study. J Thromb Haemost 2014;12:214-9. 
Mayo Clinic (2018). Deep vein thrombosis (DVT) [Web Page]. Rochester, MN: Mayo Foundation for Medical Education and Research. https://www.mayoclinic.org/diseases-conditions/deep-vein-thrombosis/symptoms-causes/syc-20352557 [Accessed: 22/08/19] 
Ministry of Health (2015). Travel and blood clots (Web Page). Wellington: New Zealand Ministry of Health. www.health.govt.nz/your-health/healthy-living/environmental-health/travelling/travel-and-blood-clots [Accessed: 22/08/19] 
NHS (2016). Deep vein thrombosis (Web Page). Redditch: National Health Service (NHS) 
England. https://www.nhs.uk/conditions/deep-vein-thrombosis-dvt/ [Accessed: 22/0/19]
New Zealand Medicines and Medical Devices Safety Authority (Medsafe) [2014]. Hormonal contraceptives and blood clots (Leaflet). Wellington: New Zealand Ministry of Health. https://www.medsafe.govt.nz/Consumers/educational-material/Hormonal%20Contraceptives.pdf  [Accessed: 22/08/19] 
O’Toole, M.T. (Ed.) (2017). Deep vein thrombosis (DVT). Mosby’s Dictionary of Medicine, Nursing & Health Professions (10th ed.). St Louis, MI: Elsevier. 
Tran, H.A., et al. (2019).New guidelines from the Thrombosis and Haemostasis Society of Australia and New Zealand for the diagnosis and management of venous thromboembolism. Med J Aust. 2019 Mar;210(5):227-235.

Last reviewed – August 2019     

About Blood Clots | Memorial Sloan Kettering Cancer Center

This information describes what a blood clot is and how it’s treated.

Normal blood clots form in blood vessels when a clump of platelets (a type of blood cell) come together to stop bleeding when you have a cut or an injury. When the cut or injury heals, your body will get rid of the blood clot. Blood clots can form anywhere in your body.

Blood clots can also form in healthy blood vessels when they aren’t needed. This is called an abnormal (not normal) blood clot. Abnormal blood clots can lead to serious health problems.

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Types of Blood Clots

There are 2 types of blood clots that can be dangerous: deep vein thrombosis and pulmonary embolisms.

Figure 1. Deep vein thrombosis in your leg

Deep vein thrombosis (DVT)

DVT can happen when an abnormal blood clot forms in a vein deep inside your body, usually in your arm or leg (see Figure 1). The clot may affect your normal blood flow and cause swelling, redness, and pain in the area. If the clot isn’t treated, new blood clots may form. The clot may also break apart and spread to other parts of your body. These things can make the swelling and pain worse and lead to trouble walking, an infection, or skin ulcers (sores).

Pulmonary embolism (PE)

Figure 2. Pulmonary embolism

A PE can happen when an abnormal blood clot blocks the flow of blood in a blood vessel in your lung (see Figure 2). Most of the time, this happens when a blood clot in a deep vein of your leg breaks loose and travels to your lung. Having a PE can keep your body from getting enough oxygen.

If you have a PE, you may have:

• Trouble breathing
• Chest pain
• A fast heartbeat
• Pale or blue-colored skin

A PE can cause death if the signs aren’t treated quickly.

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Blood Clot Risk Factors

Some things can increase your risk of forming a blood clot. The risk factors include:

• Not moving around often. This is because blood will flow slower in your deeps veins when you’re not moving, which can lead to a clot.
• Having recently had surgery. This is because some surgeries may cause your blood to become thicker, or it may pool if you’re having a long surgery and not moving much.
• Having cancer 
• Being hospitalized
• Being injured
• Pregnancy
• Taking birth control or hormone replacement therapy that contains estrogen
• Being overweight
• Family history of blood clot
• Smoking

While you’re in the hospital, you may have more than 1 of these risk factors at the same time.

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Symptoms of Blood Clots

Blood clots can reduce the flow of blood throughout your body. Sometimes, people with a blood clot don’t feel any symptoms until the problem becomes life threatening.

Symptoms of these blood clots include:

• Sudden pain and swelling in 1 arm or leg
• Trouble walking due to swelling and pain
• Sharp chest pain
• Fast heartbeat
• Trouble breathing
• Severe abdominal (belly) pain with or without vomiting (throwing up) and diarrhea (loose or watery bowel movements)
• Pale or blue-colored skin

Call your healthcare provider right away if you notice any symptoms of a blood clot.

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Diagnosing Blood Clots

Since some people don’t have any symptoms of blood clots, many blood clots are found when your healthcare provider is looking for something else, such as when you have an imaging scan. Make sure you tell your healthcare provider if you have any symptoms of a blood clot.

If your healthcare provider thinks you have a blood clot, they will recommend 1 or more of the following tests:

• A computed tomography (CT) scan of your lungs to look for a PE. A CT scan takes x-ray pictures of your internal organs.
• An ultrasound of your veins to look for blood clots in your legs or arms. The ultrasound machine uses sound waves to create pictures of the inside of your body.
• Blood tests to measure how quickly your blood clots. Blood tests can also see if you have any genes that may increase your risk blood clots.

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Treating Blood Clots

Treatment for a blood clot usually includes taking a blood thinner, also known as an anticoagulant. This is the most common treatment for blood clots. Blood thinners help prevent your body from making new clots.:

Blood thinners can be given:

• By an injection (shot) into a vein or under the skin. Examples include Heparin, enoxaparin sodium (Lovenox^®) and fondaparinux (Arixtra^®).
• By mouth as a tablet. Examples include warfarin (Coumadin^®), rivaroxaban (Xarelto^®), apixaban (Eliquis^®), and edoxaban (Savaysa^®).

Your healthcare provider will decide which type of medication is best for you.

How long you’ll need to take blood thinners depends on many factors. Your healthcare provider will consider your risk factors and will help decide how long you need to take them. Some people may need to stay on them forever. You’ll have regular visits with your healthcare provider while you’re on blood thinners.

