Scott Webb (Host): This is the St. Joseph's Health MedCast from St. Joseph's Health. I'm Scott Webb. Blood clots are fairly common, but some can become life-threatening if they aren't diagnosed and treated early. Here to tell us more today is Dr. Vincent Skovira. He's a cardiologist with St. Joseph's Health.

Doctor, it's nice to have you here today. We're going to talk blood clots, sure, but we're going to focus in on DVT, deep vein thrombosis, and PE, pulmonary embolisms, and maybe we'll abbreviate along the way because that's easier. So, let's just start there. What is DVT or deep vein thrombosis, and how can it lead to pulmonary embolisms?

Dr. Vincent Skovira: So, DVT, deep vein thrombosis, a lot of patients don't know much about them. The main thing that we are trying to talk more about is what are they? So essentially, it's a clot that forms in a vein. The veins predominantly that we're worried about are in the lower extremities. So, veins that go all the way down from your calves up to your hip. We have veins all the way up. And we also have deep veins in our upper extremities, but, you know, we don't really see a lot of DVTs in the upper extremities. They're predominantly in the lower extremities, and that's kind of what we're talking mostly about today.

Host: Yeah. And I know deep vein thrombosis can lead to pulmonary embolisms, and I know, you know, both are critical but sort of often maybe under-recognized. So, like, what are some of the symptoms and why are they under-recognized and so forth?

Dr. Vincent Skovira: Right. So, a lot of times they're under-recognized mainly because the biggest symptom we have from DVT is swelling, and swelling happens from a lot of different things. Very much so, we have providers that look to DVT. Checking that is the last thing that we do. And generally, it's diagnosed with an ultrasound.

And sometimes, you know, we think some people have chronic swelling in the legs from other things, other chronic issues that can cause it. So, a lot of times it's under-diagnosed. And also, the diagnosis sometimes is a little difficult even with ultrasound. So, a lot of patients come to us and say they've maybe had some throbbing in the leg, kind of non-specific symptoms, which may lead to the diagnosis. And it's very commonly under-diagnosed.

Host: Yeah. It does seem to be a common thread, doctor, in these podcasts that I host, is that, you know, the human body is complex. And it could be this that's causing the thing, or it could be something else, and that's why we need experts and often X-rays and things like that. So, maybe you can give us a sense anyway, like why or how PE can sort of quickly become so life-threatening. Like, how does that happen?

Dr. Vincent Skovira: Right. So generally speaking, PEs come from a DVT. And lot of times, it's more of a chronic clot, a clot that's been in your leg maybe for a little bit longer than you think. And what ends up happening is a lot of times it breaks off at the knee joint. The knee joint, you know, the hinge that you have kind of breaks the clot, goes up to the arteries in the lungs and gets stuck there.

And the main issue with that is pulmonary embolism or PE. Basically, you don't get oxygen. Your oxygenation of your blood is prohibited. You basically plugged up the dam with a clot. So, those can be life-threatening rather quickly depending on the amount of clot that gets stuck in the arterial system, and that's generally what the concern is with large DVTs, is progressing up into the lung arteries and decreasing your oxygen.

Host: Yeah, we need the oxygen, right? So, I could understand why that clot would be a problem. So then, who's most at risk? And is it because of maybe hospitalization, surgery, immobility, you know, the greatest hits perhaps in your business? But like, who should be worried about this?

Dr. Vincent Skovira: Right. So, immobility is the number one thing, and immobility can happen obviously from numerous things. Predominantly, we get them post-operatively, patients that are told maybe don't do so much after an operation, whether it's an abdominal surgery, an orthopedic surgery, kind of lay low for a little bit, right? So, you don't move as much. And unfortunately, we are fighting gravity, and gravity wins, and the blood sits a little too long in the legs and forms a clot. Those are the biggest at risk.

We also have a higher risk in pregnancy, and as well as patients with cancer. Those patients are a little bit more high risk. And there's a subset of genetic predisposition that patients may have to have more clots. But overall, those are the modifiable factors we see.

Host: Yeah, right. And things we can't outrun like family history and genetics, sure, but there are some things that are within our control, behavior, lifestyle, that kind of thing. And you gave us a sense anyway, like these are a little tricky to diagnose. So, how exactly do you diagnose PE and DVT? And why is early recognition and fast action, like, why does that matter so much?

Dr. Vincent Skovira: So, gold standard diagnosis for PE is a CT scan, which is predominantly done in the hospital. You know, if we're concerned about a PE, generally you're seen relatively urgently or emergently in the emergency department. So, CT scan is the way that we would diagnose you. DVT, ultrasound is the study of choice. We, you know, scan the entire leg with an ultrasound to see if the vein is able to be collapsed, or if you can actually visualize the clot itself. So, that's the two different modalities that we use. There's other ways to diagnose pulmonary embolism, but CT really is the best.

