All About Blood Clot Treatment and Prevention

so our next speaker this morning is Dr Michael jaff Dr Michael jaff happens to be the chair of a newly formed Institute here at Mass General Hospital the heart stroke and Vascular Institute he's also the chair of our vascular center here so mass jle is a pretty big place right you all know that I'm sure and to have three major departments come together under one leader is really quite a significant accom accomplishment and it shows how skilled and accomplished one is but it when you really think about it if we bring all the experts together around heart disease vascular disease and stroke this is all this encompasses the patients that have blood clotting problems so it's really great to put all the experts together in order to develop the best means possible to take care of patients with these problems and um and and we're delighted because Dr Jeff loves having time to spend with patients so um we're really I'm really grateful that he made time out of his busy administrative schedule with all he has to do with the Institute and is here this morning with us to share what he will tell us about um treating and preventing blood clots so please join me and welcoming Michael jaff thank you Lyn good morning everyone everybody wiggling their ankles and squeezing their c yeah right I got it I understand so uh just to give you some perspective as a as a doc um I speak a lot to doctors too and I quote Dr anel all the time and Dr raskob so for me this is like a kid in a candy store to be on the same in the same room in the same panel as them so I want to just take one second to thank Dr anel again for a really superb presentation um and I like Dr anel also love much more speaking to patients than doctors and I'll give you example of why that is when when we speak to doctors there's inevitably somebody in the audience who wants to make the speaker look bad almost all am I right I mean it's just it's just the way it is right so I have a friend who um did some scientific studies several years ago and discovered something really important and uh was asked to travel around the United States to talk about his findings and the impact of his research on Healthcare it got crazy I mean he was asked like every week to go two or three times to different cities and travel all over from large metropolitan areas to little small towns to the point where he couldn't manage his schedule it got too confusing so he hired someone to uh do his scheduling for him so make sure that he was on the right plane um got to the right airport had a hotel room to stay in that night was able to get back back to the airport for the next place and this went on for weeks and everything was working perfectly and every time he would go and he'd give this talk it'd be exactly the same talk right same 40 slides and the lights would come up and there'd be the doctors and someone always would try and peg him with some difficult question and he'd handled it perfectly and it was always the same questions so about 6 months into this uh my friend gets off the airplane his his assistant is there with a car they're driving to the next venue to give the talk and uh the doctor says to the his colleague uh you know this has been six months two or three times a week I am just sick of this you know you've been watching me do this now for six months two or three times a week I bet you could give the same talk same way I do it and so the driver goes yeah I really think I know this cold I know exactly when to advance the next slide I heard every question answered and so my friend says well let's do something no one here knows me when we get to the hotel let's go into the men's room we'll switch clothing I'll put on the driver's clothing you put on my suit and you give the talk and I'll just sit in the back and have a beer and relax the driver goes that sounds great I can definitely do this so they get to the men's room they switch clothes real fast in walks the doctor dressed as the driver goes into the back and uh the driver gets up gets introduced and gives an absolutely Flawless presentation every slide perfect everything went great lights come up doctors start asking questions everyone that this driver had heard over and over again nailed them all perfectly except that one Doctor Who stands up and says you know doctor I read that paper you published in the New England Journal of Medicine really really carefully and I think there's a really serious mistake that you made in your statistics that completely invalidates the science no one had ever asked this question before holy moly can you imagine so the driver's up there and he's thinking if I blow this I ruin this guy's career right I mean all the work that he's done so he scratches his chin and he goes you know doctor that question is so easy I'm going to ask the driver in the back of the audience to answer so so that's the reason we're much happier speaking to uh the public because you folks are here to learn you've got experience um and so my job this morning is just to give you a little background on on how to prevent and treat blood butts you already heard all about the risk factors that's the way to prevent them to know knowledge is power in this area and when you know what the risk factors are or your neighbors or your neighbors doctors know know the risk factors they can be very proactive so that for example someone who's got multiple risk factors and has had blood clots in the past and maybe one copy of that Gene for Factor 5 lien who's about to fly to Australia I suspect that Dr anel and I would give you something more than just wear stockings to prevent your