Some blood thinners may have special instructions, such as medications you’ll need to avoid while you’re taking them. If you’re taking a blood thinner with any special instructions, your healthcare provider will go over them with you.

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Preventing Blood Clots

There are many things you can do to prevent blood clots from forming. The following are ways to prevent blood clots.

Physical activity

Staying active is a good way to prevent blood clots. Mild or moderate exercise (such as walking or yoga) can improve your blood flow. Try to move every few hours, if you’re able to, as instructed by your healthcare provider. For most people, this means as much as you feel comfortable with.

It’s also important to move often if you’re sitting for long periods of time, such as while traveling on a plane or in a car. If you’re unable to get out to walk around, be sure to change positions often while on a long trip.

If you’re not able to move around easily, try doing some light stretches and movements with your feet, if you’re able. You can make circles with your feet or point your toes up and down while you’re sitting or lying down.

Medication

If your healthcare provider prescribed you anticoagulation medication (blood thinners), be sure to take your medication as instructed. This medication will reduce the chance of a blood clot forming.

Sequential compression device (SCD) sleeves

Figure 3. SCD sleeves on your legs

If you’re in the hospital, your risk of getting a blood clot is higher. To help prevent a blood clot, you can use SCD sleeves.

SCDs are sleeves that wrap around your lower legs (see Figure 3). The sleeves are connected by tubes to a machine that pushes air in and out of the sleeves to gently squeeze your legs. This is a safe and effective way to help your blood circulate (move around) to prevent clots.

You should always wear the SCD sleeves when you’re in your hospital bed, unless your healthcare provider tells you not to. Make sure you remove the SCD sleeves before getting out of bed, because the tubing could make you trip and fall. Tell your healthcare provider if you notice the tubing is pinched or the pump is beeping.

Other tips to prevent blood clots

You can also help prevent blood clots by following these tips:

• Wear loose-fitting clothes, socks, or stockings.
• If your healthcare provider recommends them, wear compression stockings. These are special stockings that can improve your blood flow.
• Avoid crossing your legs while sitting.
• Raise the bottom of your bed 4 to 6 inches with blocks or books. This will help elevate your legs to improve your blood flow.
• Eat less salt. Eating too much salt may cause swelling and can increase your risk of getting a blood clot.

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When to Call Your Healthcare Provider

Call your healthcare provider if you have:

• Increased pain, swelling, or both in the arm or leg with the blood clot
• New pain, swelling, or both in your other arm or leg
• Trouble breathing
• Severe headaches or headaches that don’t go away
• Nose bleeds
• Bleeding gums
• Blood in your urine (pee), stool (poop), vomit, or in the mucus that you cough up through your mouth
• A heavier menstrual flow (period) than usual
• Bleeding that doesn’t stop
• Bruising that doesn’t go away
• Fallen or hurt yourself in any way
• Plans for any dental procedure or surgery
• Stopped taking your blood thinner for any reason
• Any unexpected, unexplained side effects
• Any questions or concerns

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7 Blood Clot Symptoms To Look Out For – Signs You Have A Blood Clot

You know the spiel: If you’re on the Pill, you’re at a higher risk for blood clots. If you fly for more than four hours, you’re at a higher risk for blood clots. If you smoke at all, you’re at a higher risk for blood clots.

But uh, what are blood clots—and what are the blood clot symptoms you should look out for?

Basically, blood clots occur when blood thickens, forming semi-solid clumps. Most of the time, clots are harmless and simply occur to stop the body from bleeding too much (like when you get a cut). However, when blood clots form in certain areas of your body—like your heart or lunges—they can cause serious issues.

When a clot forms in a vein, it’s known as deep vein thrombosis (DVT). Usually, DVT appears in the legs, but can show up in the arms after a serious upper-body injury, according to the National Institutes of Health.

These DVT clots often dissolve on their own, but can be life-threatening if they travel elsewhere in your body—like to the lungs (a.k.a. a pulmonary embolism), or to the heart where it can cause a stroke or heart attack.

But here’s the thing: Blood clots aren’t always easily spotted—they can feel like a slight discomfort in your arm or leg, if anything at all, says Patricia Vassallo, M.D., an assistant professor of cardiology at Northwestern University. Keep these common blood clot symptoms in mind—and if you think you could have one, head to the emergency room ASAP.

.

1. You have swelling in one arm or leg.

DVT causes one leg to look puffier than the other, most often below the knee. “That’s because when a clot forms in your vein, blood can’t get back to your heart, and the pressure causes fluid to spread to the tissue in your leg,” explains Vassallo.

Your leg will likely be noticeably bigger, but if you’re not sure, whip out the measuring tape. According to Vassallo, a leg with a clot will actually measure larger.

2. Your leg or arm is red and warm to the touch.

Reduced blood flow from a limb back to the heart increases pressure in a vein, pushing fluids into your other tissues and causing inflammation, warmth, and redness, says Vassallo.

Your whole leg usually appears red, although discoloration might look patchy, but keep in mind: “you can have a clot without redness or swelling,” says Vassallo.

.

3. Your heart is racing and you’re short of breath.

A racing heart is the most common—and sometimes the only—symptom of a pulmonary embolism (PE) when the clot has traveled to your lung. “It feels like you’ve exercised when you haven’t,” says Vassallo.

To compensate for the clot clogging up your lungs, your heart does actually beat faster to get more oxygen pumped to your body. When your doctor checks, your heart rate will be greater than 100 beats per minute when it’s normally in the 60 to 100 beats-per-minute range, says Vassallo.

4. You have pain in one of your legs or arms.

Uncomfortable pressure in your leg is another common blood clot symptom, due to inflammation. It usually isn’t severe, but it will feel painful, like something’s not right—especially when you’re walking, says Vassallo.

Most often, the pain gets worse with time (unless, of course, the clot resolves on its own). “What starts as a little cramping and soreness can become throbbing because the clot is getting bigger,” she adds.