Host: Yeah. Those are the gold standard. And as is the case in most things in medicine, early recognition better, fast action, you know, preferred, right?

Dr. Vincent Skovira: Early action is very important with this disease process, and the main reason is the current guidelines in how we treat this is to give the patient a blood thinner, and your body starts to break down the clot, rather quickly if you can catch it early. The blood thinner helps to reduce the clot size, but doesn't really treat the clot.

So, recognition early is nice because your body can start to break down before the clot becomes more what we call fibrous, almost like tissue-like. And when it becomes like that, it's very hard for your body to break it down, and it takes much, much longer as opposed to the early phase, which also does kind of help us with different types of therapeutics that we can talk about.

Host: Right. Yeah, I was going to ask you. I assume that blood thinners were the standard treatment, but I'm sure in some of these trickier cases or more advanced cases that maybe catheter-based procedures are needed?

Dr. Vincent Skovira: Correct. So, the nice thing about what we do as an international cardiologist, and we have some colleagues in other fields that do the same thing, is we have new guidelines actually that just came out on how to treat pulmonary embolism. It's the first guidelines of its kind ever that just came out a few months ago actually from our governing body, the American College of Cardiology and the AHA as well. And it highlights some other modalities of treatment which we've been using for quite some time, but guidelines just haven't caught up until this year. And we're very excited about that because we think that the data that the devices have is quite good. And, you know, guidelines before that time, even last year, were patients with a pulmonary embolism, they get a blood thinner and that's it.

So now, we have other modalities of treatment, catheter-based treatments where we can essentially try to break the clot up with small doses of blood thinner or extract the clot basically sucking it out with an aspiration catheter.

Host: Yeah, it's very cool. I love science and technology and medicine and sort of geek out on this stuff. Give us a sense, interventional cardiologists, like why you're the right maybe specialist for this and how you improve outcomes for those really severe cases.

Dr. Vincent Skovira: The pulmonary embolism patients that come in to see us that meet the criteria, we have a lot of criteria we go through. You know, not everybody with a pulmonary embolism needs some sort of advanced treatment option, and that's why the guidelines are so nice because they make it very clear on who benefits and who does not benefit. And the sicker patients benefit more from this type of intervention.

And the reason that this is beneficial, and not just interventional cardiology, but we have interventional radiologists that do this as well, and our vascular team does this. But us together as a group, what we rely on is that fast acting that you touched base on iis very important. But also, from our aspect, it's about regaining oxygenation as fast as you can. So without these modalities, what you want to happen is the clot to go away. And with just a blood thinner, that can take up to three to six months, and you essentially are allowing your body to break it down over time slowly.

These modalities, the resolution of the clot or removal of the clot is much, much faster. Generally speaking, the patients that I treat, the procedure is done, and they're discharged from the hospital within a day. And the clot is removed. It's gone. You don't have to wait for it to be broken down. Of course, we still put them on a blood thinner afterwards to prevent more clots.

But the treatment is very effective, and patients have very good outcomes. Some patients even feel better right on the table when we're doing the procedure. It's very fast-acting, and what we find is that not only is it helping their quality of life and improving their symptoms. But in the very sick patients, it helps to basically prevent significant deterioration of their health, which is obviously the whole point of medicine.

Host: Yeah. That's the goal after all, right? So, just give you a chance here at the end, give us some simple prevention steps. We talked earlier about things that we could do that are modifiable. So, what do we need to do?

Dr. Vincent Skovira: Yeah. So, prevention for the most part is move around. A lot of our patients, you know, we have very classic patients that come in that may have gone on a long car ride or a long plane ride, and that's the immobility portion. So, take frequent stops if you're driving in the car. If you're on a long plane ride, get up when you can or even just try to move your calf muscles, as much as you can in the seat to try to, you know, make those muscles contract and move blood out of those deep veins.

And in doing so, you can dramatically reduce the risk of blood sitting too long in the legs and causing a clot. People that do have clots, we sometimes, you know, help with prevention, not just with pharmaceuticals. We can talk about compression socks that can help. You know, we have a lot of patients that take long-haul flights. Compression socks are a great preventative step as well if you're concerned. But really, mobility is the biggest thing.

Host: Right. We all know those socks are very fashionable. So, we probably don't have to twist a lot of arms to get those on people. But listen, it's been great having you here today. I appreciate your time and your expertise as we got rolling here today. It's, you know, this so common, often under-recognized, under-diagnosed, and I hope this helps folks.

Dr. Vincent Skovira: Yeah, definitely. Thank you again for having me. It's been a pleasure.

Host: And for more information, go to sjhsyr.org/cardiac-care. And if you found this podcast helpful, please share it on your social media. I'm Scott Webb. Thanks again for listening to the St. Joseph's Health MedCast from St. Joseph's Health.