Venous Thromboembolism

Venous thromboembolism (VTE) is a condition where a blood clot (thrombus) develops in the body. A thrombus usually occurs in a deep vein in the leg or pelvis but can occur in an upper extremity. Sometimes pieces of the thrombus can break off from its original place of development and travel through the bloodstream to other parts of the body. When a thrombus breaks off and travels through the bloodstream, it is called an embolism. The embolism can block the blood flow in the blood vessels of other organs. There are two two serious types of VTE:

  • Deep vein thrombosis (DVT). A DVT is a thrombus that usually occurs in a deep vein of the lower legs, pelvis, or in an upper extremity.

  • Pulmonary embolism (PE). A PE occurs when an embolism has formed and traveled to the lungs. A PE can block or decrease the blood flow in one or both lungs.

ExitCare Image Venous thromboembolism is a serious health condition that can cause disability or death. It is very important to not ignore symptoms or delay treatment.

CAUSES

  • A blood clot can form in a vein from different conditions. A blood clot can develop due to:

  • Blood flow within a vein that is sluggish or very slow.

  • Medical conditions that make the blood clot easily.

  • Vein damage.

RISK FACTORS

Risk factors can increase your risk of developing a blood clot. Risk factors can include:

  • Smoking.

  • Obesity.

  • Age.

  • Immobility or sedentary lifestyle.

  • Sitting or standing for long periods of time.

  • Chronic or long-term bedrest.

  • Medical or past history of blood clots.

  • Family history of blood clots.

  • Hip, leg, or pelvis injury or trauma.

  • Major surgery, especially surgery on the hip, knee, or abdomen.

  • Pregnancy and childbirth.

  • Birth control pills and hormone replacement therapy.

  • Medical conditions such as

  • Peripheral vascular disease (PVD).

  • Diabetes.

  • Cancer.

SYMPTOMS

Symptoms of VTE can depend on where the clot is located and if the clot breaks off and travels to another organ. Sometimes, there may be no symptoms.

  • DVT symptoms can include:

  • Swelling of the leg or arm, especially on one side.

  • Warmth and redness of the leg or arm, especially on one side.

  • Pain in an arm or leg. Leg pain may be more noticeable or worse when standing or walking.

  • PE symptoms can include:

  • Shortness of breath.

  • Coughing.

  • Coughing up blood or blood-tinged mucus (hemoptysis).

  • Chest pain or chest pain with deep breaths (pleuritic chest pain).

  • Apprehension, anxiety, or a feeling of impending doom.

  • Rapid heartbeat.

A PE is a medical emergency. Call your local emergency services (911 in U.S.) if you have these symptoms.

DIAGNOSIS

A venous thromboembolism is diagnosed by:

  • Looking at your medical history and risk factors. Your caregiver will perform a physical exam.

  • Blood tests, including blood work of how your blood clots.

  • Imaging tests that can detect a blood clot may be ordered. These can include:

  • Ultrasonography.

  • Computed Tomography (CT) scan.

  • Magnetic Resonance Imaging (MRI).

  • Echocardiography.

  • Electrocardiography.

TREATMENT

Initial treatment:

When a venous thromboembolism has been confirmed, initial treatment consists of using blood thinning (anticoagulant) medicines. Anticoagulant medicines affect how your blood clots and can cause bleeding. Therefore, your blood clotting times are monitored by blood tests called prothrombin time (PT) and International Normalized Ratio (INR) when you are on anticoagulants. Typically, the anticoagulants are intravenous (IV) heparin and warfarin. IV heparin is normally started right away because IV heparin has a rapid onset of action and thins the blood quickly. Warfarin is also started with IV heparin therapy. Warfarin has a slower onset of action and takes longer to work. This overlap therapy of IV heparin and oral warfarin is continued until PT and INR levels are therapeutic. After the PT and INR levels are therapeutic, IV heparin is discontinued and you are maintained on warfarin.

Other treatment options:

  • Catheter-directed thrombolysis. This is a clot-busting therapy for a DVT in which a small, flexible hollow tube (catheter) is threaded to the blood clot inside the vein. A clot-busting drug (thrombolytic) is then infused through the catheter. The thrombolytic helps to break up the clot in the vein and restore blood flow.

  • Direct thrombin inhibitor (DTI) medicine. A DTI is an anticoagulant that slows blood clotting. It is given through an IV.

  • If you cannot take an anticoagulant, a filter called an inferior vena cava filter (IVC filter) can be placed. The IVC filter is placed in a large vein, in either your leg or abdomen. An IVC filter is left in the vein permanently. The IVC filter can help prevent blood clots from going to your lungs.

  • Surgery. Blood clots may need to be removed surgically if other treatment options are not working or cannot be used. Types of surgery can include:

  • Thrombectomy.

  • Embolectomy.

  • Venous stenting.

  • Pain medicine (analgesic). Medicine to control pain is given in addition to the above treatment options.