5. You feel like you’re having a panic attack.

It’s not uncommon to feel super anxious if you’re experiencing a PE. In addition to lightheadedness and dizziness, “it’s often a sense of impending doom, like you’re going to die,” says Vassallo.

That can sound very similar to a panic attack—which is actually a very common misdiagnosis among women under 40. Be sure to explain any other symptoms you’re experiencing along with your risk factors to your doctor.

.

6. You have a sharp pain in your chest

In some cases of PE, you might feel chest pain that’s sharp, sudden, and hurts more if you take a deep breath or cough, says Vassallo.

Important to note: This feeling is different than chest pain caused by a heart attack, which is more of a dull ache or pressure, like an elephant is sitting on your chest.

7. You’re coughing up blood.

A clot can result in inflammation and fluid buildup in your lungs, causing you to cough up blood. “That also happens with pneumonia, but it’s usually due to inflammation from PE,” says Vassallo.

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Deep vein thrombosis – diagnosis and treatment at a phlebologist’s appointment at the St. Petersburg hospital of the Russian Academy of Sciences

Deep vein thrombosis is a condition in which the lumen of a vein is filled with blood clots – blood clots that interfere with normal blood flow, and sometimes completely stop venous return from the lower extremities.

Most often, the causes of this disease are associated with increased blood clotting (including congenital thrombophilia, taking medications), operations, trauma and other concomitant diseases.In some cases, thrombosis occurs as a result of the spread of thrombotic masses from the porous veins to the deep network.

Speaking about the clinical manifestations of deep vein thrombosis, the following are most often distinguished: acute pain in the leg, abrupt edema, cyanosis of the lower extremities, increased venous pattern and venous congestion, which makes varicose nodes on the surface of the skin especially pronounced, hot flashes and a feeling of heat in the lower limbs, the temperature may rise to subfebrile values ​​- 37.5-37.8 S.

It should be noted that in about a quarter of cases, deep vein thrombosis resolves without any symptoms.

With the development of modern methods of hardware diagnostics (ultrasound, MRI, CT) in medicine, the disease is easily diagnosed. For the correct diagnosis, it is considered sufficient to conduct an ultrasound scan of the veins of the lower extremities, ideally supplemented by a laboratory study of the D-dimer in the blood; its determination is of particular importance for assessing the process in dynamics.

To understand the cause of the disease, a number of additional instrumental and laboratory studies may be required to clarify the features of the blood coagulation system. In clinical practice, there is a legitimate opinion that thrombosis does not occur in healthy people. Often this is only the first sign of a breakdown in the body. In some cases, thrombosis is a marker of a developing oncological process, long-term inflammation.

Depending on the location of the thrombus in the vessel, the following is isolated:

– occlusive thrombosis – the thrombus completely closes the lumen of the vein;

– non-occlusive – parietal thrombus, attached to one wall.This variant of a thrombus can become occlusive or floating (freely “dangle” in the blood stream). In this case, the thrombus can separate from the wall, block the lumen of the pulmonary artery, cause the development of pulmonary embolism – PE, in some cases – with a lethal outcome.

Treatment of thrombosis can be conservative, consisting in prolonged wearing of compression hosiery, taking anticoagulant therapy (drugs that reduce blood clotting ability – heparins, warfarin and new oral anticoagulants).

Surgical treatment includes thrombectomy (removal of a thrombus from the lumen of a vein), or the installation of cava filters, which will prevent the passage of the thrombus to the heart. The most advanced and effective method today is the dissolution of thrombotic masses in the lumen of the vein with the introduction of thrombolytic agents to the clot – catheter thrombolysis. However, it should be noted that the dissolution of the thrombus is possible only in the first few days of the development of the disease.The organized dense thrombotic masses can damage the valves of the deep veins, causing post-thrombotic disease and trophic skin disorders.

After the postponed thrombosis, the body’s predisposition to relapse, re-emergence of thrombotic clots in the same or another place remains for a long time. It is this pattern that dictates the need for long-term use of anticoagulant drugs in the period from 3 to 6-12 months after the acute process.In some cases, a conclusion is made about the need for lifelong intake of such drugs, which avoids recurrence of thrombosis and disability.

Deep vein thrombosis description and treatment of the disease from Vascul Clinic

The causes of deep vein thrombosis are manifold. Disturbance of venous outflow (stagnation of venous blood), damage to the vascular wall and disorders of the blood coagulation system are of decisive importance in the formation of blood clots.

In the Russian Federation, from 80,000 to 230,000 cases of deep vein thrombosis are reported per year.Thrombosis is a potentially dangerous disease. Fragmentation of thrombotic masses can lead to blood clots entering the bloodstream and cause pulmonary embolism (PE). The incidence of this complication reaches 35-40 cases per 100,000 population. At the same time, up to 25% of PE ends in instant death. Mortality from PE in European countries exceeds the total mortality from AIDS, breast and prostate cancer and road traffic accidents.

Acute deep vein thrombosis is accompanied by a pronounced impairment of venous outflow, which is manifested by edema, an increase in limb volume and pain syndrome of varying intensity.The higher the level of thrombosis, the more severe blood flow disturbances this can cause.

The resulting thrombus does not remain permanently in the vessel. Under the influence of natural mechanisms, thrombotic masses can dissolve over time. In this case, the lumen of the vein and blood flow through it are restored. The thrombus is recanalized. If the resorption does not occur completely, then part of the thrombotic masses is organized and turns into fibrous tissue, resembling a scar. The lumen of the vein in this case remains narrowed to a greater or lesser extent or completely closed (occlusion).In any case, 100% vein recovery does not occur. The venous wall after the postponed thrombosis remains altered, the valves in the vessel are destroyed. All this leads to chronic disorders of blood flow, called post-thrombotic disease.

