Venous Thromboembolism

Knee and hip replacement surgery, in particular, carry a high risk for VTE, as does peripheral and coronary artery bypass surgery, surgery to remove cancer, neurosurgery, abdominal surgery, and other major operations. Clotting is one of the body’s natural ways to heal the damage to your blood vessels from surgery. While you wear a cast or stay in bed to heal, your venous circulation slows because you stop moving as much as usual. This lack of movement increases the risk of blood clotting.

The risk of developing VTE is highest in the first three months after surgery and decreases with time. Ask your medical team about prevention strategies if you are scheduled for major surgery.

Certain medical conditions can increase your risk of developing a DVT. Some conditions are more closely linked to getting a DVT than others and include the following:

• Spinal cord injury. In addition to damaging veins deep in your body, spinal cord injury may cause paralysis, which can reduce blood flow and raise your risk of VTE. The risk is highest in the first weeks after the injury.
• A broken hip or leg bone or other trauma.
• Cancers such as advanced brain, breast, colon, and pancreatic cancer. Cancer chemotherapy, surgical treatment, and placement of a central venous catheter—a tube inserted into a vein to deliver chemotherapy treatment or other medicine—all increase the risk of VTE. Some cancers release substances that can make it easier for blood to clot. Some cancerous tumors may directly block blood flow by pressing on a vein. A central venous catheter increases the risk for VTE in arm veins, especially in children.
• Heart conditions such as heart attack or congestive heart failure.
• Stroke
• Obesity
• Varicose veins. Most varicose veins do not cause problems, but large, untreated varicose veins can lead to VTE.
• Infections
• Sickle cell disease. This condition makes the blood clot more easily and can be a risk factor for VTE.

Women who take birth control pills or get hormone therapy have an increased risk of clotting. Some medicines appear to put people at a higher risk than other medicines do, and the risk tends to be highest in the first few months after starting to take them. If you have other risk factors in addition to taking hormone-based medicines, keep in mind that risk for blood clots may be even higher.

Women are at higher risk for VTE during the first six weeks after giving birth to a baby. The risk is also somewhat higher than usual during pregnancy. This may be due to hormones or other factors in the blood, changes in the way blood flows through your veins, or damage to your blood vessels during delivery. If you are required to be on bed rest while you are pregnant, the lack of movement can reduce blood flow through your veins. Surgery for a cesarean delivery may also increase your risk.

Being still slows blood flow through the veins in your arms and legs, raising your risk of deep vein thrombosis. Especially when combined with other risk factors, not moving for long periods of time—such as when on bed rest in a nursing home or hospital setting, when you have a cast, or during a long flight—can increase your risk. Slower blood flow can create a low-oxygen environment that makes it easier for clots to form or trap blood in places such as the veins in the legs where they have a tougher time breaking up.

VTE can occur at any age, but your risk increases as you age. After age 40, the risk of VTE almost doubles every 10 years.

Heredity can affect your chances of developing VTE. Researchers have found dozens of genetic changes that can increase your risk of VTE. Some changes make your blood more likely to clot. If your parents have these genetic changes, you may have inherited them. Studies show that the risk of VTE among siblings of someone who has had VTE is more than double the risk among the general population.

Factor V Leiden is the most common known genetic risk factor for VTE. What is Factor V Leiden?

Studies suggest that the frequency and severity of VTE may vary by a person’s race and ethnicity. In the United States, African Americans have the highest rates of VTE. VTE is less common among Asian Americans and Pacific Islanders. Recent findings have revealed new genetic factors influencing a person’s risk for VTE, and those appear to be more common among African Americans.

Women in their childbearing years are more likely to develop VTE than men of the same age. After menopause, women’s risk is lower than men’s.

If you are preparing to go to the hospital for a procedure or have other risk factors for VTE, talk with your doctor about a plan for preventing blood clots from forming. Doctors may suggest three ways to help prevent VTE:

• Movement. Helping your blood circulate makes it harder for clots to form. Your doctor may recommend that you move around as soon as possible after surgery and as you heal. If you cannot get up and walk, try to flex and stretch your feet to improve blood flow in your calves.
• Pressure. Gentle pressure keeps blood from pooling and clotting. Your doctor may recommend applying pressure—for example, by wearing a sleeve or boot that periodically fills with air, or by wearing graduated compression stockings.
• Medicines. Your doctor may give you anticoagulant, or blood-thinning, medicines to prevent clotting. Sometimes this preventive therapy starts before surgery. Or, you may be asked to take a blood thinner during your recovery period at home. These medicines, such as heparin, warfarin, and direct oral anticoagulants, are also used to treat VTE.

Your doctor may recommend some combination of these preventive treatments for a month or more after surgery. These approaches to prevention may also be appropriate if you are admitted to the hospital for reasons other than surgery, cannot move for an extended period, or have a condition that makes it more likely that your blood will clot.

• Diagnosis will discuss tests and procedures that your doctor may use to diagnose VTE.
• Life After will explain what your doctor may recommend to prevent your VTE from recurring, getting worse, or causing complications.
• Research for Your Health will discuss how we are using current research and advancing research to prevent VTE.
• Participate in NHLBI Clinical Trials will explain our ongoing clinical studies that are investigating prevention strategies for VTE.