risk right so it's knowledge that tells it but I'm also going to talk about um how to treat these now I don't have the time to go through this in great deta detail you're not going to be able to give a lecture about treatment after we're done but I think you'll get a perspective on the standard treatment and what's coming what's new what's exciting in this area which frankly five years ago we were only able able to talk about kind of hypothetically so it's exciting that there are new things that can be used so you already heard about this and and by the way I'm going to I'm going to uh actually take some time to show you some of my patience because I think the best way to learn about how this stuff can happen is to see what other people have gone through uh so these are the two big consequences of uh blood clots this is what we all worry about the one on your left is a CAT scan and it shows um this say shows a big blood clot here we call this a saddle blood clot because it kind of crosses over to the right and left so that's that Stripe Right There we worry about that and this is one thing that may not kill you but it certainly impacts on your quality of life and that's an ulcer due to Chronic leg swelling that can occur after a blood clot and what this does is it makes you go back to the doctor a lot more often you have to wear uh bandages and get them changed all the time it can be really uncomfortable and remember that blood clots can affect anyone and everyone at any age in any Walk of Life this just shows you you don't have to be a scientist these are the years this is the expected increased risk of blood clotting over time this is the real deal folks we're not we're not tailing off this problem is going to be around it's going to be around for a long time and there's a lot of misperceptions out there about blood clots and what they do how many of you remember zah jaag Gabor right yeah I mean you know I'm I certainly remember her but you want to see this is a press release that was put out about jaaag Gabor and what it says here is that she was admitted to a hospital in Los Angeles for the treatment of swelling in her legs that's not why she was admitted and it says here that she had massive blood clots in her legs which could make her vulnerable to a heart attack so the perspective here was that jaaja Gabor was admitted to the hospital for a heart attack that's not true jaaja gabora had a hip fracture had her hip fixed and developed blood clots in her legs and had a pulmer Amis or a blood clot to the lungs not a heart attack as Dr anel said lots of misperceptions when people call something something that it's not the case of think about the healthiest person you could imagine who never In Your Wildest Dreams could end up with a blood clot how about Serena Williams could you imagine had a big time blood clot to her lungs how could she get one this is all over the Press even our local mayor Tom manino Right bunch of medical problems you all know he was in the hospital at the brigam for a long time uh earlier in the year and last fall and he had a blood clot that traveled from his leg to his lungs so it doesn't matter how healthy you are it doesn't matter how young you are it doesn't matter what status you have in the community this is a non-discriminatory disorder now there's this guy back in the 1970s named Rua veral and if you think about in I'm sorry it's 1970s please how about the 1700s uh who came up with the reason why people get blood clots in veins and they came out with three components part of this you already heard about earlier today slow blood flow vain blood flow is not as fast as artery blood flow so the blood kind of is takes its time getting out of the veins some sort of damage to the inner lining of the vein irritation injury that can be from a fracture it can be from a cast it can be from a prior blood clot or a burn any of that stuff can be the second component and then the third one is thick blood you heard a great deal about the protein in the blood that make your blood thick but there are other things that can do it like pregnancy that thicken the blood you take these three things you put them together the risk of getting a blood clot goes up so how do we prevent blood clots well you again I would stick with what you just heard I don't have to spend any time on this we divide patients risk into low moderate high and very high risk all due to the factors that Dr anel mentioned age body weight underlying health activity level those kinds of things increase the risk and when you add up risk factors the risk goes up so for example if you're having a hip fracture replacement in a an 85-year-old person who fell and broke a hip who also by the way is being treated for cancer you start adding up these risks that that person's a setup for a vain blood clot but if you take a 35 or a 40y old person who needs to have their gallbladder taken out and it's done through a scope and they go home either later that day or the next morning and they have no other medical history well that person risk is significantly lower it doesn't mean they can't get one but the odds are much lower than the person who had surgery for hip fracture while they're 85 and being treated for cancer and of course also as you heard you always weigh the risk of clotting to the risk of bleeding just like Dr anel said if the risk of bleeding is really high someone's got a history of an active ulcer in the stomach and actually bled from that ulcer and now they're going to go and have um uh a bunion repaired we're going to be preventing that blood clot in a much different way than we would in someone who's never had a bleeding