The earlier the diagnosis of deep vein thrombosis is made and the earlier the treatment is started, the better the result can be achieved. It must be remembered that timely diagnosis allows you to identify blood clots that are potentially dangerous in terms of pulmonary embolism (floating clots).The first sign that allows one to suspect deep vein thrombosis is edema of one lower limb, pain and tension in the calf muscles, cyanosis of the skin. When these symptoms appear, it is necessary to urgently consult a specialist and conduct an ultrasound examination of the vessels of the lower extremities.

Treatment of deep vein thrombosis consists in prescribing drugs that prevent further progression of thrombosis (anticoagulants) and compression treatment using elastic bandages and medical compression stockings.

Deep vein thrombosis: causes, symptoms

Deep vein thrombosis (DVT) occurs when blood clots in the deep veins of the extremities, most often in the large veins of the legs.
Sometimes these clots are released and travel through the veins through the heart to settle in the arteries of the lungs. This related condition is known as pulmonary embolism (PE) and can cause severe chest pain or shortness of breath. LE can be life-threatening if the embolus (circulating clot) is large.

Reasons

DVT can occur when blood collects in the deep veins of your legs, when there is something that makes a blood clot more likely, or when the vein wall is damaged.The blood will thicken if the flow is interrupted. This can be due to the compression of the vessel.
For example, when you are bedridden (after surgery) or when you sit still for extended periods (such as on a long plane flight), blood can accumulate in the large veins of your legs and form clots. Trauma, certain types of serious illnesses, and certain medications also increase the tendency for blood to clot.

Symptoms

About half of people with DVT have no symptoms.These are the so-called “silent” DVTs, which can resolve on their own or lead to pulmonary embolism. When symptoms do occur, they usually occur on only one leg and include:

• swelling in the lower leg, ankle, foot, or (rarely) thigh;
• slight inflammation of the affected area;
• touch sensitivity;
• Pain in the calf or behind the knee;
• leg cramps at night;
• the affected skin is slightly redder than usual; a bluish tint means a serious blockade;
• pain on exertion on the leg;
• Sharp pain in the lower leg when your leg is bent upward;
• slightly elevated temperature;

Who is at risk?

Deep vein thrombosis occurs in about two out of 1000 people and is most commonly seen in adults over 60 years of age.Diseases and circumstances that increase the risk of developing DVT:

• obesity;

90,057 smoking;

• pregnancy;
• use of oral contraceptives;
• oncological diseases;
• trauma or surgery to the lower extremities;
• family history of DVT;
• previous thrombosis or embolism;
• recent surgery or trauma;
• fractures of the thigh or lower leg;
• to be bedridden or in a wheelchair;
• stroke;
• heart attack.

Diagnostics

Your doctor will review your medical history and perform a physical examination. However, more tests are needed to confirm the diagnosis of deep vein thrombosis because the symptoms are often similar to those of other conditions. Frequent Diagnostic Tests for DVT:

1. Doppler and Duplex Vascular Scan is a combination of ultrasound and a flow-through “probe” that shows the direction of blood flow in the veins. This combination will show any blockage in the veins.
2. Contrast venography involves the injection of a substance into the veins, which is found on an x-ray.

Blood clots are sometimes found on CT scans. A sample of your blood may also be sent to a laboratory to check for conditions that are causing your blood to clot.

Treatment

Treatment usually requires hospitalization and bed rest, at least initially. However, prolonged sitting in one position should be avoided.First, a combination of anticoagulant drugs is used that “thin” the blood to prevent further clotting. Regular blood tests tell your doctor when these drugs are working correctly.

Your doctor will prescribe and monitor medications.

Leg compressors are often used to prevent DVT while you are in the hospital. The leg can be raised to reduce swelling. A warm and damp bandage can be applied to the affected area to relieve pain.
In rare cases, the clot may require surgical removal.

Prevention

General health measures such as exercise, smoking cessation, and weight control can help reduce your overall risk of developing DVT. For people who have had DVT or are at risk of developing DVT, the following preventive measures are recommended:

1. Avoid prolonged bed rest or stiff legs. Exercising your legs can help prevent ailment. Walking as soon as possible after surgery can help reduce the risk of DVT.If you are unable to exercise, your healthcare professional should massage your legs and do passive exercises on them within their range of motion.
2. Ask your doctor or pharmacist about special elastic support stockings. Make sure the stockings fit snugly, but not too tightly in any one area, as this can block blood flow. Take them off once a day to wash them and check your skin for discoloration or irritation.
3. Keep your legs elevated when lying or sitting to help blood flow back through the veins in your legs.

For air passengers:

1. Drink plenty of (non-alcoholic) liquids while flying.
2. Regularly lift your ankles and massage your calves while you are sitting.
3. Wear loose, non-restrictive clothing.
4. Do not take sleeping pills as they will make you move less during the flight.
5. Be vigilant for DVT symptoms for a month after long flights.

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“The consequences are dire.” Who is at risk of thrombosis with COVID-19

“The consequences are dire.” Who is at risk of thrombosis with COVID-19 – RIA Novosti, 05/26/2021

“The consequences are dire.” Who is at risk of thrombosis with COVID-19

Thrombosis occurs in a third of patients with severe COVID-19. Now it is treated well, but the standard recommendations are not suitable for everyone.We need … RIA Novosti, 26.05.2021