Deep vein thrombosis may cause the following to occur around the area of a blood clot:

• Swelling
• Pain or tenderness
• Increased warmth, cramps, or aching in the area that is swollen or painful, usually the calf or thigh
• Red or discolored skin

Signs and symptoms of pulmonary embolism include:

• Shortness of breath
• Pain with deep breathing
• Rapid breathing
• Increased heart rate

Less common signs and symptoms of pulmonary embolism may include coughing, with or without blood; feelings of anxiety or dread; light-headedness or fainting; and sweating.

Contact your doctor right away if you suspect that you have signs or symptoms of VTE. Deep vein thrombosis should be taken seriously, as it may lead to pulmonary embolism.

Possible complications of VTE include:

• Post-thrombotic syndrome (PTS), in which poor blood flow, inflammation, and blood vessel damage from deep vein thrombosis cause swelling and discomfort. PTS is a long-lasting condition that can be disabling. With PTS, you may notice swelling, pain, itchiness, or discoloration in the affected area, along with cramping or fatigue. The symptoms may feel worse if you have been on your feet for an extended period. In severe cases, skin sores may develop. Compression stockings may help relieve PTS symptoms.
• Pulmonary hypertension, which occurs when pulmonary embolism blocks blood flow and raises blood pressure in the vessels leading to your lungs. This condition can lead to heart failure. If you develop pulmonary hypertension, you may find it hard to breathe, especially after physical activity, or you may cough up blood, notice swelling, feel tired, have palpitations, or faint. If you still have pulmonary hypertension several months after a VTE event, your doctor may refer you to a specialist to talk about the possibility of surgery to remove a lung clot that has not gone away with treatment.

• Diagnosis will discuss tests and procedures used to detect signs of blood clots and blockage and help rule out other conditions that may mimic VTE.
• Treatment will explain treatment-related complications or side effects of VTE, such as bleeding.

Your doctor will ask you about your risk factors and your signs and symptoms for VTE. Your doctor may examine your heart rate and the area that is affected and ask about your overall health, including:

• Your recent medical history, especially any paralysis or periods of immobilization
• Medicines you are taking
• Recent surgeries or injuries you have had
• Whether you have been treated for cancer

• D-dimer test to measure a substance in the blood that is released when the fibrin proteins in a blood clot dissolve. If the test shows high levels of the substance, you may have VTE. If your test results are normal and you have few risk factors, you likely do not have VTE.
• Ultrasound to look for deep vein blood clots. This test uses sound waves to create pictures of blood flowing in your veins. The person doing the test may press on your veins to see if they compress normally or if they are stiff with blood clots.
• Computed tomography (CT) angiography to take pictures of your blood vessels and 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 video of the blood flow to your lung so your doctor can identify any blood clots.
• Other imaging tests to look at blood flow through your veins, heart function, and lung function if the results of previous tests could not diagnose or rule out VTE. These include venography, echocardiography, ventilation/perfusion scanning, and magnetic resonance imaging (MRI).

To help diagnose VTE, your doctor may need to do tests to find out if other medical conditions are causing your symptoms. Other tests include:

• Blood tests to check whether you have an inherited blood clotting disorder if you have had repeated blood clots that are not related to another cause. Blood clots in an unusual location, such as the liver, kidney, or brain, may also suggest an inherited clotting disorder. Blood tests can also measure the level of oxygen and other gases in your blood.
• Chest X-ray to give your doctor information about what may be causing your symptoms, such as pneumonia or fluid in the lungs. A chest X-ray does not show whether you have a pulmonary embolism.
• Electrocardiogram (ECG) to identify other conditions that are causing signs of pulmonary embolism. An ECG records the electrical activity of your heart.

• Return to Risk Factors to review family history, lifestyle, or other environmental factors that increase your risk of developing clots.
• Return to Signs, Symptoms, and Complications to review common signs and symptoms of VTE.
• Return to Screening and Prevention to review what you can do to prevent clots from forming.

Anticoagulants, or blood thinners, and thrombolytics are medicines commonly used to treat VTE.

• Anticoagulants, or blood thinners, keep blood clots from getting larger and stop new clots from forming. Conventional blood thinners include warfarin and heparin, but newer blood-thinning medicines are also available. To take them, you might get an injection, take a pill, or have an IV tube inserted. Possible side effects include bleeding, especially if you are taking other medicines that also thin your blood, such as aspirin.
• Thrombin inhibitors interfere with the process of clot formation. They may be used for people who cannot take heparin.
• Thrombolytics may be used to dissolve large blood clots that cause severe symptoms or other serious complications. Because thrombolytics can cause sudden bleeding, they are used only for serious and potentially life-threatening VTE events, such as pulmonary embolism.

In some cases, including emergencies, a doctor may need to do a catheter-assisted thrombus removal. This procedure uses a flexible tube to reach a blood clot in your lung. The doctor can insert a tool in the tube to break up the clot or to deliver medicine through the tube. Usually you will get medicine to put you to sleep for this procedure.

