What is?

Deep vein thrombosis, or DVT, is a blood clot that forms in a vein deep in the body. Most deep vein blood clots occur in the lower leg or thigh, but they also can occur in the upper extremities. 

DVT manifests by lower extremity swelling and pain. It can be diagnosed with a simple ultrasound of the legs.  A blood clot in a deep vein can break off and travel through the bloodstream to the lungs, blocking the blood flow. This can be a life threatning condition and is called pulmonary embolism, or PE. 

Traditionally, DVT is treated with blood thinners. However, with the advent of new devices and medications, interventional radiologists are now able to remove the blood clots using minimally invasive techniques, restoring the normal flow of blood in the extremities. 

Why we remove the blood clots?

Although the blood thinners can prevent serious complications of Deep Venous Thrombosis, like pulmonary embolism, they do not necessary dissolve the clot. Overtime, these clots can cause damage to the vein in the legs, causing severe long-term circulation problems including chronic leg swelling and ulcers in the legs. 

Removal of the blood clots can not only speed the recovery, but also prevent these long term sequela. Frequently patients who undergo the clot removal procedures (thrombectomy) can return to their normal activities in only a few days.  

What are the risks?

As with any interventional procedure, there is a risk of bleeding at the catheter insertion site. When blood thinners and clot busting medications are used, there is also a risk of bleeding in other parts of the body, including urinary system, stomach and intestine.  There is also a small risk of intracranial hemorrhage in patients with predisposing conditions. 

After any decloting procedure, there is a risk of re-clotting.  You will continue on blood thinners typically for 3 months after the procedure to avoid this. We will also use compression devices and compression stocking in the recovery period to improve the circulation. 

There is a small chance of allergic reaction to the contrast material used to view your vessels with X-ray. There is also a risk for kidney damage, especially for patients with diabetes or pre-existing kidney disease. The effects from the contrast vary for every patient.  Medicines and IV fluids are given to help prevent or relieve most of these side effects. Also, steps can be taken before the procedure to prevent allergic reactions to contrast and lessen the chance of kidney damage for those at risk.

Reasons to avoid this procedure?

If you have a history of uncontrolled bleeding, bleeding disorder or intracranial tumor you should avoid the use of blood thinners and clot busters.  If you have these kind of problems you are a candidate for a inferior vena cava filter, which is a little umbrella that is placed in the main vein going to the heart and blocks the blood clots from traveling to the lungs. 

How you prepare? 

Usually this procedure is performed with IV sedation and local anesthesia. You will need to be fasting for 8 hours before the procedure. We recommend, no eating or drinking after midnight before the procedure. Generally, you should take your daily morning medications with a small sip of water.

If you take blood thinners you need to stop before the procedure. Please refer to pre-procedure instructions for detailed instructions about your medications. 

Please leave all valuables such as jewelry, credit cards and money at home on the day of the procedure. Family members may wish to bring a magazine or book to read during the extended wait time.

After checking in at Patient Registration, you will be directed to the Short Stay pre procedure unit on 2B. Once in the department a nurse will prepare you for the procedure. This preparation will include changing into a gown, a nurse taking your vital signs, starting an IV in your arm, lab tests and giving you IV fluids and IV medications (antibiotics, anti-nausea, etc). 

How the procedure is done?

The procedure is performed in the catheterization laboratory, also called “cath lab”. An entire team will be taking care of you during the procedure including 2 nurses, a radiography technologist and the physician. In the Interventional Radiology procedure room, the nurse will help you lay on an exam table. You will be lying on your stomach. You will be connected to heart and blood pressure monitors. IV medicine will be given to relax you. Your groin area will be shaved and washed with a special soap and covered with sterile sheets. Numbing medicine is injected into the area behind your knee. You will feel some burning as the medicine is given. Once it takes effect, the area will be numb. The procedure time varies, but usually takes 1 to 2 hours. Throughout the procedure, medication is given through your IV to keep you comfortable. Your oxygen saturation, blood pressure and pulse are checked closely during and after the procedure.

Using Ultrasound guidance, the interventional radiologist will introduce a small catheter in the vein behind your knee.  With the guidance of x-rays, this small catheter will be directed to the area with blood clots. 

Once the catheter is there, the interventional radiologists can use clot busters and one or more devices to remove the clots. The clot buster (also called TPA) is a enzyme that dissolves the clot. Several devices can also be used in combination with the clot busters.  These devices perform a combination of “maceration” and suction of the clot (mechanical thrombectomy). In some cases, if we cannot remove the clot completely, we may leave a catheter within the vein and administer clot busters (TPA) over several hours (up to 24 hours). In these cases a repeat procedure is performed in the following day to assure the complete resolutions of the clots. 

After the clot is completely removed, contrast material (dye) is injected in the veins and pictures of the veins are taken.  Frequently, we identify a narrowing of one or more veins, and this is usually the reason why the clot developed in the first place.  Today, these narrowing can be easily fixed through these same catheters, using balloons and stents. 

What you can expect after the procedure? 

After the procedure you will be taken to a regular room at El Camino Hospital. Your nurse will monitor your blood pressure and pulse. They will also check your procedure site, where the catheter was placed and removed, for bleeding or bruising and check the pulses in your feet. Don’t worry. You will be able to eat and drink after the procedure. You will be able to see you family members soon after the procedure.

It is important to lie keep your legs elevated immediately after the procedure, to improve the venous return. Most patients need to be on bed rest for only 1 hour. We then recommend walking to improve the blood circulation in the lower extremities.  While you are still on bed rest will place compression devices in your legs to improve the circulation.  The nurse will also give you a pair of compression stockings, which should be placed immediately after the procedure. 

After this procedure we recommend the patients to continue to use a high-end compression stockings for at least 4-6 weeks. We will give you a prescription for that. Note that some insurances will reimburse you for the compression stockings. 

Some patients can be discharge in the same day of the procedure. At home, we recommend that you take it slow the day of the procedure. You should not drive or operate heavy machinery until the following day after the procedure, if you received sedation. 

What type of compression stockings should I wear?

We recommend 30-40mmHg compression stockings. Those can be bought at medical supply stores or online. They are usually not available in regular pharmacies. There are at least three types of compression stockings: Pantyhose, thigh high and knee high. Although the pantyhose stockings are more effective, some patients do not tolerate using them and should use the knee high type.

How long does it take to recover?

Most patients should be able to return to their normal activities 3-5 days after the procedure. 

We recommend no contact sports or extraneous activity for a period of approximately 1 week post procedure to minimize the chance of bleeding.  

What should I watch for?

You may be sore after the procedure. However, the pain should not be getting worse and should subside in 2-3 days. If you develop severe pain or if the pain is getting worse you should call us at 650-988-7900 and seek immediate medical attention.

Worsening of pain, redness, warmth or discharge at the site of the procedure may be signs of infection. 

Call your interventional radiologist if the swelling does not improve over the next 24 hours after the procedure.