2021-05-26T08: 00

2021-05-26T08: 00

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MOSCOW, May 26 – RIA Novosti, Tatyana Pichugina. Thrombosis occurs in a third of patients with severe COVID-19. Now it is treated well, but the standard recommendations are not suitable for everyone. This requires personalized therapy, scientists say. A special property of the coronavirus Usually, people do not pay attention to small scratches and cuts. Everyone knows that a dark crust will quickly appear on the wound – a blood clot, or thrombus, which will prevent bleeding and infection from the outside. So the body independently copes with vascular damage.“We are used to considering blood clots as something pathological. But, in fact, their formation – thrombosis – is a normal process that protects against blood loss. But when it fails, the consequences are dire. Half of strokes are bleeding into the brain after how the vessel burst and the system could not quickly repair it, “explains Fazli Ataullakhanov, professor at Moscow State University, scientific director of the Center for Theoretical Problems of Physicochemical Pharmacology, Russian Academy of Sciences. Thrombosis becomes a problem in many diseases that violate hemostasis (blood clotting).Including viral. So, with the flu, similar complications occur in one to two percent of patients admitted to the hospital. During the 2009 epidemic in New York, their share reached almost six percent. Approximately the same figures were expected in the case of coronavirus infection. However, the scale turned out to be much larger: about a third of severe patients develop thrombotic events. “The virus infects endothelial cells (the layer lining blood vessels from the inside. – Ed.), Damages them, the body responds with thrombosis.The lungs are especially affected. But not only: blood clots are found everywhere. In young healthy people, COVID-19 usually proceeds without complications. In the elderly, suffering from various diseases, the reaction to damaged vessels is hypertrophied. The lung tissues are closed for normal blood flow, this leads to serious disorders and even death, “- says the scientist.” Thrombosis in COVID-19 is a serious situation, there is undoubtedly a violation of hemostasis. In the spring of last year, when we encountered an infection, patients had a large number of thromboembolisms (blockage of a vessel by a torn off thrombus.- Approx. ed.). The standard doses of anticoagulants used for prophylaxis did not work; it was necessary to quickly rebuild and prescribe high doses of drugs. We actually improved the results, but we got a small amount of bleeding. The question arose of controlling the treatment of thrombosis. There were not enough standard methods, new approaches were required that would make it possible to select doses of drugs for each such patient, “says Doctor of Medical Sciences, Honored Doctor of Russia Sergei Tsarenko, Deputy Chief Physician for Anesthesiology and Intensive Care at Moscow City Clinical Hospital No. 52.Hemostasis under control Among the standard methods are thromboelastography, thromboelastometry, tests for activated partial thromboplastin time and protombin time. Russian scientists have proposed another one: registration of thrombodynamics. “At the site of damage to the vessel wall, the blood comes into contact with special factors triggering clotting. We made them genetically, placed them on the surface of the cuvette and simulated the area of ​​damage to the vessel wall. We pour the patient’s blood plasma into it and look at it. how a blood clot grows from there.We measure growth parameters, first of all, speed. If it is faster than normal, the risk of thrombosis is high. If slower – bleeding “, – explains Professor Ataullakhanov. The device” Thrombodynamics Recorder “was developed ten years ago by scientists and engineers under his leadership in the framework of the projects” Rusnano “and” Skolkovo “. Now it is used in many clinics in Russia and abroad. the pandemic reached Russia, Ataullakhanov proposed to compare all existing methods for assessing the state of the coagulation system and, choosing the best one, to use it for patients with COVID-19.”More than 70 percent of severe patients admitted to intensive care have a risk of thrombosis. They are immediately prescribed heparin and in most cases the dose is chosen correctly, but in about 30 percent it does not work. Of these, twenty continue to hypercoagulate, which means that the dose must be increased. and the rest, on the contrary, should be reduced in order to prevent bleeding, “the researcher says. The first stage of testing took place in seven Moscow covid hospitals, including Kommunarka. The best way to cope with the task of dose selection was thrombodynamics.It was necessary to carry out the second stage of testing, but there was not enough money. In “Kommunarka” and City Clinical Hospital No. 52, they met halfway and organized a randomized study. The intensive care patients were randomly selected and conditionally divided into two groups. In the first, they were treated according to standard protocols, in the second, too, but under the control of hemostasis by thrombodynamics. “We identified about 350 cases and analyzed the frequency of thrombosis. Where the therapy was adjusted using our approach, their number was halved.Bleeding statistics are still insufficient. Already now we can conclude: for severe patients it is necessary to conduct heparin therapy under the control of the state of hemostasis, and not blindly “, – Fazli Ataullakhanov notes. Struggle for serious patients” The method of Ataullakhanov’s group is useful, but not the only one. In combination with others, it makes up a diagnostic complex that helps to choose the optimal anticoagulant therapy regimen, “comments Sergei Tsarenko. In the City Clinical Hospital No. 52, very serious patients with COVID-19 who are on ECMO – extracorporeal membrane oxygenation – are treated.It is used when artificial ventilation of the lungs does not help. Thick catheters are inserted into the patient and the entire volume of blood is pumped through a separate device, where oxygen is saturated. “Since the device is made of plastic, the contact of blood with its surfaces leads to even greater coagulation problems. In this situation, very careful monitoring is needed. And then the significance of the diagnostic complex, which assesses the state of hemostasis increases significantly, “the doctor notes. In the risk group for thrombosis are patients with COVID-19 and concomitant chronic venous thrombosis of the lower extremities and pelvis, with atrial fibrillation and oncology.Sergei Tsarenko emphasizes: patients with these diseases already take anticoagulants. When a coronavirus infection is applied, the dose is adjusted. “Outpatients in 90 percent of cases do not need to prescribe anticoagulants. They walk around the apartment, muscles contract, blood is squeezed out of the veins where it is needed,” the doctor continues. It is also not necessary to pass a bunch of tests, fearing thrombosis, but not having aggravating diseases. “An outpatient needs two tests. The first is a clinical blood test to correct, if necessary, treatment tactics.In most cases, the indicators will be good, the number of lymphocytes is reduced, since the disease is viral. The second test is for C-reactive protein, an integrative marker of the degree of inflammation. The rest of the tests without concomitant diseases are useless, “says Dr. Tsarenko. In particular, it makes no sense to take tests for the now popular D-dimer, ferritin without indications. These are inflammatory proteins, but, unlike C-reactive, they are more inert, therefore less information is given at the outpatient stage.In addition, they do not always indicate thrombosis or iron deficiency, so it is extremely dangerous to focus on them on your own and self-medicate.