event um has had a previous blood clot five years ago and is now going to get on a plane to go to Australia right it's all weighing the risks of clotting to the risk of bleeding it is not always clear it there's not always a right wrong the flip of the coin is actually often how the discussion goes many times you'll say to me well what would you do if it were you doc or your wife or your mother and the first thing I'll say is well you presume I love my mother right because you know it's but um it's not always black and white and it really does require that discussion of risks of bleeding or clotting with the patient and the doctor one thing that we like to do is do things that cause no harm that offer potential benefit right if it doesn't cause any harm and can offer help why not give it a try so if you're going to have an operation and I'm worried about bleeding and I want to lower your risk of blood clots I can use something like this this is a thing that wraps around your leg how many of you have been in the hospital and have had surgery and you had one of these things on your calf that yeah right I mean it's not a miserable thing it's a little inconvenient but in the scope of things it's a lot worse than getting a a lot better than getting a blood clot what this thing does is it rhythmically compresses and releases and it forces that vein blood out of your leg makes the blood flow faster and more repeatedly and so it lowers the incidence of blood clots and in some situations this is all we have to do in others this is one component of what we do but the nice thing about this is it really doesn't increase your risk of anything and yet it could lower your risk of a blood clot so there are lots of recommendations out there lots of scores again I'm not going to go through this in detail but you can see here that we increase what we do based on what our view is your risk of having a clot is so if we think your risk is extraordinarily low extraordinarily low we might tell you that don't do anything specific except get out of bed quickly so that person who gets the laparoscopic H bladder removal we just tell them get up and out of bed quickly period that's all you need to do but in someone who's had a hip fracture and is older and is not mobile and has cancer we're going to really think about using one of those compression pumps putting on a compression stocking and giving shots of some medication or a pill blood thinner so you see what I mean you take the number of risks you add them up and as the risk goes up you jack up what you use to prevent blood cloths now that's the prevention part if you're not lucky enough to have prevented it and now you have one what do we do so there are a whole bunch of guidelines out there when I was in training this was all we did IV heprin come into the hospital they put an IV in the vein in your arm and they put this bag of heprin and it runs through you 24 hours a day and every six hours you get a blood test and it tells us whether the heprin at the right dose in other words is your blood thinned appropriately but not too thin that you could bleed this is still widely accepted as a very effective way to treat blood clots and remember our goal for treating the blood clot you have is to make sure you don't get another blood clot that's the goal in the short term that's a high highrisk situation if you have a blood clot in the middle of your thigh in a deep vein in the middle of your thigh and you don't do anything about it there's a 50 5050 chance not a one in a th000 chance a one in two chance that that blood clots going to travel up your leg break off and go to the heart and the lungs so we got to do something right away this is one way to do it it's really not convenient right I mean first of all who wants to be in a hospital for 5 to seven days Tethered to an IV it's not but this works what you're probably more used to are these types of shots of medicines called Low molecular weight Hein just an example of advances of Medical Science it's the same type of treatment but now you don't have to be tied to an IV and you don't have to be laying in a hospital bed those are all good so you take shots of this medication and it thins your blood and it works and many times we use these shots in different doses for people who are getting on planes going to Australia so it's not in frequent that I'll say to my high-risk patients I want you to take a shot of this in the restroom an hour before you get on the plane so these medications work and they're far more convenient now there's another one also by injection that works a different way so the mechanism whereby it prevents blood clots from getting worse is different but it does the same it accomplishes the same goal it lowers the risk of new BL blood clots from forming it's called Fonda parino or or rra and the nice thing about this one is that it's got a longer halflife it means it stays around longer so you only have to use it once a day as compared to twice a day um that could be a downside too if you have a really long halflife and you start bleeding you got to worry about its effects longer so again these are kind of the risk of clotting versus risk of bleeding story that you keep hearing me talk about and then of course good old cumin we already heard the questions about what other side effects can occur with cinin I can tell you I've never been in cinin and uh you can see a little bit of hair loss there um here's the issue with cinin word to the wise it does take five days for cinin to actually prevent new blood clots from forming so during those five days you're not protected if you have a new blood clot you can't