Ulka Sachdev, MD, Co-director of the Vein Center at UPMC Heart and Vascular Institute

Deep Vein Thrombosis (DVT) can be a life-threatening condition. Ulka Sachdev, MD, Co-director of the Vein Center at UPMC Heart and Vascular Institute, discusses causes, the warning signs and what you should discuss with your doctor.

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– This podcast is for informational and educational purposes only. It is not medical care or advice. Clinicians should rely on their own medical judgments when advising their patients. Patients in need of medical care should consult their personal care provider.

– It can be a life-threatening condition – deep vein thrombosis, or DVT. So, what are the warning signs, and what else do you need to know? Hi, I’m Tonia Caruso. Welcome to this UPMC HealthBeat Podcast. And, joining us right now: Dr. Ulka Sachdev. She’s a vascular surgeon and co-director of the Vein Center at UPMC Heart and Vascular Institute. Thanks so much for joining us.

– Thank you for inviting me.

– OK, let’s really begin with the basics. How would you define deep vein thrombosis, or DVT?

– A deep vein thrombosis is a blood clot that involves, as the name suggests, the deep veins, usually of your leg, sometimes of your arm. So, our extremities have two sets of venous systems. The deep system tends to run closer to the bones and not something that you would necessarily see. And the superficial veins are the ones that you can kind of see on the skin surface sometimes. So, a deep vein thrombosis involves those veins that are running a little bit closer to the bone and in a place where you might not be able to see it just by looking. And it’s different. The way that clots are managed in deep veins is different from the way that they’re managed in superficial veins.

– Why can they be so dangerous?

– To start off with, deep vein thrombosis, or DVT, in the vast majority of cases are not necessarily going to provide or put you at risk for a life-threatening event if it’s treated. The risk is that a piece of the clot can break off, travel through your venous system, through your heart, and into your lungs, and cause something called a pulmonary embolism. And that is what can be the life-threatening event.

– And, so, then, how do you discover them? What are the signs and symptoms?

– Right. So, as I mentioned, if it is a blood clot in the deep system, that is not something that a patient or a physician is necessarily going to be able to see with their eyes. It’s not like having a rash. It’s not like having a varicose vein that’s bulging out where you can see it and feel it. The most common presentation for a patient would be leg swelling, or arm swelling if it happens to be in the arm, pain, redness, and usually an acute onset of these symptoms. So, if you’ve been having swelling over the course of a year or so, it’s unlikely that that is coming from an acute DVT. But, if let’s say you took a long flight somewhere, you weren’t able to get up and walk around, you came home, and the next morning your leg was three times its normal size, red, blueish, discolored, painful, that’s the kind of thing that would tip someone off that they might have a blood clot, and it should be evaluated.

– That leads us right into what are some of the risk factors? So, obviously, if you are sitting still for long periods of time, traveling, driving, flying. What are some of the other risk factors?

– That’s a great question. So, there are some people who have a genetic predisposition to having them or to developing blood clots in the vein. There are also people who can get blood clots in arteries as well. This is a little bit different. So, there are genetic factors that might put patients at risk. If, as a patient, you have a strong family history of blood clots, that might indicate that you’re at a higher risk for getting a blood clot. There are other clinical conditions that put you at risk, such as immobility for reasons such as paralysis, spinal cord injury, prolonged hospitalization for chronic illness. Cancer is another thing that could put you at risk. So, these are things that we will try to assess clinically if we’re seeing a patient either in an outpatient or an inpatient setting, to try to determine what their risk factors are.

– Then what does treatment look like?

– So, treatment for the vast majority of cases looks like an anticoagulant. So, it’s a medication that is specifically designed to counteract the clotting system that we see in veins. And that’s a whole kind of complicated system, but the medications for it are really good at interrupting the process. And the point of the medications is really to stop the progression of further clots so that your body’s own system of breaking up that clot can work unopposed. And generally speaking, if someone comes in with an acute DVT, and we believe that it is provoked, meaning that they had recent major surgery, or they were immobilized, or they have had an injury of some sort, the anticoagulation therapy can be somewhat limited. We say usually around three to six months. However, there are some people who will have recurrent DVTs. So, they get treated, they maybe come off treatment, and then they get another blood clot for one reason or the other, maybe because they have a genetic predisposition. And for those people, they may need to be on some type of anticoagulation medicine indefinitely.

– Right. So, then, what happens when it comes to the pulmonary embolism, and how are those diagnosed? And, you already said, like, the danger there is so much greater. What does that treatment look like as well?

– That’s a great question. For pulmonary embolism, the presentation is oftentimes someone who presents with shortness of breath and chest pain. And, a lot of times clinically, we can document a drop in their oxygen level in their blood, we can document irregularities in their heart rhythm and rate, and sometimes even document a strain on the heart muscle itself. And, actually, here, we have a very robust protocol of trying to assess which of those patients might benefit from some type of invasive treatment to try to get rid of the clot. Not everybody needs that, but that is an option in certain types of pulmonary embolism where we feel that an intervention is warranted to try to protect that patient’s life and also to prevent long-term complications. A lot of times, people with pulmonary embolism can be treated much in the same way as those who have had a DVT, meaning they can be put on a blood thinner or an anticoagulant that they take, usually by mouth, and be treated for a defined period of time.

– Is there anything that can be done to prevent DVT?