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MOSCOW, May 26 – RIA Novosti, Tatyana Pichugina. Thrombosis occurs in a third of patients with severe COVID-19. Now it is treated well, but the standard recommendations are not suitable for everyone. This requires personalized therapy, scientists say.

A special feature of the coronavirus

Usually people do not pay attention to small scratches and cuts. Everyone knows that a dark crust will quickly appear on the wound – a blood clot, or thrombus, which will prevent bleeding and infection from the outside. So the body independently copes with vascular damage.

“We used to think of blood clots as something pathological. But, actually, their formation – thrombosis – is a normal process that protects against blood loss. But when it fails, the consequences are dire. Half of strokes are bleeding into the brain after that. how the vessel burst and the system could not quickly repair it, “explains Fazli Ataullakhanov, professor at Moscow State University, scientific director of the Center for Theoretical Problems of Physicochemical Pharmacology of the Russian Academy of Sciences. Thrombosis becomes a problem in many diseases that violate hemostasis (blood clotting).Including viral. So, with the flu, similar complications occur in one to two percent of patients admitted to the hospital. During the 2009 epidemic in New York, their share of 90,048 reached 90,049 to almost six percent. Approximately the same figures were expected in the case of coronavirus infection. However, the scale turned out to be much larger: about a third of severe patients develop thrombotic events.

“The virus infects endothelial cells (the layer lining the blood vessels from the inside. – Ed.), Damages them, the body responds with thrombosis.The lungs are especially affected. But not only: blood clots are found everywhere. In young healthy people, COVID-19 usually proceeds without complications. In the elderly, suffering from various diseases, the reaction to damaged vessels is hypertrophied. The lung tissues are closed for normal blood flow, this leads to serious disorders and even death, “says the scientist.

” Thrombosis in COVID-19 is a serious situation, there is undoubtedly a violation of hemostasis. In the spring of last year, when we encountered an infection, patients had a large number of thromboembolisms (blockage of a vessel by a torn off thrombus.- Approx. ed.). The standard doses of anticoagulants used for prophylaxis did not work; it was necessary to quickly rebuild and prescribe high doses of drugs. We actually improved the results, but we got a small amount of bleeding. The question arose of controlling the treatment of thrombosis. There were not enough standard methods, new approaches were required that would make it possible to select doses of drugs for each such patient, “says Doctor of Medical Sciences, Honored Doctor of Russia Sergei Tsarenko, Deputy Chief Physician for Anesthesiology and Intensive Care at Moscow City Clinical Hospital No. 52.

Hemostasis under control

Standard methods include thromboelastography, thromboelastometry, tests for activated partial thromboplastin time and prothrombin time. Russian scientists have proposed another one: registration of thrombodynamics.

“At the site of damage to the vessel wall, the blood comes into contact with special factors that trigger clotting. We made them genetically, placed them on the surface of the cuvette and simulated the area of ​​damage to the vessel wall. We pour the patient’s blood plasma into it and watch how a thrombus grows from there.We measure growth parameters, first of all, speed. If it is faster than normal, the risk of thrombosis is high. If slower – bleeding “, – explains Professor Ataullakhanov. The device” Thrombodynamics Recorder “was developed ten years ago by scientists and engineers under his leadership in the framework of the projects” Rusnano “and” Skolkovo “. Now it is used in many clinics in Russia and abroad.

When the pandemic reached Russia, Ataullakhanov proposed to compare all existing methods for assessing the state of the coagulation system and, choosing the best one, to use it for patients with COVID-19.

“More than 70 percent of severe patients admitted to intensive care have a risk of thrombosis. They are immediately prescribed heparin and in most cases the dose is chosen correctly, but in about 30 percent it does not work. Of these, twenty continue hypercoagulation, which means that the dose is needed increase, and the rest, on the contrary, decrease in order to prevent bleeding, “- says the researcher.

The first stage of testing took place in seven Moscow covid hospitals, including Kommunarka. The best way to cope with the task of dose selection was thrombodynamics.It was necessary to carry out the second stage of testing, but there was not enough money. In “Kommunarka” and City Clinical Hospital No. 52, they met halfway and organized a randomized study. The intensive care patients were randomly selected and conditionally divided into two groups. In the first, they were treated according to standard protocols, in the second, too, but under the control of hemostasis by thrombodynamics.

“We identified approximately 350 cases and analyzed the incidence of thrombosis. Where therapy was adjusted using our approach, the number was halved.Bleeding statistics are still insufficient. Already now we can conclude: for severe patients it is necessary to conduct heparin therapy under the control of hemostasis, and not blindly “, – notes Fazli Ataullakhanov.

Struggle for serious patients

” The method of Ataullakhanov’s group is useful, but not the only one. In combination with others, it makes up a diagnostic complex that helps to choose the optimal anticoagulant therapy regimen, “comments Sergei Tsarenko.

City Clinical Hospital No. 52 deals with very serious patients with COVID-19 who are on ECMO – extracorporeal membrane oxygenation. It is used when artificial ventilation of the lungs does not help. Thick catheters are introduced to the patient and the entire volume of blood is pumped through a separate device, where oxygen is saturated.

“Since the device is made of plastic, the contact of blood with its surfaces leads to even greater coagulation problems. In this situation, very careful monitoring is needed. And then the significance of the diagnostic complex, which assesses the state of hemostasis, increases significantly,” the doctor notes.

September 2, 2020, 18:31 Sergei Tsarenko emphasizes: patients with these diseases already take anticoagulants. When coronavirus infection is superimposed, the dose is adjusted.

“Outpatients do not need anticoagulants in 90 percent of cases.They walk around the apartment, the muscles contract, the blood is squeezed out of the veins, goes where it is required “, – continues the doctor. It is also not necessary to pass a bunch of tests, fearing thrombosis, but not having aggravating diseases.

” An outpatient needs two tests. The first is a clinical blood test to adjust, if necessary, treatment tactics. In most cases, the indicators will be good, the number of lymphocytes is reduced, since the disease is viral. The second test is for C-reactive protein, an integrative marker of the degree of inflammation.The rest of the tests without concomitant diseases are useless, “says Dr. Tsarenko.