just start cumin alone if you have a new blood clot that's why your doctor uses a shot of one of those other medications while you're taking cinin just to get you started right and once the blood test shows that the cumin is where it needs to be it's at the right dose that INR test that says that it's right where it needs to be that's when you can stop the shots usually you got to overlap them for four or five days and that's an important word to the wise so if you uh or someone you love love is diagnosed with a new vein blood clot in a leg or the lung and someone says just take this prescription for cumin and you know it's time to ring that wait a minute whistle because uh that's not necessarily right now here's here's something that any of you have ever how many of you have ever taken cinin before so you know better than me this is not a fun medication to take right you got to think about everything you do when you're taking cumin in every day like when you go to the local pharmacy to buy something for a cough or a cold you got to think is there something in that over-the-counter cough or cold medicine that could interfere or make my risks of bleeding on cinin worse or if you go to an urgent care center for a productive cough and they say you have bronchitis here's an antibiotic your bell needs to go off in your head and remember that you read that book when you started cumin in that says don't take any prescription medications until you tell your doctor that you're on cinin cuz so many medications interact with cumin in a way you wouldn't want it to some of them make your blood thicker so your clot risk goes up some of them make your blood thinner so your bleeding risk goes up it's an entirely sensitive interaction that you need to be aware of you don't have to know all the names of the medications that interact in fact I have to look them up because there are so many that interact with cinin you just have to know no new medication either over the counter or by prescription until you check with the person who's giving you your cinin so here for example the anti-coagulation management service is a phenomenal resource and if you get told by somebody outside of here that you need a new something call them and say is it okay for me to take or do I have to adjust my cumin and dose or get my our checked a little sooner it's pretty simple to do there are so many issues with this medication I mean I could spend the whole hour just talking about how many problems there are you got to watch what you eat you have to be consistent on your diet you have to be careful about alcohol these are all factors that play play a role and no matter how compliant you are no matter how good you are about taking it at 6:00 every evening like they told me to do there is an unpredict response to this medicine you could be perfectly stable on cinin for months at a time and all of a sudden your test comes back with an irr four and a half right and you say I didn't do anything different and someone like me says come on level with me what what did you doc I swear I didn't it's not that you did anything different it's a crazy drug period it's a crazy drug so you got to be careful with this now just to show you that it's not you when you look at medical studies that have compared cumin and dosing to other treatments where the goal of treatment was to keep that INR between two and three in the best of medical studies where the results are always better than outside of medical studies they just always are only 66% of the time is the INR where it's supposed to be that's in the best of situations that's kind of unbelievable but in the real world it can be as low as less than half the time so it's not you it's the drug it's a crazy drug period so what's new well there's this whole new class of things called novel novel meaning kind of cool oral meaning you take them by mouth that's a good thing no needles as my kids say anything without a needle is a good thing and anti-coagulants blood thinners called call them novel oral anti-coagulants or NOA that's kind of the buzz phrase for this here's the beauty of this check this out someone gets diagnosed today with a new blood clot in a vein and a leg and I decide that I don't need to give them a shot I don't need to put him in the hospital I give him a pill and from the day they take that pill they're protected sounds almost too good to be true right no needles no overlap no recurrent blood tests in the first few days no laying in a hospital bed it's unbelievable there are several of these some of these are available in the United States for the treatment and prevention of blood clots in people with irregular heart rhythms and I'm not going to talk about that at all today but there's one medication that's approved by the Food and Drug Administration to use in the United States for the treatment of new blood clots in the veins and the legs and even new blood clots in the veins and the lungs that's this one River oxyen approved in the United States so here's what we're going to tell you this is a medication that's actually available in the United States but not for vein blood clots for that heart rhythm issue and you don't have to be a scientist to be able to tell that if I show you that the red line is cumin and the Blue Line's this new drug and we're looking at the risk of blood clots look at that they're identical that tells you that this pill is just as effective as cinin but we always say well what about the bleeding risk well check this out this is looking at any bleeding cinin and this new medication and notice here that there's actually lower bleeding risk with the new medication than cumin