Melanie Cole, MS (Host): Acute leg deep vein thrombosis affects people of all ages. Left untreated, it can lead to chronic leg pain and swelling or a pulmonary embolism, which can be lethal. There is, however, a medical treatment to prevent pulmonary embolism and a new technology to remove deep vein thrombosis to decrease or prevent long-term leg pain and swelling.

Welcome to Answers in Vascular with the Vascular Care Group. I'm Melanie Cole. And joining me today, we have Dr. Paul Gagné. He's a board-certified vascular surgeon, founding partner of the Vascular Care Group, Darien, Connecticut, and Chief of Clinical Operations and Research at Mangrove Management Partners.

Dr. Gagné, it's a pleasure to have you join us today as we get into this topic. Can you explain to the listeners what DVT or deep vein thrombosis is?

Dr Paul Gagne: Sure, Melanie. And thank you for the opportunity to do this. So, the blood moves through our legs, first through the arteries from our heart to the different tissues in our bodies, including the legs. And then, the blood has to leave those tissues to go back to the heart to complete the circuit. And they go back to the heart through the veins. And so, blood, of course, is a liquid. But what happens is, when you cut yourself, blood has to then convert into a semi-solid state like jello or pudding, and that's what a blood clot is. It's that semi-solid state.

Normally, when we cut ourselves, the blood forms that semi-solid state and plugs the hole so we don't bleed. What happens with a blood clot or a DVT, a deep vein thrombosis, is the body creates a blood clot in the vein unnaturally in a way that we really don't want to happen. It's more of an illness than a normal function. And when it does that, it can either completely block the vein so that no blood goes through that segment of the vein, or it can partially block the vein and cause inflammation and pain.

Melanie Cole, MS: That was an excellent description of what a DVT is. So, why do they happen, doctor?

Dr Paul Gagne: So, we talked in the medical field about three things that cause blood clots. One is trauma. So if you break your leg, next to the bone are the veins and arteries. And so, the bone when it breaks can sometimes ding or bang into the vein, and that can cause a blood clot. When blood's not moving very fast, it can cause a blood clot. And that would be in an instance, for example, if you're sitting on a plane for 24 hours and you don't get up and walk, or for long car rides for say 8, 10 hours and you're not walking, or you're in a hospital bed, sick and you're not moving around very much, then when the blood's not moving quickly, it has a tendency to want to convert into that semi-solid state or that deep vein thrombosis. So, that's number two. Number three is occasionally patients have an underlying genetic or some other disease that causes the blood to get sticky. And so, they have a predisposition to forming blood clots, and they form blood clots sometimes early in life, sometimes later in life, but sometimes there's a genetic origin of that predisposition.

Melanie Cole, MS: And I'd like to get into that in just a minute. But as we talk about risk factors, Dr. Gagne, you mentioned long airplane rides or hospitalization being in bed and the genetic component. Is there any lifestyle factors that come into play if somebody is a sedentary lifestyle or obesity? Does that predispose them to these deep vein thromboses as well?

Dr Paul Gagne: I think that a sedentary lifestyle more so even than obesity, although unfortunately the two of them often go together. When you're not moving around much, when you're sitting with your legs down in a dependent position, gravity is pulling blood down to your legs. It's not leaving your legs normally and going back to your heart. And so when it's kind of pooling there and not leaving the legs the way it's supposed to, not moving at the speed it's supposed to normally move at, in that instance, you're at a higher risk for a blood clot.

Melanie Cole, MS: What's the complication? What happens if somebody does develop one of these? How does it affect our everyday life? Is it lethal? Tell us about that.

Dr Paul Gagne: One of the things that I think, for the listeners, this is a really important point because oftentimes, patients get diagnosed with a deep vein thrombosis or a DVT. And they get put on blood thinners and not much more is talked about. It's just kind of like you're going to be on these blood thinners for three months or six months and then that's it. The problem is that the acute risk of a DVT, in other words, when it's diagnosed, what are we trying to avoid, is managed by blood thinners. And what are we trying to avoid? Well, we don't want the blood clot to get bigger and grow into other parts of the vein. So, the blood thinners are very effective in stopping the growth of the blood clots. And then, we don't want the blood clots to break off and travel in the blood stream back to the heart and lungs. And Melanie, you mentioned the danger of these. That's the danger because if the blood clot goes up into the heart and lungs, it can clog up or block the blood vessel, kind of like a cork in a bottle, so that the blood is not moving through the heart and lungs the way it needs to. It puts a lot of strain on the heart. The patients may not have enough oxygen in their blood, because it's not moving through the lungs properly. And that can sometimes lead to death. And so, the blood thinners are the first treatment for trying to prevent all that from happening. And it's important that every patient know about it.

Melanie Cole, MS: So expanding on that then, Dr. Gagne, historically, as you mentioned, Coumadin, blood thinners, is that still the medicine of choice? Have we moved on from that? Because we know that there's Coumadin clinics and it can lead to bleeding. It can be quite scary. It's something that people really have to know a lot about to be on them for any long term. So, what are we doing now? Is that the medication we're using? Is that the only available treatment these days?

Dr Paul Gagne: Yeah. So fortunately, the field of medicine and pharmaceuticals has advanced past Coumadin and warfarin. Certainly, those were the mainstays of treatment for decades, and they are effective. But you have to work very hard to adjust the dose. And things as simple as the foods you eat can impact how therapeutic it is in your body. And oftentimes, we would have patients whose blood thinner level from the Coumadin or warfarin was too low or too high. And when it's too low, you run the risk of a new blood clot. And when it's too high, you run the risk of bleeding. So in general, we've moved away from Coumadin and warfarin for the majority of patients who have a deep vein thrombosis.

