The average person doesn’t think very much about clotting problems, but this is something that all surgeons have to think of on a daily basis. If 100 random patients come into a surgeon’s office for consultation and if you study them carefully and get a good history, you will discover that 10-20 percent of them have potential problems associated with too little or too much clotting.
Problems with excessive clotting causing venous thromboembolism (VTE) or blood clots going to the lung are responsible for 300,000 deaths a year in the U.S. and 500,000 deaths a year in Europe. Of patients in the hospital who have a VTE, one in eight will die. The chance of having a death from VTE is five times greater in a hospital than as an outpatient. Note that deaths from blood clots are greater in number in one year than the total deaths from all breast cancer, all prostate cancer, all AIDS, and all traffic accidents in the U.S.
Unfortunately, VTE can remain silent until a patient is discharged from the hospital, and then at home it can appear as a clot embolism to the lungs. This risk increases in a patient with cancer, those over age 65, or those with other cardiovascular problems. In addition, 25-50 percent of people who have deep leg vein thrombosis will develop a “post-thrombotic syndrome” with chronic swollen legs due to leg and pelvic vein blockage.
Venous thromboembolism is the third most common cardiovascular disease after heart attack and stroke. With VTE, a clot will form in the legs from immobility or a predisposition to clotting, and then the clot can break off and travel to the lungs and lodge in the blood vessels, which can cause sudden death. About 30 percent of the lung vessels have to be occupied with clot before there is a major problem.
Additional factors tied to excessive clotting include smoking, being overweight with a BMI over 30, hormone replacement therapy with estrogen, or a combination of these factors. A family history of deep vein thrombosis or a past history in the patient of having had a blood clot in the leg or the lung increases risk for the patient. Having pancreatic, ovarian, or lung cancer or being treated on tomoxifen for follow-up after breast cancer treatment is also an increased risk factor. Pregnancy, prolonged immobility after leg or hip surgery, being in a wheelchair or in coma, or long travel times during which the legs are in a cramped position can cause deep vein thrombosis. A family history of any type of clot is important and can include multiple genetic clotting problems such as lack of anti-thrombin 3, proteins S and C deficiency, and factor V Leiden anomaly. In atrial fibrillation, clots can go to the legs, abdomen, eyes, or brain and cause stroke, leg gangrene, or blindness.
These problems are common and can affect you and your family. Problems with clotting are responsible for some of the most serious complications after a surgical procedure. Whether you or your family member is at risk for clotting can be detected by history and laboratory testing. You should make your doctor aware of any positive family history of this. A high level of awareness on the part of you and your doctor can lead to lower risk levels for you.
Hypercoagulation or excessive bleeding can also be problematic. As a surgeon operating on minor and major cases, I sometimes see excessive bleeding and bruising in patients who either forgot to stop their aspirin or were not told to do so prior to their surgery. NSAIDs such as Aleve, Motrin, Advil, and others can cause this type of problem as well. These drugs combine with a protein on the surface of the platelet and prevent it from forming a clot. It takes about 4-6 weeks for your body to get rid of the effects of the drug and to make enough new platelets that clot normally. We have patients stop these drugs 4-6 weeks prior to their surgery. In some cases, however, patients are required to stay on aspirin or Plavix to prevent cardiovascular problems. In those patients who are on Coumadin for atrial fibrillation, aspirin is not a good substitute for prevention of thromboembolism to the brain, which can cause a stroke. Coumadin must be carefully monitored in the pre- and postoperative periods in order to make sure that we can guide the patients safely through the surgery.
In the case of a patient on Coumadin, we have to stop this before surgery so that the bleeding will not be excessive. After surgery a type of heparin called Lovonox is often given by subcutaneous injection to prevent clotting while the Coumadin is being restarted. Also, in patients who are undergoing abdominal surgery, abdominoplasty with liposuction, or other combined procedures, giving Lovonox injections after surgery reduces their risk of problems to the miniscule level. No matter what is done, there is always some slight risk of complications after surgery, but the bleeding and clotting problems can be some of the worst. Compression garments and early ambulation also can help reduce the risks.
You can be very effective in helping reduce risks as a knowledgeable patient or family advocate by staying aware of all that is occurring during and after surgery. Stay informed and ask questions of your doctor as needed.
Dr. Carraway is the director of the Plastic & Cosmetic Surgery Center of EVMS. Call 757-557-0300 for more information.