Some people who cannot take blood thinners may need a vena cava filter to treat their deep vein thrombosis. The filter is inserted inside a large vein called the vena cava. The filter catches blood clots before they travel to the lungs, which prevents pulmonary embolism. However, the filter does not stop new blood clots from forming. A filter is not usually recommended if you have taken blood thinners.

• Life After will discuss what your doctor may recommend, including lifelong lifestyle changes and medical care to prevent your condition from recurring, getting worse, or causing complications.
• Research for Your Health will explain how we are using current research and advancing research to treat people who have VTE.
• Participate in NHLBI Clinical Trials features ongoing clinical studies that are investigating treatments for VTE.

Follow your doctor’s instructions and schedule regular appointments.

• Tell your doctor if symptoms such as pain or swelling continue. Your doctor may prescribe graduated compression stockings to give you relief.
• Take all medicines as prescribed. You will probably keep taking medicines to treat VTE for three months or longer. The most common side effect of blood thinners is bleeding. This side effect can be life-threatening.
• Check your legs for any signs or symptoms of deep vein clotting, such as swollen areas, pain or tenderness, increased warmth in swollen or painful areas, or red or discolored skin. If you think you may have another deep vein clot or are having symptoms of pulmonary embolism, contact your doctor right away.
• Tell your doctor if you notice that you bruise easily; have unexpected bleeding, such as when you floss or go to the toilet; or have unusually heavy menstrual periods.

To monitor your condition, your doctor may recommend the following tests:

• Blood tests to monitor the proper dose of medicine so that adjustments can be made as necessary. If you are taking warfarin to treat VTE, you will need to take regular tests that show how long it takes for your blood to clot. Usually, you do these tests at the doctor’s office or at a clinic. The FDA has approved several devices for self-testing. Your doctor may also run regular blood tests to check your kidneys or liver if you have been taking other blood-thinning medicines for more than a year. This will help your doctor make sure your body can still tolerate the medicine well.
• Ultrasounds to monitor your blood clot. These tests will help your doctor see if your blood clot has gotten bigger or has moved.

When you return home, your doctor may recommend healthy lifestyle changes to help improve your recovery.

• Heart-healthy eating. Heart-healthy eating includes limiting the amount of alcohol you drink. Alcohol can also be dangerous if you are taking blood-thinning medicine. If you are taking warfarin, talk with your doctor about your eating patterns and any supplements you take. Foods that contain vitamin K can affect how well warfarin works, so it is important to eat about the same amount of vitamin K each day. Vitamin K is found in green leafy vegetables and some oils, such as canola and soybean oils.
• Being physically active. It is important to keep moving regularly while you are healing. Ask your medical care team when you can start being physically active and how much activity is appropriate.
• Aiming for a healthy weight. If you are overweight or have obesity, you can improve your health by aiming for a healthy weight. Obesity is a risk factor for a repeat VTE event.
• Managing stress. Stress can increase the risk of other conditions that can lead to VTE, such as heart attack and stroke.
• Quitting smoking. Smoking also increases the risk of heart attack and stroke, and it may aggravate other factors known to raise the risk of VTE. Visit Smoking and Your Heart and the National Heart, Lung, and Blood Institute’s Your Guide to a Healthy Heart. For free help quitting smoking, you may call the National Cancer Institute’s Smoking Quitline at 1-877-44U-QUIT (1-877-448-7848).

Nearly one in three patients who have had VTE will experience a repeat VTE event in the next 10 years. It can take a year or more for clots to break up or stabilize and for blood flow to return to normal. If you were previously treated with blood thinners and experience a repeat VTE event, your doctor may recommend changing your medicine dose or switching you to a different type of blood thinner.

To prevent a repeat VTE event:

• See your doctor for regular checkups and follow-up tests and treatment.
• Talk to your doctor about your risk for a repeat VTE event. The risk of a repeat VTE is higher for African Americans and Hispanic Americans than it is for white Americans. It is also higher for men than for women.
• Take all medicines as your doctor prescribes. A repeat event while you are taking medicines is rare, but if it does occur, your doctor may switch your medicine or increase the dose.
• If you stop taking blood-thinning medicines, your doctor may suggest that you take aspirin to reduce the risk of getting another clot.

Medicines used to treat VTE can thin your blood too much or impair your body’s ability to clot after a wound. If you take a dose of blood-thinning medicine that is too high, it may cause bleeding in the digestive system or in the brain. These side effects can be life threatening.

Signs and symptoms of bleeding in the digestive system include:

• Bright red vomit or vomit that looks like coffee grounds
• Bright red blood in your stool or black, tarry stools
• Pain in your abdomen

Signs and symptoms of bleeding in the brain include:

• Severe pain in your head
• Sudden changes in your vision
• Sudden inability to move your legs or arms
• Memory loss or confusion

A lot of bleeding after a fall or injury, or easy bruising or bleeding, may mean that your blood is too thin. Excessive bleeding is bleeding that will not stop after you apply pressure to a wound for 10 minutes. Call your doctor right away if you have any of these signs. If you have severe bleeding, call 9-1-1.