– I would say to patients that if they have family members that have had blood clots in their legs and in their veins or have had a history of a pulmonary embolism, it’s probably a good idea to just ask your physician whether it’s worth getting tested to see if you might have a risk for developing a DVT in the future. Certainly, activity, and staying active, and walking is a very simple way to help prevent blood clots. The daily activity of people getting up, walking to the bathroom for self-care, going to work, et cetera, all of that actually helps. Every movement kind of counts. If you’re going to be in a situation in which you are immobilized for a period of time, and that includes on a long flight or in a car trip, wearing compression stockings, trying to get up when it’s safe to do so, and walk up and down. The calf muscle movement actually helps to push the blood out of the veins in your legs and prevent stagnation. And that really can go a long way at reducing your risk of getting a blood clot.

– How do things like smoking and high blood pressure, do they have a role in this, and even age?

– Age is certainly associated with an increased risk of blood clots. Smoking and hypertension can also contribute in their own ways. And a lot of times we’ll see a risk of arterial clots, which are a little bit different than DVTs for those patients who have chronic hypertension and are heavy smokers. So, obviously, you know, anything you can do to try to quit smoking, I think, will help reduce your risk of getting blood clots in the future.

– And why age? Because people may tend to slow down when they’re older?

– Slow down a little bit, yes. And there’s probably some aging factors that can contribute to diseases that affect the lining of the blood vessels that might put someone at a higher risk. And we see that in a lot of different types of age-related disorders, I should say.

– You mentioned testing for DVT. You can be tested to see if you might be at a higher risk for this?

– The tests that could be performed to see whether you are at a higher risk of developing a DVT are usually tests that are done as a blood test. And that’s to look for certain circulating factors that might determine or might indicate that you’re at a higher risk for getting a blood clot in the future. That is not the major population. OK, so, those are usually people who are going to have some genetic predisposition. I would really only recommend that if you have a family history of blood clots or there are certain other types of diseases that might put people at risk for blood clots, such as lupus is one in which where we might. Or certain rheumatologic diseases might put people at risk for getting DVTs. And in those people, it might make sense to look for some of those markers.

– And tell me a little bit about your work, how you chose this as a specialty, and why you think in particular this topic is so important.

– I chose vascular surgery because I think it is really one of the only fields where you can have a very diverse patient population where you can manage patients medically, surgically, endovascularly from the inside of blood vessels. I may have a clinic full of patients that I never operate on, but I get to see them every year because they have either an arterial issue or a venous issue. And it allows me, I think, to form really strong bonds with my patients. So, I really love that aspect of what I do. And I do have a fairly robust venous practice, where I will see patients who have DVTs or who have had DVTs in the past. And one of the things that can happen with people who have had DVTs in the past is they develop changes in their legs that can put them at risk for getting ulcers in the future. And, so, we try to mitigate those risks.

– Talk about the team that’s in place at UPMC in the Heart and Vascular Institute, and what that collaboration looks like, and all of these experts around the table.

– UPMC has a team that is referred to as a PERT, akin to a PE rapid response team and effort, that allows for collaboration between pulmonary medicine, ICU, cardiology, interventional cardiology, and vascular surgery. If a patient comes in who appears to be suffering from what we call a submassive PE, which has a number of criteria that helps to define when a patient is in that category, those are people who may benefit from an intervention. And oftentimes, there will be a collaborative effort amongst the teams that I had just mentioned to try to determine whether that patient is a good candidate or not. And that’s actually shown to be a very effective way for helping patients do better when they present with a submassive PE. We are certainly a place that has really led the effort on this in a lot of different ways.

– All right, so, before we leave, let’s give people the elevator, what they need to know before they leave. So, what would you want people to take away when it comes to DVTs and PEs?

– I would want them to know that DVTs, for the most part, if you get diagnosed with a DVT, the treatment should be an anticoagulant, usually an oral blood thinner. And that I don’t want people who have DVTs to suddenly think that, “Oh my God, I’m going to die tomorrow.” Or that this is a potential fatal problem and be extremely worried about it. We have very, very good treatments for DVT that are highly effective. And, that if they suspect a DVT, they should seek emergency care. Either go to the emergency room, which is probably your safest bet, where they can do an ultrasound to either rule it in or to rule it out. And ultrasound is, we have many people who can perform them. The ERs are trained to do them, and we can get an answer very quickly.

– Remind folks of the symptoms.

– The symptoms are swelling, pain, usually redness or some type of discoloration of the limb. We see DVTs more commonly in the legs than we do in the arms, but that doesn’t mean they don’t happen in the arm. So they can happen in the arm as well. Especially in people who have had catheters in place, either for chemotherapy or for dialysis access, those can actually increase the risk of people getting DVTs in their arms as well. So, swelling, pain, redness, that’s a sign that you may have a DVT and you should seek medical care.

– OK, and PE. What do you want to leave them with?

– So, PE, also, if you have had a recent DVT, and then you, a few days later, start to have shortness of breath or chest pain, that might indicate that you are suffering from a PE. Again, you must seek medical care immediately. And, again, know that there are certain interventions that you may be a candidate for that can help improve your outcome, but a lot of times, being on a blood thinner is enough to take care of the problem.

– Well, doctor, we thank you so much for coming in and spending time with us today. Some really good information. Thank you for your time.

– Thank you so much for having me.

– You’re welcome. I’m Tonia Caruso. Thank you for joining us. This is UPMC HealthBeat.

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About Heart and Vascular Institute

The UPMC Heart and Vascular Institute has long been a leader in cardiovascular care, with a rich history in clinical research and innovation. As one of the first heart transplant centers in the country and as the developer of one of the first heart-assist devices, UPMC has contributed to advancing the field of cardiovascular medicine. We strive to provide the most advanced, cutting-edge care for our patients, treating both common and complex conditions. We also offer services that seek to improve the health of our communities, including heart screenings, free clinics, and heart health education. Find an expert near you.