And now, there's some new medicines that we call DOAC, D-O-A-C. Some of the brand names are Eliquis, or Xarelto, or Pradaxa. And these are pills that you can take that have a very low risk of bleeding, and they're as good or better than Coumadin or warfarin for preventing new blood clots in pulmonary emboli. And so, we've been using those over the last six to eight years on a regular basis.

Melanie Cole, MS: Are there any surgical interventions that you would use in the case of maybe a bigger one or one that you feel has a higher chance of breaking off?

Dr Paul Gagne: One of the things that has really evolved over the last 20 years is removing the blood clot from the veins before it causes some of the harm that it can do. Now, the good news is the blood thinners are pretty effective in preventing blood clots from traveling up to the lungs. So really, much of the therapy that's directed towards removing blood clots in the legs and in the pelvis is to prevent the long-term complications that you mentioned on your lead end to the legs, which is swelling, pain. And then long-term, that can lead to skin damage and chronic ulceration or sores on the leg. And that's called the post-thrombotic syndrome.

And what happens is when you get a blood clot, the liquid blood converts into that gelatinous or semi-solid state that I described. And the way it heals over time is much like anything else in our body. You get a little cut on the skin, and you get a little inflammation that helps the skin to heal. When the blood clot heals within the veins of the legs, what happens is an inflammatory process starts and that inflammation leads to scarring within the vein. So what may happen is although the vein may in part reopen partially, there's a lot of scar tissue in the vein. And so, it's kind of like a three or four-lane highway with either construction or an accident where we go down to one lane. And you know what happens when that happens is there's a backup of traffic. And the same thing happens in the leg. If the veins are mostly blocked by scar tissue, as it heals from this deep vein thrombosis, then you get a buildup of pressure in the lower leg. And that leads to swelling; that leads to pain, particularly when you're walking. The leg feels like it's swelling up like a balloon and gonna burst or some people will get dark discoloration of the skin. And then occasionally, a proportion of those patients will go on to have sores that are very difficult to heal.

Melanie Cole, MS: Yes. Those complications can be quality of life-limiting. And Dr. Gagne, when someone has gone on one of these newer medications that you've discussed, when can they get back to normal? Do you want them exercising? Because that claudication, that pain in the legs, that swelling that they get, that can limit their ability to be active as well. So, speak a little bit about the lifestyle that they can get while they're on these medications trying to break up that blood clot.

Dr Paul Gagne: So as you can imagine, if the blood's not moving through the leg in a normal way, it can lead to pain and heaviness in the leg and swelling, because the blood's just pooling there. And so, walking is good. A compression stocking can be helpful. Leg elevation can be helpful. But unfortunately, once you get the scar tissue in there, there are limited options for making that problem go away.

And one of the things that we do sometimes in patients who have a new blood clot, in order to avoid those long term complications as you kind of mentioned before, Melanie, is besides the blood thinners, this is a procedure we can do even in the office. We put a small intravenous in the vein. And then, there's devices that we can use to either capture the clot in what looks like a net and pull it out of the body or with a device that looks like a straw, and we attach it to a small pump that sucks the blood clot out of the vein, so that it doesn't create that inflammatory process and scarring and then lead to the lifestyle complications that you talked about. And in fact, that's the most effective way of getting somebody back to their normal life, is to go ahead and remove the blood clot from the leg so that the blood is now moving normally and you don't get that buildup of scar tissue. And that's the big jump forward over the last eight or 10 years, is we now have newer, safer devices for doing that. And it used to only happen in a hospital, but as the devices have become safer and more minimally invasive, we're now doing this in the outpatient setting.

Melanie Cole, MS: It sounds similar to a mechanical thrombectomy that they might use in the case of a stroke. And so, isn't that just fascinating? What an exciting time in your field. There are so many advances happening so quickly. As we wrap up, is there any way to prevent them? You mentioned pressure stockings, or if we're sitting up for a long time. Give us your best advice, Dr. Gagné, for preventing them based on what we're doing every day.

Dr Paul Gagne: So, if you've never had a blood clot, then the best way to prevent a blood clot from happening, a deep vein thrombosis, is to stay active to stay well-hydrated. And so if you are going on a long trip, rather than sitting in the airplane terminal, for example, for an hour or two, not moving around, and then getting on your four to six-hour flight cross country, where you basically haven't moved much for six to eight hours, get up while you're in the terminal, walk around every 30 minutes or so. Take a little walk to get the legs moving. Stay well-hydrated. You don't want to be thirsty. That keeps the blood thin and less likely to convert into that gelatinous blood clot that we're trying to avoid.

And then, the other thing that I would say, Melanie, that's really important is that patients need to advocate for themselves. Unfortunately, the progress in being able to remove the blood clots and get patients back to their normal life is not recognized by a lot of doctors. That field has moved so quickly. A lot of people in the medical field haven't been able to keep up with the advances. And so if you do get a blood clot with a lot of swelling in your leg, you need to see a vascular surgeon or a specialist who can take out the blood clot within the first week of diagnosis. The best time for removing that blood clot is within the first one to two to three weeks. That's the best opportunity to get somebody back to normal.

Melanie Cole, MS: What great advice. You're an excellent educator. Dr. Gagne, thank you so much for joining us today and sharing your incredible expertise with us. And for more information, please visit our website at thevascularcaregroup.com. Thank you so much for listening to Answers in Vascular with the Vascular Care Group. I'm Melanie Cole. Thanks so much for joining us today.