Deep vein thrombosis (DVT), means cloth formation in the deep veins.

There are 3 main theories of its formation:

• Slowing of blood flow
• Increased susceptibility to blood clotting
• Damage or deterioration of the inner surface of the vein

DVT has another clinical importance besides the complaints it gives to the patient, reducing the quality of life and causing loss of internal strength; pulmonary embolism (clot in the lung).

The blood cloths may resolve spontaneously in the vein and proceed with the blood circulation. This loose clot is called an embolus. Embolism can progress and damage any organ, although all these conditions are important, the most important thing in DVT clinic is that the clot goes to the lungs and prevents blood flow, this situation is called pulmonary embolism (PE). PE is a very serious condition, it can cause death.

Superficial vein thrombosis, that is, clots formed in the veins closer to the skin surface, do not break up and do not cause pulmonary embolism.

PROGRESS OF DEEP VEIN THROMBOSIS

Among the body's defense systems is a system that dissolves the clot and is called fibrinolytic activity. Following the formation of the clot, this system is activated immediately and begins to dissolve the clot, but this melting is quite slow and often incomplete. It leads to the formation of irregularities, strictures and most importantly, the deterioration of the valves in the affected vessel. In this case, years after the clot has formed, the flow of venous blood, which must gradually return from the legs, is blocked, and the blood starts to pool in the veins and the pressure increases. In this case, Post Phlebitic Syndrome (PFS) develops, which is characterized by swelling, pain, discoloration in the leg and sores on the wrist (venous ulcer) as a result of damage to the tissues by the high blood pressure in the veins.

Rarely, as a result of the obstructed vein preventing the discharge of the pooled blood in the leg, the leg swells gradually and as a result, the arterial circulation deteriorates and gangrene develops in the leg. This condition, called Phlegmasia Cerulea Dolens, is the only vein disease that can cause loss of the leg.

REASONS OF DEEP VEIN THROMBOSIS

Although the presence of the risk factors listed above is the biggest factor, DVT can appear in many different forms in our daily lives, even without risk factors. The most important of these is long-term bed rest or not being able to walk after an accident or major surgery. These examples include stroke, heart attack, long-term airplane or car journeys, and DVT may develop due to sitting still for a long time. In addition, some people have a congenital predisposition to coagulation, and DVT or similar conditions may occur frequently in these individuals and their relatives. Cancer patients, patients on hormone therapy and pregnant women are at risk for DVT. Pregnancy, birth control pills, advanced varicose veins, advanced age and obesity are also risk groups.

Among these conditions, the problem that is often overlooked is thrombophilia, which is characterized by a genetic predisposition to coagulation. Most of these are due to deficiencies in the natural mechanisms that prevent blood clotting. The main of these conditions are Hyperhomocysteinemia, FV Leiden, G20210A AT III deficiency, Protein C deficiency, Protein S deficiency, high coagulation factor levels II, VIII, IX, XI are conditions with antiphospholipid antibodies. The above diseases should be investigated in cases such as DVT at a young age, frequently recurring DVT, family history of DVT, DVT in abnormal (clots not common) vessels, and recurrent miscarriage.

SYMPTOMS OF DEEP VEIN THROMBOSIS

The most common complaints are

• Severe pain in the leg
• Sensibility
• Usually sudden onset of swelling
• It is the color change that occurs on the leg, especially when standing.
• Heat increase
• Color change

If the clot reaches the lung

• Shortness of breath
• Chest pain
• Cough
• Complaint of producing bloody sputum
• Death may develop

Half of the patients with DVT may have pulmonary embolism with or without symptoms at the time of diagnosis.

DIAGNOSIS OF DEEP VEIN THROMBOSIS

In the presence of risk factors, the appearance of the above complaints should bring DVT to mind. Diagnosis is quite easy and effortless. The easiest and most reliable method is color Doppler ultrasonography. In cases where DVT is common; Color Doppler ultrasonography examination of the vessels in the abdomen, near the heart and in the chest cavity is insufficient. In such cases, computed tomography and magnetic resonance venography can be used. These methods can also be used in the diagnosis of pulmonary embolism in the same session. Laboratory tests are used to support the diagnosis. The most important is D-dimer measurement. If the D-dimer is normal, it most likely indicates the absence of DVT. However, elevation of D-dimer in the blood does not always indicate DVT.

TREATMENT OF DEEP VEIN THROMBOSIS

The main goals of DVT treatment are:

• Stopping the growth of blood clot
• Preventing the blood clot from breaking down and transporting it to the lungs
• Reducing the chance of another blood clot forming
• Reducing the complaint in the patient's leg
• Preventing problems that may occur in the future (PTS)

Blood thinners (anticoagulants)

They are commonly used drugs in the initial and maintenance treatment of DVT. In order to prevent coagulation, treatment is started with drugs called heparin or low molecular weight heparin in ready-to-use syringes. Treatment is continued with warfarin (Coumadin) or new generation antithrombotics , that is, oral medications. Heparin group drugs given in the form of needles are used for 4-6 days. Meanwhile, heparin group drugs are discontinued after 4-6 days when oral drugs started simultaneously are effective. Coumadin is monitored by blood tests called prothrombin time and related INR. For an effective treatment, the desired INR value should be between 2 and 3. When it is below these values, the treatment will be ineffective, and if it is above these values, there will be a risk of bleeding. Bleeding often occurs in the form of gingival, nose, light bleeding in the urine or stomach bleeding. Bleeding is an emergency and requires hospital admission. New generation antithrombotics are drug groups whose preparations end with -parinux, -xaban and -gatran. Unlike Coumadin, they do not require follow-up with blood levels, they do not interact with food and drink, their bioavailability is extremely high, but both the long-term results are not known because they are new drugs, and it is possible to reduce the effect of coumadin when an emergency surgical procedure is required, which is more difficult for this group.