In particular, it makes no sense to take tests for the now popular D-dimer, ferritin without indications. These are inflammatory proteins, but, unlike C-reactive, they are more inert , so at the outpatient stage they give less information. In addition, they do not always indicate thrombosis or iron deficiency, so it is extremely dangerous to focus on them and self-medicate.

May 13, 08:00The doctor spoke about the torment of postcoid patients 90,000 Treatment of post-thrombophlebitic disease (PTFS) of the lower extremities

Contents:

Post-thrombophlebitis disease (PTFE) is one of the adverse outcomes of deep vein thrombosis (DVT). Not every DVT leads to the formation of post-thrombophlebitis disease. As a rule, the higher the blockage is localized in the body, the greater the chances of developing PTFB.

Development of the disease

After suffering DVT, the blood clots in the veins begin to dissolve and the blood flow is restored.Recovery can be complete or partial, most often, the vein can no longer function as healthy. DVT destroys the venous valves that keep blood flowing in the right direction, from the limbs to the heart. Due to dysfunction of the valves and reverse blood discharge (reflux), blood is retained in the extremities (venous congestion), pressure in the veins increases, and the risk of developing PTFB increases.

The diagnosis can be made 1 month (or more) after deep vein thrombosis in the presence of the following symptoms:

• heaviness, fatigue, swelling in the lower leg: sensations intensify in the evening and especially after prolonged static load, that is, a long stay in a sitting or standing position;
• expansion and subsequent transformation of the saphenous veins of the perineum, pubis, anterior abdominal wall and lower extremities.This is the process of compensation. Deep veins can no longer cope with the load, blood outflow occurs through the saphenous veins and they increase.
• pigmentation, thickening of the skin and subcutaneous tissues, the formation of venous trophic ulcers. Changes usually appear in the lower part of the lower leg, from the inside;

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Diagnostics and treatment

Diagnostics is performed both at the stage of acute thrombosis and after, if complaints persist.

The main instrumental methods of examining a patient with PTFS include:

1. duplex / triplex angioscanning of the veins of the lower extremities;
2. phlebography (CT, MR or X-ray contrast phlebography). This study is performed in the case of “high” thrombosis (also called proximal thrombosis, that is, thrombosis of the arteries of the ilio-femoral segment) when deciding whether to perform stenting or thrombolysis;

Methods to combat the development of pathology include drug therapy, sports and the use of compression underwear.Thrombotic survivors should be monitored regularly by a phlebologist . After an episode of DVT, surgery may be necessary:

• Laser coagulation of dilated perforating veins;
• miniflebectomy of the venous tributaries of the lower leg;
• stenting of the great veins – the installation of a special “frame” in the lumen of the vein to expand it;

If you need a consultation with a phlebologist, we recommend that you contact our Medical Center.You can make an appointment by calling the 24-hour call center.

causes of phlebothrombosis, symptoms, treatment, prices in St. Petersburg

Why does thrombosis develop

Conditions associated with an increased risk of thrombosis:

• Hormonal imbalance. Endocrine diseases, pregnancy, age restructuring, hormonal therapy, taking oral contraceptives are common causes of thrombosis in women.
• Overweight (obesity).
• Varicose veins, congenital vascular defects, consequences of traumatic vascular injuries.
• Malignant neoplasms of any location.
• The use of drugs that directly or indirectly affect the work of the blood coagulation system. Moreover, both regular admission and violation of doctor’s recommendations can be important /
• Injuries, surgical interventions, childbirth and other conditions requiring urgent activation of the blood coagulation system to stop massive blood loss.Postoperative thrombosis often complicates the recovery period during cesarean section, osteosynthesis of large bones, operations on large joints and the spine.
• Severe bacterial infections, sepsis (blood poisoning), massive pneumonia (pneumonia).
• Massive burns.
• Paralysis of the legs due to various neurological diseases or injuries of the spine. Polyneuropathies of the lower extremities of various origins.

Predisposing factors include smoking, old age, taking a large number of various medications, temporary immobility after surgery, trauma, and the imposition of plaster casts.

Physical inactivity, with a predominantly sedentary lifestyle, is also of great importance. This is accompanied by a slowdown in the outflow of blood from the legs, with congestion and a tendency to thrombus formation in the veins of the lower extremities. And the combination of a long sitting position with a drop in atmospheric pressure (as happens during flights) is a frequent provocateur of acute deep vein thrombosis of the lower leg among travelers.

How blood clots form in the veins

Currently, there are 3 key mechanisms in the process of intravenous thrombus formation:

• Violation of integrity, damage (so-called alteration) of the endothelium – the inner lining of blood vessels. The exposure of the underlying layers in their walls is perceived by the body and stimulates the processes of restoration and stopping bleeding. In the area of ​​the defect, tissue thromboplastin is released, this zone becomes the site of thrombus growth.
• Hemodynamic disorders – changes in the speed and nature of blood flow in the vessels.The presence of abnormal narrowing, uneven expansion, bending of the venous walls, defects in the valves of the veins negatively affects the blood flow. It becomes turbulent, uneven, with zones of turbulence, deceleration and retracement (reflux). This increases the risk of damage to the walls of blood vessels and the formation of blood clots. Therefore, illiterate treatment of varicose veins of the lower extremities predisposes to repeated thrombosis.
• Activation of the blood coagulation system, which is enhanced by the production of thromboplastin.A complex cascade of reactions is triggered with the participation of many biochemical and cellular components.

Thrombus formation is a natural defense mechanism aimed at stopping bleeding when a vessel is damaged. But in the case of thrombosis, blood coagulation takes on a pathological, maladaptive character. And the occurrence of a blood clot becomes the cause of circulatory disorders in the affected and adjacent veins.

