Posts Tagged ‘blood clot’

Why do I Have Calf Pain? Could be……… Deep Vein Thrombosis

October 19, 2013

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A young woman presents to her podiatrist office with pain and swelling in her calf.  She was seen two weeks prior and was found to have a fractured bone in her foot. To treat this condition, she was given a CAM boot (walking cast) to stabilize the fracture. Current medications she is taking include oral contraceptives (birth control pills). What is the cause of her pain?

Definition of Deep Vein Thrombosis (DVT)

The ability of blood to clot plays a major role in healing. Upon injury that causes bleeding, platelets and fibrin clump together to form a durable barricade to blood flow.  This prevents loss of blood from the body and facilitates the healing process. However, this process can occur at times that are unnecessary, resulting in an unwanted blockage of blood flow in blood vessels. A common site for blood clotting gone awry is the deep vein of the calf. Deep vein thrombosis, or DVT, occurs when a blood clot forms in the deep vein of the calf. You may have heard about episodes of DVT caused by sitting or lying down for a long period of time, such as on an airplane or in a hospital bed. A long period of immobility slows down blood flow through the veins, which is a major risk factor for clot formation. DVT can also occur after surgery due to damage to the venous vessel wall. Hypercoagulability of blood is another reason why DVT can arise. Hypercoagulability is a state of excessive clotting in the blood, and could possibly be the reason why the patient in the above example presents to the clinic today. Supplemental estrogen from contraceptive use can increase the coagulability of blood. Notice also that the patient arrived in a CAM walker, which rendered her immobile for a considerable period of time and furthered her risk of developing DVT. Other risk factors include pregnancy, smoking, or genetic conditions like thrombophilia.

Clinical Presentation

A patient with DVT can present with pain in one leg that gets better when the leg is elevated. Redness, swelling and tenderness are other symptoms to take into account. It should be noted, however, that a patient with DVT might not experience symptoms at all.

Potential complications

A major concern for development of DVT is the potential for portions of the clot to break off, forming an embolus. An embolus flows through the blood and can lodge itself in a downstream location. A pulmonary embolism is a dangerous complication that occurs when a portion of the clot breaks and gets stuck in an artery in the lungs. Symptoms of pulmonary embolism include a sudden shortness of breath and cough. Patients experiencing these symptoms should immediately visit the emergency department.  This condition can be life threatening! Physical Exam When a podiatrist suspects a DVT, there are certain simple physical test that can be performed as screening tools. Some patients may exhibit pain when their foot is extended towards the ankle, eliciting a positive Homan’s sign. A positive Bancroft’s sign is observed when the patient experiences pain when the doctor squeezes their calf from the front and back. Neither of these tests can absolutely confirm that a DVT is present, but can certainly aid in diagnosis when combined with patient history and further diagnostic testing.

Diagnostic test

Use of a duplex ultrasound is a sure-fire way to confirm diagnosis of DVT. This noninvasive procedure measures the blood vessels in the patient’s calf for irregularities in flow. A thrombus is present when blockage of flow is observed. A d-dimer test can also be used. D-dimer is a fragment of fibrin, one of the molecules involved with building a robust clot in blood vessels. Blood is drawn from the patient and the level of d-dimer is measured. If measured level is high, indicating a positive test, then further testing can be done to confirm DVT. This test is usually used when there is a low probability that the patient has DVT because a negative test rules it out.

Treatment

The importance of treating DVT, even if it is asymptomatic, is to prevent the occurrence of more lethal complications such as a pulmonary embolism. Anticoagulants can be prescribed for the purpose of achieving this goal by dissolving the clot or preventing it from growing larger. These medications include injections of Low Molecular Weight Heparins (LMWH) or oral Coumadin. Prophylactic measures can also be taken in patients that are at risk of developing DVT. Compression stockings can be used on patients who are bed-bound for a long period of time. Anticoagulants can also be used prophylactically. It is important to advise patients who have had previous episodes or are at risk of clotting to not stay seated for too long when flying long distances since this can cause development of DVT. If you are reading this because you think that this might be what is causing your calf pain….call 911 or go quickly to the nearest emergency room!