so it's just as effective in preventing blood clots with lower bleeding risk well that sounds pretty good right but let's get to what's available in the United States this was a press release that came out by the Food and Drug Administration that's got to be pretty important November 2nd 2012 so almost a year ago saying that they are now approving this drug River roiban to treat blood clots in the veins and the legs or the lungs why did they do this they did because of two big time trials they were called the Einstein studies pretty smart people who were involved in this obviously maybe a little arrogant but um uh so this is one looking at this pill for the treatment of vain blood clots and again I'm just going to show you the standard way to take care of it is the shot of Lovenox right and the cinin overlapped and then you continue the cinin right that you guys have done that this is that treatment this is the pill alone no shots no IVs just the pill and we're looking at the event rate of new blood clots forming over the course of a year there actually were fewer blood clots in the new drug treatment that didn't require a shot didn't require an IV didn't require a hospitalization and this is actually looking at after you completed 6 months of treatment with either the new pill or cinin and you stopped the medication because you completed six months of treatment and then they randomized Again by chance half of those patients to the medication and half those patients to a sugar pill that had no activity look at the long-term reduction and risk over the next year of new blood clots dramatically lower with the new medication it's why Dr anel said that all things being equal and people who have blood clots particularly if we don't know why they had them we like to treat them longer because look at this risk of getting another blood clot in the first year after you completed treatment compared to if you're on this medication but again you appropriately say well this sounds too good to be true I bet you there's more bleeding with this new medicine not so this is the combination right shots of Lovenox with orrine compared to River oxan no difference in bleeding so more effective in preventing blood clots in the early stage much more effective than preventing new blood clots a year after you complete therapy than no treatment and similar bleeding risk so you say okay Dr Jeff you took the easy way out that's vein blood clots in the legs what about in the lungs same story this is the pill versus however you want to treat a blood clot in the lungs either through an IV heprin with cinin or a shots of Lovenox with cinin similar event rates recurrent blood clots similar bleeding risk this data is really good thousands of patients randomized multiple centers all over the place highest levels of science major bleading actually occurred less often with the new pill than standard therapy statistically lower so I think this is a game changer folks first time in 60 years we have something to talk about other than kumin now there's got to be a hitch right in medicine nothing's 100% no way that's why we can't list every risk factor we can't say every problem that can occur what what's the hitch so the benefits of this medication wide therapeutic margin means you only take this pill once a day you don't have to do it more often there are very few food and drug interactions so although there are some drug interactions they're very uncommon they're not usually with medications that you take regularly and the food interactions are even less common so all that stuff about green leafy vegetables and Li liver and all that stuff you don't have to worry about with this I know see it's unbelievable but look at this one you don't have to go get INR tests see I'm telling you she needs to be in my corner right here she's she's just gasping with excitement over this it's phenomenal you don't have to go and get INR test this dose is so predictable in thousands and thousands of patients tested that we know it thins the blood these are huge changes in quality of life for our patients but where's the downside we can't monitor whether you're on exactly the right amount or not now most of the time it works perfectly but nothing in medicine's 100% it's very hard right now to measure the impact of this medication on blood thinning okay it's not like I just send you to the lab to get an INR and I know or stick your finger and I know in a matter of seconds where your blood thinning is we don't actually have this INR of 2 to three with this new medication there is no such thing here's the big one if God forbid you're on cinin and you come into Dr anel or me in our emergency room and you're bleeding we can reverse the effects of cinin literally within an hour you're out of trouble that is not the case with these medications we don't have a rapidly effective therapy to reverse the impact of these medications so that's worrisome right if you start bleeding and you're on one of these it's a concern now we we think we know what to do in the event that this happens there are it's not like we're going to stand there and say sorry you're out of luck there's nothing we can do I mean there are things we do it's just not as reliable as we know what to do with cumin now the good news is just this past week There's an anote that's been going through Phase 2 trials in the in the United States that's actually performing very well and I suspect within the next couple of years that'll be available in the United States it is available overseas so the hope for this is going to change it's going to come around but right now today that antidote is not available so