What happens next with a thrombus

The thrombus initially formed in the lumen of the vessel has a small size and is located parietally, attaching to the area of ​​the endothelial defect.His subsequent fate may be different:

• The thrombus can continue to grow, filling the lumen of the vein and spreading along its length
• A clot or part of it may break off and travel with the blood stream.
• With sufficient activation of the fibrinolysis system, the reverse development of thrombosis begins, with the resorption of the thrombus. At the same time, a tunnel for blood often appears in a large clot, this process is called recanalization. But spontaneous thrombus fibrinolysis is a very dangerous moment during thrombosis, because this is what can lead to the formation of migrating fragments.
• The thrombus can remain in the lumen of the vein, while it thickens, grows with fibrin filaments and calcium salts and, as it were, “ossifies”.

It should be understood that a spontaneously resolved episode of thrombosis does not mean a complete cure of the patient. In the absence of adequate treatment, a relapse of the disease with the development of formidable complications is possible, which occurs in about 21–35% of cases. And almost ¼ of repeated thrombosis are accompanied by thromboembolism. Therefore, timely access to a doctor and compliance with all his recommendations are so important.

How phlebothrombosis manifests itself. Main symptoms

Venous thrombosis of the extremities is a rather insidious disease. In a significant percentage of cases, it is initially asymptomatic, making itself felt only with a significant progression of the process or with the development of complications. A person may not even be aware of the presence of a small non-occlusive blood clot, considering himself absolutely healthy.

The main clinical symptoms of leg thrombosis include:

• Swelling of the limb below the level of occlusion (blockage) of the vessel.At the same time, the skin becomes glossy, with a clearly visible network of superficial veins. At first, she is pale, with a bluish tinge. When the inflammatory process joins, redness appears.
• Increased fatigue of the affected limb is a sign of tissue oxygen deprivation and venous insufficiency.
• Pain in the leg, usually of a bursting-pulling character, aggravated in the upright position of the body and when walking.
• Consolidation, thickening, coarsening, soreness of the thrombosed area of ​​the superficial vessel.For example, with thrombosis of the PMV (superficial vein of the thigh), these changes can be detected on the anterior-inner surface of the thigh.

The appearance of the first signs of venous thrombosis is a reason for an urgent visit to a doctor, preferably a phlebologist. After all, this disease requires special attention, which is associated with a rather high risk of developing severe complications.

Why venous thrombosis is dangerous

Major complications and consequences of venous thrombosis:

• Inflammation of the vascular wall adjacent to the thrombus, in this case they speak of the development of thrombophlebitis.
• Violation of blood supply with the development of ischemia (oxygen starvation) of tissues, which is manifested by pain and other symptoms. The greater the degree of overlap (occlusion) of the lumen of the vessel by a thrombus, the more severe the consequences. And massive occlusive deep vein thrombosis can even cause venous gangrene of the lower limb.
• Further growth of a thrombus with the capture of larger or adjacent vessels. Starting in the lower leg, it is able to pass into the lumen of the popliteal vein, and then into the overlying iliac vein.And from the superficial venous network, thrombosis can spread through the communicative (connecting) vessels to deep veins.
• The most lethal variant of such a complication is PE (pulmonary embolism).
• Detachment and subsequent migration of a part of the thrombus, with penetration into the aorta and then into the arterial vessels. The result of such a “journey” often becomes their blockage with the development of thromboembolism. Thrombus migration can also result in myocardial infarction, stroke, kidney infarction, thromboembolism of mesenteric vessels in the abdominal cavity – this refers to arterial thrombosis
• Formation of post-thrombotic syndrome of the lower extremities.We are talking about poorly treatable chronic venous insufficiency with edema, pain, trophic disorders.

Many patients underestimate the danger of venous thrombosis, not seeking medical attention and preferring to self-medicate. This approach is fraught with an aggravation of the situation, increases the risk of relapse and can even lead to the development of severe, life-threatening complications.

Diagnostics

At the first suspicion, a doctor’s consultation is required. Moreover, it is preferable to contact specialized vascular, phlebological clinics, since it is not easy to accurately determine venous thrombosis without additional examination.

Diagnosis of this disease includes:

Detailed examination with a doctor’s special tests (tests) for the functioning of the veins of the extremities.

Ultrasound of the superficial and deep veins of the extremities, with the determination of the course of the vessels, the size and position of blood clots.

USDG or duplex scanning of veins, which allows you to assess the nature of blood flow, the degree of its deficit and a number of other parameters.

According to the doctor’s prescription, laboratory studies of the blood coagulation system can be additionally carried out.In controversial and severe cases, other, more complex and expensive diagnostic procedures may be recommended.

How to treat venous thrombosis

Identification of symptoms and treatment of venous thrombosis is the prerogative of a specialist, self-medication is unacceptable. Therapeutic tactics depend on the affected area, the size and nature of the thrombus, the age of the process and a number of other factors. The selection of drugs and the necessary techniques is carried out individually.

Treatment of venous thrombosis may include:

• Reception of drugs of various pharmacological groups.Such therapy can be aimed at lysis (“dissolution”) of blood clots, restoration of adequate work of the blood coagulation system, reduction of the severity of tissue ischemia, mitigation of inflammation and pain, prevention of relapses.
• Mechanical removal of a thrombus. It is practiced infrequently, since this manipulation is associated with a high risk of detachment and migration of a part of the clot.
• Endovasal laser coagulation of superficial veins above phlebothrombosis or surgical treatment in the form of crossectomy to prevent further thrombus migration.

After the resolution of thrombosis, a competent phlebologist can recommend a complex specialized treatment of varicose veins. This will prevent relapse and improve the condition of the entire venous system.

Flebolife Clinic is a specialized modern phlebological center. We carry out high-quality reliable diagnostics and competent treatment of thrombosis and other venous diseases. Our specialists are highly qualified, use modern medical diagnostic equipment and effective treatment regimens.Operations are carried out in a minimally invasive, low-traumatic way, using safe certified techniques and materials.

We are waiting for you at the Flebolife Clinic.