Venous Thromboembolism

Venous thromboembolism, blood clots in the veins, can lead to deep vein thrombosis (DVT) and pulmonary embolism (PE), two serious but preventable conditions. Patients who have or are at risk for these conditions can benefit from the advanced vascular specialty care offered at NewYork-Presbyterian. Our vascular specialists have pioneered many of the minimally invasive techniques and treatments that have become standards of care for venous conditions. With the latest technologies and vast resources available at our two renowned medical centers – NewYork-Presbyterian/Columbia University Irving Medical Center and NewYork-Presbyterian/Weill Cornell Medical Center – we’re here to provide the best possible care to reduce your risk of life-threatening illness and enhance your quality of life.

Accolades:

• NewYork-Presbyterian is a member of the Pulmonary Embolism Response Team (PERT) Consortium, a national initiative to advance the care of patients with pulmonary embolism by performing research, developing advanced treatment protocols, and educating clinicians and community members.

• Both NewYork-Presbyterian/Columbia University Irving Medical Center and NewYork-Presbyterian/Weill Cornell Medical Center offer a multidisciplinary program for chronic thromboembolic pulmonary hypertension (CTEPH), the end result of persistent obstruction of the pulmonary arteries by acute or recurrent pulmonary clots.

What are Deep Vein Thrombosis & Pulmonary Embolism?

Deep vein thrombosis (DVT) is a blood clot, or thrombus, in a deep vein. DVT is most common in the legs, but can also occur in the arm or other parts of the body. The most significant danger for people with DVT is a pulmonary embolism (PE), a life-threatening blockage of the lung’s blood supply. A PE occurs when part of a blood clot breaks off, travels through the veins to the heart, and from there into the pulmonary arteries, which supply the lungs with blood. The clot can cut off blood supply to the lung, causing shortness of breath, chest pain, and other symptoms. PE is uncommon but can be deadly if not identified and treated promptly. Recognizing and treating PE quickly can reduce the risk of serious complications and death. In rare cases, DVT or PE can lead to chronic thromboembolic pulmonary hypertension (CTEPH), the end result of persistent obstruction of the pulmonary (lung) arteries by acute or recurrent pulmonary clots.

Other blood clot complications include chronic venous insufficiency, a condition in which blood pools in the veins of the leg instead of flowing back to the heart, causing pain and swelling in the leg, and post-thrombotic syndrome, a condition in which the vein is permanently damaged, causing patients to develop varicose veins, pain, swelling, and, in some cases, skin ulcers.

Signs & Symptoms

Deep Vein Thrombosis (DVT) may occur without symptoms. If symptoms are present, they may include:

• A “pulling” sensation in the calf of the lower leg
• Swelling of the leg
• Pain while walking or standing
• Warmth, redness, and swelling of the leg Symptoms of a pulmonary embolism (PE) include:
• Shortness of breath or needing to breathe rapidly
• Chest pain, especially sharp, knife-like pain while taking a deep breath
• Coughing or coughing up blood
• A rapid heart rate
• Dizziness or fainting

A PE can be life-threatening and requires immediate medical attention. If you have the above symptoms, call 911.

Risk Factors

People at risk of developing DVT and PE include those with one or more of the following factors:

• Age over 60
• Fracture of leg bones
• Recent surgery
• History of venous disease/varicose veins, or blood clotting disorders
• Prolonged bedrest, immobility, or paralysis
• Overweight or obesity
• Pregnancy
• Hormonal medications such as birth control pills or hormone replacement therapy
• Certain diseases and conditions including infection, heart problems, inflammatory bowel disease (IBD), Lupus, and cancer and some cancer treatments

Diagnosis

At NewYork-Presbyterian, our vascular specialists begin with an assessment and consultation. Your doctor will review your medical history, obtain any necessary imaging and blood tests, and establish a treatment plan with you. Specific tests may include:

• D-dimer tests to measure a substance in the blood that is released when a blood clot dissolves
• Duplex ultrasound to look for deep vein blood clots
• Computed tomography (CT) to look for blood clots in the lungs and legs. This is the most common diagnostic test for pulmonary embolism.
• Pulmonary angiography to confirm a pulmonary embolism if, after other testing, your doctor suspects you might have one. This test requires inserting a tube into your blood vessel. It also uses X-rays to create a video of the blood flow to your lung so your doctor can identify any blood clots.