management of bleeding is a is a problem and of course we've been using cumin now for 60 plus years we know exactly everything about that medicine there is to know these medicine's not the case right they're just out in use over the past several years around the world and within the last year here and then the last piece of bad news sorry guys how much is generic cinin I mean it's Pennies on the dollar it's one of the cheapest medications we prescribe this one big time Big Time expensive hundreds of times the cost of cinin now when it first came out late last year many private insurance plans would not cover this so we couldn't use it just because the I mean it's hard to pay for it out of your pocket a lot of plans over the past six to eight months have started to accept this so if God forbid you need this or you're going to talk to your doctor about it just call your insurance plan and ask him it's becoming much more approved by uh plans because of the reasons that I've shown you so here's my here's my kind of simp simple end point for this why should a patient not switch from cumin in today you've been on cumin in a long time you're doing fine why should you not switch to this new medication here's my gestal you tell me which one of these is true based on what I told you this a this is a multiple choice question warring's easier to take is that true or false false right I told you it's miserable to take so that's not the right answer river oxan is more expensive right I told you it's a lot more expensive but that's not a reason to switch it's easier to reverse the effects of river oxan than warrin that's false right I told you we don't know yet how to reverse this there are more food and drug interactions with River oxan than warrin that's not true and Warren's more effective in preventing blood clots than River oxan that's also not true so this is the reason you shouldn't switch for sure it is so much more expensive that if you're doing fine on cumin in and you've got your life together on it it's not worth the cost I don't think until the cost starts coming down so here's my personal View and I if I see somebody with DVT and I'm thinking about River Roxy ban versus my usual way this is why I wouldn't just put somebody on River oxan a big blood clot in the leg or a blood clot up into the pelvis I'm going to bring them in the hospital see how things are going I'm not just going to send somebody home we don't really know how effective this medication is in people with cancer or cancer in chemotherapy it's probably okay but we don't know I know exactly how to take care of people with cancer related blood clots I don't use warrin in those people either I use one of these other injectable medications so I'm not switching yet on that and all sorts of other things like kidney problems if you have kidney problems this particular medication is metabolized largely through the kidneys so it can cause a real problem you can end up with too much River oxan and more bleeding so I don't use it in people like that same thing for pulmon ulis if somebody's got a is really sick very short of breath their blood pressure is a little low I've got to have them on oxygen I'm not just going to give them the pill I'm going to bring them in the hospital I'm going to make sure I know what I'm doing I'm going to make sure they're doing well I'm not just going to give them a pill and send them home same thing for all these other reasons now how long should you be on blood CL blood thinners somebody said uh you got to be on it for life how do how do we make that judgment so here's kind of a clue here's a clue Dr anel uh alluded to this before if this is a first blood clot you ever had and it's due to something we know causes blood clots that's a short-term treatment you have a knee replacement you get a blood clot in a vein in a calf I'm not leaving you on blood thinners for life I know why you got it that's a three-month treatment and you're Off to the Races if it's a recurrent your second blood clot or more or it happens and I can't explain why so not throwing the medicine ball uh not having cancer you know you just come in out of the blue healthy no air travel nothing and you got a blood clot to the lung I'm going to treat you for longer at least six months and I always talk about the need for indefinite or prolonged treatment if you have canc caner related blood clots first of all I don't start with cinin it doesn't really work and I usually treat with one of these injectable medications until their Cancer's controlled so until they're in remission and I'm happy with how things are going I'm a big fan of compression stockings they actually look a lot nicer now than they used to a couple of words about IVC filters anybody here have an IVC filter that's a big metal screen that's putting the vein in your your belly to prevent the blood clot from the leg getting to the lungs couple of people some of you must have heard about this if you've had blood clot someone said to you somewhere along the way well we could put a filter in maybe we will maybe we won't okay oh it's not the coffee filter it's not that's not what I meant look the bottom line with filters is it's this screen that's placed through a small needle puncture in the vein in the groin that catches a blood clot when it breaks off from the leg and traps it so it doesn't make it to the lungs you do this in a situation where either you can't give blood thinners for other reasons or you're worried so much about this breaking off and going to the lungs and the good news is that most patients with blood clots to the lungs really do very well it's a very very small percentage of