Deep Vein Thrombosis

Understanding the Significance of DVT

When Serena Williams shielded her eyes from the glare of a setting sun in Miami Gardens, Florida, on March 22nd, 2019, photographers and spectators saw a muscled, seasoned athlete about to win her opening match. They saw her chuckling, talking herself through a rough set, as she is known to do, before getting down to business and playing the game as the great athlete she is. What many spectators might not have realized is that Serena courageously faces a chronic health issue every day, one she meets head on, one she has discussed frankly following the birth of her young child.⁵

Serena Williams is one of an estimated 900,000 Americans that have experienced a DVT (deep vein thrombosis) or PE (pulmonary embolism) or both. Serena suffered a pulmonary embolism in 2011. Consequently, she was concerned during the birth of her baby about a potential recurrence. Depending upon the initial event as well as extenuating risk factors, physicians will calculate the likelihood of having another clot. Unfortunately for Serena, she wasn’t even 24 hrs. postpartum (off her anticoagulant following a caesarean section) before she began experiencing symptoms of dyspnea and chest pain, which she immediately recognized as reminiscent of symptoms from her 2011 PE. When she became alarmed and notified the nurses, they didn’t believe her!⁴

Subsequent scans demonstrated Serena was correct, but the delay could have been detrimental to her health.

It is imperative nurses recognize signs and symptoms of DVT, which could occur with or without PE, rather than relying on patients to report the recurrence of problematic (and potentially deadly) symptoms themselves. Many nursing colleagues would realize Serena could be high risk for several reasons: the recent surgery, but also her pregnancy, as well as the first few weeks following childbirth. All of these are additional risk factors for DVT.⁴

“DVT is a serious but preventable medical condition in which blood clots occur.” Most of these clots occur in veins in the lower legs, pelvis, thigh, and occasionally in the arms. Clots can occur in superficial veins close to the skin and lead to a condition called phlebitis, which usually does not produce clots that travel to larger vessels. Many risk factors contribute to DVT, including female gender, older age, carcinomas, major surgery or injury to a muscle or blood vessel, i.e. trauma such as long bone fractures, immobility, high estrogen levels, pregnancy, HRT, family history of blood disorders or hyper coagulopathy, the presence of an implanted central venous catheter, smoking, joint replacement surgery, especially hip or knee surgery, and lengthy airplane flights.²

DVT³and PE³are more likely to affect women of childbearing age than men of the same age, but once women reach menopause the risk reverses. What is important is how to recognize the signs of possible DVT when the process is in the early stages, and to seek assistance as soon as DVT is suspected. Symptoms could include one or all the following:³

Pain or warmth in the extremity.

A feeling of sharp pain or a cramp-like sensation in the calf or behind the knee.

Redness or swelling of the affected extremity.

Swollen or thickened blood vessels on the affected side.

Pulmonary embolism³ can occur with or without signs of DVT, but if any of the following symptoms occur, seek assistance immediately. Do not wait for the pain to ease, or to see if the symptoms go away. You may feel a sudden onset of anxiety or dizziness, a feeling of faintness, or have an episode of low blood pressure. Additionally, any of these may occur:³

• A sudden stabbing pain in the back, difficulty breathing, or chest pain with deep breaths.
• An irregular or quickened heartbeat.
• Shortness of breath that persists even when resting or sitting upright.
• Coughing up blood.

Diagnosis of DVT or PE can be accomplished quickly without invasive or uncomfortable testing. One of the first tests that may be performed could be a D-Dimer test, which examines the blood for active blood clotting formation in the body. A positive D-Dimer test isn’t conclusive of either DVT or PE, though, it is merely a clue that excessive clotting has taken place. It might be falsely positive following recent surgery or trauma. Other tests could be a duplex ultrasound of the vessels in the lower extremities to check for clots, or a spiral CT scan of the chest (with contrast) to examine the pulmonary arteries in the lungs.

If a clot is diagnosed, anticoagulants are usually indicated, unless a significant risk of bleeding is present (e.g. recent surgery). For example, with Serena’s caesarean, her physicians determined the risk to her health was more of a priority than the risk of bleeding from surgery. Her incision, as she reported in interviews following the birth of her baby, did begin to bleed and opened after the initiation of anticoagulants, but she believed this was a small price to pay during treatment for recurrent PE.

It is a common misconception that anticoagulants “break up” or minimize clots. They do not. They prevent the formation of further clots, and they stop existing clots from becoming larger, which is important if there are many small clots in the bloodstream. For most patients, the minimum period of treatment with anticoagulants is three months, but for each patient, the decision is unique. A hyper coagulopathy profile may be ordered to determine if the patient has inherited a tendency to have recurrent clots, in which case, like Serena, a lifetime of medication may be discussed.²

But suppose the patient has a life-threatening clot (e.g. saddle embolus) that consumes too much of the pulmonary vasculature? These emboli can be fatal, and patients with such large, compromising clots need to be treated quickly, either through thrombolytic therapy: tissue plasminogen activator (tPA) and/or thrombectomy in Interventional Radiology to attempt reperfusion and stabilize the patient hemodynamically. Although such large clots are rare, they do occur, and it is a case for quick, coordinated care.²

For patients with diagnosed clots that cannot be anticoagulated, an IVC (inferior vena cava) filter may need to be placed. These could be used for patients that have a high risk of bleeding but have recurrent clots that could cause PE. The filter is placed into the large vein in the abdomen (groin) called the inferior vena cava and stays in place to secure clots before they can travel to the lungs. Occasionally, clots can attach themselves to the filter, detach, and/or manage to travel. These devices are not without problems, but for a specific set of patients, they work well.²

Knowing how to recognize signs and symptoms of DVT and PE, as well as their clinical significance goes a long way in prevention of a problem that affects 900,000 Americans each year. We can also avoid further episodes by teaching patients to avoid a sedentary lifestyle. We can encourage patients to ask family members specifically about a history of blood clotting and/or issues with “clots in their lungs.” Additionally, we can coach patients about keeping the circulation moving as much as possible, especially when sitting at work or while relaxing at home.¹

We want to remind patients as well as our colleagues that sitting for prolonged periods of time can be dangerous. If we’re at a conference, perhaps we can remember to do concentric circles with our feet, clockwise and then counterclockwise, point our toes, perform ankle pumps, or maybe stand and stretch intermittently. We also need to take frequent drinks of fluids (water, seltzer, or juice) and wear compression stockings when indicated. If we’re flying, don’t forget to stand and walk the aisle at least once or twice (ignore the glares!).  Chuckle if you must.¹

Pretend you’re Serena Williams having a chat during the rough patch of your opening round. There’s no reason you couldn’t be. We can all be winners in this match.

References

1. Mayoclinic.org “Deep Vein Thrombosis (DVT).” March 06, 2018. Patient Care and Health Information.
2. Medicalnewstoday.com “Deep Vein Thrombosis and Pulmonary Embolism.” Fitzgerald, J. Last updated Wed. 26 sept. 2018. Revised by Staicy Sampson, DO.
3. My.clevelandclinic.org “Deep Vein Thrombosis.” Cleveland Clinic News.
4. Self.com “Serena Williams Is (Understandably) Worried About Blood Clots While at The Australian Open.” Miller, K. January 18, 2019.
5. Washingtonpost.com “Serena Williams, Naomi Osaka Win Opening Matches in Miami.” Wine, S. March 22nd, 2019.