Treatment

The goal of treatment for DVT is to dissolve the blood clot so that it does not cause damage to the leg veins or travel to the heart or lungs. Treatment for PE depends upon the type and severity of the blockage and may include medications and/or surgery.

Medical management

Medical management of DVT and PE involves two types of medication:

• Anticoagulants (blood thinners) prevent clots by thinning the blood and include drugs such as warfarin (commonly known as Coumadin), direct oral anticoagulants (DOACs), and heparin
• Once clots have formed, clot dissolvers (thrombolytics) can break them up quickly. Clot-dissolving medication is only used in life-threatening situations because side effects include severe bleeding.

Pharmacomechanical thrombolysis

In this minimally invasive approach, vascular specialists use a small needle stick to place devices that dissolve clots by softening them and vacuuming them out of the body in a matter of hours. This removes clots, allowing patients to return to normal activity more quickly than after traditional methods of DVT management.

Inferior vena cava (IVC) filter

An IVC filter is a device inserted in the main vein leading from the legs to the heart. It is designed to trap blood clots that dislodge from veins in the legs that would otherwise cause a pulmonary embolism. Most commonly, IVC filters are inserted if someone is not a candidate for a blood thinner or continues to have blood clots in spite of being treated with blood thinners.

Pulmonary thromboendarterectomy (PTE)

In rare cases, medical management of a PE fails to adequately treat blood clots, or there may be severely unstable blood flow from a very large embolus. In these cases, a surgeon can remove the clot and restore proper blood flow to the lungs with pulmonary thromboendarterectomy (PTE), a complex surgical procedure that removes life-threatening chronic clots from the pulmonary arteries. NewYork-Presbyterian is one of the few centers in the country that routinely address chronic thromboembolic pulmonary hypertension (CTEPH) with pulmonary thromboendarterectomy (PTE).

Prevention

Venous thromboembolism, such as DVT and PE, can often be prevented with strategies that stop clots from developing in at-risk people. Our vascular specialists can determine risk by learning about a patient’s age, weight, medical history, medications, and lifestyle factors. Prevention measures can include:

• Anticoagulant medicines are given to certain patients having surgery to prevent blood clots
• Wiggling the toes and moving the ankles helps to prevent blood clots caused by long periods of sitting or lying down
• When you travel and must sit for long periods of time, you can reduce your risk of a blood clot by doing the following:
  • Walk up and down the aisles (if traveling by plane or bus)
  • Stop about every hour and walk a little (if traveling by car)
  • While sitting, move your legs, ankles, and toes
  • Wear loose clothing
  • Limit the amount of alcohol you drink
  • Drink a lot of water and other healthy drinks

Prevention may also include:

• Getting up and moving as soon as possible after surgery or illness
• Sequential compression (SCD) or intermittent pneumatic compression (IPC) devices, which apply gentle pressure to the legs
• Elastic or compression stockings, if prescribed by your doctor

DVT and PE assessment program

NewYork-Presbyterian features a hospital-wide initiative to reduce the incidence of DVT, which, along with pulmonary embolism, is the number one cause of preventable hospital death. Vascular specialists assess DVT risk among all patients admitted to the hospital using a risk assessment tool that is now part of the patient electronic medical record system. Patients who are at risk receive DVT prophylaxis (such as unfractionated heparin, low molecular-weight heparin, DOAC or Coumadin). Patients and their caregivers also receive literature and information about DVT and its prevention.