people that are looking very sick at the time that they present these are what these things look like you can see they're wild designs look at this thing someone was drunk at night and just drew this thing on a piece of paper and the next thing you know it's on made in a medical device these have been around for for a long time but these are the new ones now they don't might not look different from you except look at this little hook at the top see that these come out so the cool thing about the new ones is in the past when we'd put these filters in it was with you forever couldn't come out now if you are someone you know is riding a motorcycle God God forbid they get in an accident and they have closed head trauma that's a very high-risk situation for blood clots but only for a short period of time till they recover from their injury you put in one of these retrievable filters for a week the patient awake and alert moving around you pull it out it's a great thing right so when do we put in these filters we put them in when you cannot get thin with when you can't take blood thinners so someone comes in with a blood clot to the lungs and two days ago they had major chest surgery for a lung cancer or they just coughed up blood because they've got a stomach ulcer or something you can't get blood thinners right away you put in a in a uh an IVC filter there are lots of situations where we don't know if filters are needed or not but people get them so if we're going to dissolve a blood clot in a leg which I'm going to talk to you about in a second do you need a blood a filter put in to catch a piece of the blood clot while you're dissolving it or if you have a big blood clot at a vein a leg that looks like it's moving a little bit at the top is that someone who needs a filter we just don't know we don't know but you can see here that the rate of placing filters in the United States is astronomically Rising look at this these are these removable filters so if everybody who got one of these removable filters had them put in and pulled out for the right reason you'd say okay but the fact is only a third of these filters are ever removed so they're put in because they think you need one the advantage is it can be pulled out but then it doesn't get pulled out and bad things can happen so now I'm going to teach you how to read a cat skin this is easy this is really easy let me tell you I'm no x-ray radiologist this is the spine this is the belly wall so you're laying on that table like this right this is your back this is your belly this is your aorta big artery in the belly see this thing right here that's the top of one of those filters okay you're looking through a slice see these two stripes here where the heck are they the vein that's in here is right here these have penetrated that vein wall and are sticking something else that shouldn't be stuck that's pretty worrisome or they can break look at this one here's a filter where they're missing one piece broke off and look the sixth leg is still inside the body so you can see sometimes you need these filters right if you can't if you have a new blood clot and you can't get your blood thinned you need a filter but not everybody needs a filter and they're not always safe so now I'm going to talk to you about two of my patients all right 26 year-old lovely young woman who's got no past medical history at all and just takes the birth control pill she lives here in Boston her boyfriend lives in Northern Virginia and every Friday after work she gets on a bus and she goes to Northern Virginia to spend the weekend with her boyfriend and every Sunday night she gets on the bus and comes back and she's been doing this a long time weekend after weekend one time she goes for 10 hours to see her fiance and after 24 hours on Saturday ready to go off for dinner she gets sudden onset of pain in the chest she gets a little shortness of breath it gets worse she can't get on the bus Sunday night because she can hardly breathe she goes to a local hospital her only complaint is my chest wall hurts when I take a deep breath and I feel a little winded but otherwise I'm fine and on exam her blood pressure is fine the amount of oxygen in her blood is perfect she's just got pain she's got a blood clot on the right side of her lung okay so in my view and I suspect in Dr anel's view as well we would treat somebody like this with blood thinners and follow them but in this case for reasons that to this day I can't explain to you they did put her on blood thinners but they also put in one of these filters I don't know why she went home on the shots of Lovenox and waren and she was sent to me to take care of her now that she lives in Boston right she was had this in Northern Virginia someone's got to take care of her so I see her and I say I'm happy to take care of you but I don't know why they put that filter in so I called the doctor in Northern Virginia and I say hey why' you put that filter they said well we thought it'd be safer this woman had no risk of bleeding she was totally healthy 26 years old here's her this is a this is an injection of contrast into the big vein in the belly this is the filter the tip is sticking out inside the vein here this leg is already outside the vein and look at all of these this is a disaster this is her CAT scan and look what happened when we took this out this is actually tissue from her own body she didn't need this filter in the first place she's doing great by the way and they're married now and she just called me last week and she's pregnant so now I got to deal with managing her pregnancy with all this but now there are ways to uh five minutes okay