Living with Peripheral Arterial Disease

March 8, 2012

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Definition of Peripheral Arterial Disease

Peripheral arterial disease (PAD) can be a debilitating disease. It is caused by fatty deposits that accumulate on the inner walls of arteries.  These deposits in the arteries of the lower extremity will result in poor blood flow to the legs and feet. If arteries are clogged and narrowed, blood will not be able reach its destination to supply muscles and organs with oxygen and nutrients. Decreased oxygen and nutrients to muscles can result in severe cramping in the legs, especially with increased workload such as walking. Patients with diabetes, high blood pressure, high cholesterol and smokers can be at increased risk of developing PAD. It is also important to note that persons, who have PAD, are also at increase risk of having fatty deposits in the arteries of the heart, which can result in a heart attack or stroke.

 

Symptoms of PAD

Most people with PAD are non-symptomatic.  However, if symptomatic, the most common complaint from patients with PAD is they get severe cramping or burning in the calf muscles when walking. Typically the cramping begins after one or two blocks of walking and will subside after a few minutes of rest. The cramping results from a build up of a waste product produced by exerting muscles called “lactate”. This is produced when there is not enough oxygen getting to the muscles. The cramping can significantly alter a patient’s lifestyle and prevent the patient from enjoying normal daily activities.  Aside from physical limitations, severe PAD can lead to non-healing wounds on the leg and foot and black/gangrene in the toes.  Some of these patients with PAD may require an amputation of the foot or leg.

 

Physical Examination for PAD

When a podiatrist evaluates a patient for PAD, there are key signs that are presented on the feet. Patients with PAD tend to have diminished or absent digital hair growth and nails that are brittle and thickened as well as decreased temperature in the feet. The podiatrist may ask the patient to hang their legs over the side of the exam chair, in patients with PAD the legs begin to display a deep purplish color. Patients with PAD will have a white, pale discoloration to the feet if the legs are elevated above the heart for one minute. The podiatrist will also feel the pulses in the feet. If the pulses are weak, it may indicate that there is poor blood flow to the feet. These are important signs that lead to a high suspicion of PAD.

 

Testing for PAD

The most common and least expensive office test for PAD is called an ankle-brachial index. This is done by taking the blood pressure of the arm (brachial) and comparing that number to the blood pressure in the ankle. This test requires a blood pressure cuff and Doppler ultrasound to hear the pulse.  The blood pressure cuff is inflated on both the arm and the leg. Next, the cuff is slowly deflated; the first sound heard in sync with the blood pressure number is recorded and compared by ratio. The normal ankle-brachial index is 1, in other words the arm and the ankle should ideally have the same pressure. Patients with an ankle-brachial index of 0.4-0.9 are considered to have PAD.  There are also additional tests that can determine poor blood flow. PAD can also be visualized with an MRI/MRA or angiogram, which requires injecting a dye through the blood vessels and using an imaging system to follow the dye through the arteries in order to visualize artery narrowing.

 

Conservative Treatment of Peripheral Arterial Disease

The most important goal in treating PAD in the lower extremity is to reduce the risk of amputation. Treatment is usually administered by the primary care or vascular physician. Drugs that thin the blood, such as aspirin, are often prescribed to patients with PAD to prevent the risk of clotting.  Smoking cessation programs and good control of cholesterol, blood pressure, and blood sugar levels are also strongly advocated. Foot care is also important in managing peripheral arterial disease to prevent ulceration to the feet. In treating cramping sensations from PAD, exercise therapy has been scientifically shown to increase maximal walking distance because it promotes small vessel formation around the area of the clot.

 

Surgical Treatment of Peripheral Arterial Disease

If the symptoms of PAD are severe, inhibiting lifestyle or resulting in non-healing wound or gangrene on the feet, surgical treatment may be required by the vascular physician. The goal of surgery is to increase blood flow to the legs and feet.  Surgical treatment may include bypassing the area of clot with a vessel graft or vein or opening the artery with a balloon and placing a stent to increase the diameter the artery and attempt to keep it open.