Home treatment:

  • Continued treatment at home consists of taking either warfarin or under-the-skin (subcutaneous) injections of an anticoagulant.

PREVENTION

  • In-hospital prevention:

  • Activity. Getting out of bed and walking while you are in the hospital can help prevent blood clots.

  • Medicines may be given to help prevent blood clots.

  • Sequential compression device (SCD). A SCD can help prevent blood clots in the lower legs. A compression sleeve is wrapped around each of your legs. The tubing of the sleeve is connected to a machine that pumps air into the compression sleeve. The pumping action of the sleeve helps circulate the blood in your legs.

  • Compression stockings. Compression stockings are tight, elastic stockings that apply pressure to the lower legs and help prevent blood from pooling in the lower legs. Compression stockings are sometimes used with SCDs.

  • General prevention:

  • Exercise regularly if you are able.

  • Avoid sitting or lying in bed for long periods of time without moving the legs.

  • Do not smoke. If you smoke, quit. Ask your caregiver for help.

  • Avoid exposure to smoke.

  • Maintain a healthy weight.

  • Women over the age of 35 should consider the risk of blood clots while taking birth control pills or hormone replacement therapy.

  • Long distance travel along with prolonged sitting and standing can increase the risk of a DVT. Exercise your legs by walking or by pumping your leg muscles every hour.

HOME CARE INSTRUCTIONS

  • Take all medicines prescribed by your caregiver. Follow the directions carefully.

  • Warfarin. Most people will continue taking warfarin. Your caregiver will advise you on the length of treatment (usually 3 to 6 months, sometimes lifelong).

  • Too much and too little warfarin are both dangerous. Too much warfarin increases the risk of bleeding. Too little warfarin continues to allow the risk for blood clots. While taking warfarin, you will need to have regular blood tests to measure your blood clotting time. These blood tests usually include both the PT and INR tests. The PT and INR results allow your caregiver to adjust your dose of warfarin. The dose can change for many reasons. It is critically important that you take warfarin exactly as prescribed, and that you have your PT and INR levels drawn exactly as directed.

  • Many foods, especially foods high in vitamin K can interfere with warfarin and affect the PT and INR results. Foods high in vitamin K include spinach, kale, broccoli, cabbage, collard and turnip greens, brussels sprouts, peas, cauliflower, seaweed, and parsley as well as beef and pork liver, green tea, and soybean oil. You should eat a consistent amount of foods high in vitamin K. Avoid major changes in your diet, or notify your caregiver before changing your diet. Arrange a visit with a dietitian to answer your questions.

  • Many medicines can interfere with warfarin and affect the PT and INR results. You must tell your caregiver about any and all medicines you take, this includes all vitamins and supplements. Be especially cautious with aspirin and anti-inflammatory medicines. Do not take or discontinue any prescribed or over-the-counter medicine except on the advice of your caregiver or pharmacist.

  • Warfarin can have side effects, such as excessive bruising or bleeding. You will need to hold pressure over cuts for longer than usual. Your caregiver or pharmacist will discuss other potential side effects.

  • Avoid sports or activities that may cause injury or bleeding.

  • Be mindful when shaving, flossing your teeth, or handling sharp objects.

  • Alcohol can change the body's ability to handle warfarin. It is best to avoid alcoholic drinks or consume only very small amounts while taking warfarin. Notify your caregiver if you change your alcohol intake.

  • Notify your dentist or other caregivers before procedures.

  • Activity. Ask your caregiver how soon you can go back to normal activities if you have had a blood blot.

  • Exercise. It is very important to exercise and stay active to prevent future blood clots. This is especially important while traveling, sitting, or standing for long periods of time. Exercise your legs by walking or by pumping the muscles frequently.

  • Compression stockings. You may need to wear compression stockings to help prevent a DVT.

  • Smoking. If you smoke, quit. Ask your caregiver for help with quitting smoking.

  • Learn as much as you can about VTE. Educating yourself can help prevent VTE from reoccurring.

  • Wear a medical alert bracelet or carry a medical alert card.

SEEK MEDICAL CARE IF:

  • You feel faint or dizzy.

  • You feel rapid or skipped heartbeats.

  • You feel weaker or more tired than usual.

  • You feel you are not getting better in the time expected.

  • You believe you are having side effects from medicine.

  • You have joint pain.

  • You have abdominal pain.

  • You have new or increased bruising.

SEEK IMMEDIATE MEDICAL CARE IF:

  • You vomit bright red blood or your vomit has a coffee ground type appearance.

  • You have bowel movements that have bright red blood or are dark or tarry in appearance.

  • You have bleeding from your rectum.

  • You have pink or bloody urine.

  • You develop breathing problems such as shortness of breath or pain with breathing.

  • You are coughing up blood.

  • You develop warmth, swelling, or redness in an arm or a leg.

  • You have chest pain.

  • You have a sudden, unexplained severe headache.

  • You have a cut that does not stop bleeding after 10 minutes.

  • You have a nosebleed that does not stop bleeding after 10 minutes.