um there are ways to dissolve blood clots we've got all these devices that can uh dissolve blood clots and we can get big pieces of blood clots out look at this this is not like a worm sitting there that's actually what a blood clot looks like this is this is BigTime stuff but this is somebody who was dying I mean they were literally dying and we didn't have time to use blood thinners and all this other stuff so now I'm gonna wrap it up with a final story this is one of the saddest cases I've ever had but it tells the story that Dr anel said and we didn't even talk beforehand this is a 44 yearold attorney who's a BigTime athlete plays rugby does triathletes all that stuff and he hurt his left foot and it hurt it kept him from competing and so he went to a foot doctor who said you need an operation to fix the bone in your foot so he has this foot operation done he's given a cast a cast that goes up to the knee and he's only wearing it for two weeks and at the end of two weeks he calls the foot doctor and says my leg feels tied in the cast so the doctor brings him in and removes the cast and his leg looks swollen so he calls me and says hey you know could this be a blood clot and I say send him right over let's figure it out he otherwise feels completely well so the bottom line is this is what his leg look like I wouldn't say it's terribly swollen right here's the bandage from the foot surgery but he he it felt uncomfortable this is the ultrasound that Dr anel showed you the blood uh in these veins is not flowing these are veins in the calf only so kind of middle of the calf on the operated leg so he's got a blood clot so what would you do now well there are several things you could do I offered him what I thought was the right thing to do which would be to start blood thinners why would a healthy athlete who had foot surgery and a cast for only two weeks develop a blood clot I said you ought to be on blood thinners that's what I told him and he said I don't really want to do that I don't want to get involved with all this headache of shots and worrying about what I'm eating and I like to compete and I'm going to start to train again so I don't want to do that so I said okay since your blood clots only in the calf the risk of that breaking off and going to the lungs is so low that we'll just see you on a regular basis to do ultrasounds to make sure the clots not growing so that's what we did two days later he comes in for his ultrasound and it shows the blood clots exactly in the same place that it was two days before and in fact his legs feeling a little better so I said okay four days from now we'll do another ultrasound the day before his other ultrasound he wakes up in the middle of the night with pain in his chest otherwise feeling fine and his leg is now totally perfect this is his blood clot so he developed the blood clot from this vein in the calf to the lungs very unusual so I think to myself something is not right here this was not the foot surgery because a healthy young athlete should not get a blood clot to the lungs from a little vein clot in the calf unbelievable what else this this guy's never smoked a day in his life this was cancer 44 years old so remember what Dr anel said if you get a blood clot for no reason you can't explain it you got to think that this might be a marker of something bad to come so the take-home message DVT and PE these blood clots in the veins and legs can be prevented know what your risks are and you treat those risks know the symptoms of a blood clot like we talked about there are lots of exciting treatments that are available ask your doctor it's always a pleasure to be here thanks for the national blood clot Alliance for the invitation thank you so much Dr Jack so we'll take two very short questions up in the back I saw the first hand hi we're live tweeting and I have a question from the internet um it was really probably for Dr Andel but I'll ask if you know the answer um I tweeted about the risks for lien 5 and somebody asked if we know the risks for Factor 2 uh I for passing down to children I I don't actually know the risk for fact that's I'll tell them sorry I don't mean to put be the that's okay there plenty of things I don't know the answers to just ask my kids yes uh I have a question I have recurrence of blood clot but uh there there was no reason explaining why I had the the clot because the only thing that I see a lot and I've been uh in um wering for at least I would say 2 years what would you suggest so just like Dr anel you and I just met it's not like we've been working behind the scenes here um I can't give you a good medical advice but I would tell you this couple of basic rules all things being equal if you have a new blood clot after a first one and no one can figure out why that's one of those situations where I think you're on blood finners for a long time now I would tell you that 10 years ago we didn't even know what factor 5 lien was right we had never heard about protham and gene mutation look what we've learned we're going to continue to learn about new risk factors for blood clotting so it might very well be that what you have might turn up over the course of the next several years but I would say you're on blood thinners for a longer period of time and you and your doctor have to be very closely joined at the hip to make sure that you're medically healthy going forward so that nothing else turns up

Channel: stoptheclot

Views: 72,129

Keywords: Blood, Clot, DVT, PE, Deep, Vein, Thrombosis, Pulmonary, Embolism, Thrombophilia, blood, clotting, disorders

Id: 71Bvyt9nejI

Length: 50min 50sec (3050 seconds)

Published: Tue Nov 19 2013