The important point to remember is that patients under this treatment cannot have their teeth extracted and cannot have surgery except in emergencies. When you need any interventional treatment, be sure to tell your doctor that you are using medication.

Thrombolytic therapy (Dissolving the clot)

It is an inpatient treatment where DVT is very common, progresses into the abdomen or is applied in experienced centers with a high number of patients. This treatment significantly reduces the patient's complaints about the leg, protects against pulmonary embolism and reduces the risk of developing PTS, but does not eliminate it. The reason for this is that the clot in the leg is not completely dissolved and the blockage is not opened.

Unclogging is only possible with some special methods. These methods are to dissolve the clot by administering the clot-dissolving drugs to the clogged vessel with catheters, and to remove the clot with catheters or surgical methods. When the clot is dissolved, angioplasty and stent may sometimes be necessary to prevent the opened vessel from becoming occluded again. These methods really help the patient's complaints to pass significantly or completely. However, these methods are applied in some special cases because they carry certain risks. Especially in young and active people, DVT should be treated in this way. In addition, in the case of “Phlegmasya cerulea dolens” where DVT disrupts the leg blood flow and causes gangrene, the obstruction should be removed by removing the clot with these methods.

NEW TREATMENTS (INTERVENTIONAL)

* Even though the spread and embolization of the clot can be prevented with classical drug treatments, the inability to dissolve the existing clot and the failure to prevent long-term complications such as deterioration of venous valve functions and the development of venous hypertension, especially Post thrombotic syndrome (PTS), led to the need for new and clot-destroying methods.

Thanks to the developments in modern medicine and catheter methods, dangerous complications of deep vein thrombosis can be prevented by entering directly into the clot in the early period, ensuring active clot dissolution and treating patients before valve damage develops.

* EKOS Catheter: Under local anesthesia, the clot occluded vein is entered with the help of a needle under ultrasound guidance and the catheter is inserted into the clot. Then, a clot-dissolving drug is given through this catheter, while a high-frequency ultrasonic sound wave is given at the same time. Ultrasound waves allow the clot-dissolving drug to penetrate deep into the clot. Another important advantage of thrombolytic therapy is the dissolution of the clots remaining behind the venous valves, thus preventing the most troubling long-term complication of post thrombotic Syndrome (PTS). In the treatment with EKOS, intervention in the first 15 days is very important. As you wait, the chance of dissolving the organized and hardening clot decreases day by day.

* ANGIOJET Catheter: It works with the principle of dissolving the clot with simultaneous infusion of clot-dissolving drug and high-speed jet serum flow, and removing the fragments from the body by aspiration. The use of low blood thinners therefore lowers the risk of bleeding. Its advantages are that hemolysis (trauma of blood elements) is less common, and that it is safer in patients with risky use of blood thinners or who have recently undergone major surgery (Orthopedics, Neurosurgery). It is a painless method performed with local anesthesia. After entering the vein, the AngioJet catheter is advanced to the occluded part, and the entire clot is aspirated from the vein within 5-10 minutes, accompanied by a low blood thinner. With the control angiography performed afterwards, it is shown that the vessel is completely cleaned at the end of the procedure, the flow is restored and the clot is completely dissolved. If there is a previous chronic stenosis in the vessel, balloon angioplasty and stenting can be performed simultaneously and a complete treatment is offered. Another advantage of the AngioJet catheter is that the risk of pulmonary embolism or distal embolization due to the clot breaking off and joining the circulation is very low, since the clot pieces that melt at a very high negative pressure are aspirated

* Compression Stockings: One of the most important steps of DVT treatment is compression stockings. Anti-embolic stockings should be worn at 25-35 mmHg pressure (medium pressure) for chronic venous insufficiency, and over .35mmHg (high pressure) in patients with PTS, embolism or high risk. Compression stockings should be worn continuously for the first few days and then only during the day. Socks are put on before getting out of bed and taken off at night. The duration of the socks will be determined by your doctor according to the course of the disease. In the first days, resting by raising the legs above the level of the heart reduces the complaint in the legs.

* Filter placement: Sometimes, despite all efforts, it is not possible to prevent pulmonary embolism. If treatment is unsuccessful, or if there are recurrent embolisms despite treatment, a filter that prevents clots may need to be placed in the main vein. It is placed in the vena cava inferior in the abdomen, the largest vein, with inguinal or neck catheters.

DAILY LIFE RECOMMENDATIONS FOR THOSE WITH DEEP VEIN THROMBOSIS

When DVT develops, patients' movements and lives become difficult due to pain and swelling. Therefore, it may take time for life to return to normal. To reduce swelling in the legs it can be rested by placing a few pillows under the legs and lifting them above the level of the heart with a slight bend in the knee. Since this position can be difficult while sleeping at night, 10-15 cm elevation can be placed on the foot side of the bed and the foot side can be raised a little.

It can also be done in the following applications

• When sitting for a long time, the legs should be moved (such as repetitive pedal pressing).
• While awake, you can get up every hour and take short walks.
• Clothing that tightens the legs should not be worn.
• Compression stockings should be used in accordance with the doctor's advice.
• Heavy movements that may cause injury should be avoided.
• Regular walking should be done

PREVENTION OF DVT

It is possible to prevent DVT, which can lead to very important problems and even death. For this, the risk factors that may lead to the development of DVT are reduced. Especially in major surgical interventions and long-term hospitalizations, low doses of anticoagulant drugs, patients getting up and walking as early as possible, using compression stockings during and after surgery, and even better air compression devices reduce the risk of DVT development. In addition, intermittent leg exercises and abundant water consumption on long journeys can reduce the risk of DVT. If you have a diagnosed coagulation disease, you must inform your doctor.