At The Forefront Live: Vascular Disease Questions and Answers
February 18, 2020
Occasional stiffness or soreness in your legs might not require a visit to the doctor, but leg pain or fatigue that develops after you've been walking or climbing stairs could be a sign of a vascular disease. Vascular surgeon, Chelsea Dorsey, joins interventional cardiologist, Jonathan Paul, and vascular and interventional radiologist, Osman Ahmed, to discuss how to detect, treat, and prevent a variety of vascular diseases. We'll also take your questions live. Coming up now on At the Forefront Live.
We're going to remind our viewers that today's program is not designed to take the place of a visit with your physician. If you have questions for our physicians, please type them into the comments section, and we'll get to as many as possible over the next half hour. Thanks for joining us today. We appreciate you being on.
Glad to be here.
So let's just start out with the basics, and I'm going to have each of you introduce yourselves to our audience, and tell us a little bit about what you do here at UChicago Medicine. And Dr. Paul, we'll start with you.
Great. I'm Jonathan Paul. I'm an interventional cardiologist here university Chicago Medicine. I specialize in treating a wide variety of cardiovascular diseases via interventional techniques, using catheters and small devices to treat a number of vascular diseases, including coronary artery disease. I have a particular interest in venous disease, in treating patients with pulmonary embolism, and deep vein thrombosis. And we have an interesting array of technologies to address those issues as well.
Fantastic. Dr. Dorsey.
Hi. Again, I'm Chelsea Dorsey. I am in the section of vascular surgery here at UChicago Medicine. I'm actually the director of our vein clinic here at UChicago Medicine. I'm very excited to be here today to talk to you a little bit about some of the services we have. We see a ton of patients in our vein clinic with conditions such as varicose veins, venous insufficiency, venous status ulcers, and so I'm very excited to talk to you a little bit about what we can do for patients with those conditions.
Great. Dr. Ahmed, you're our veteran. You've been on twice now.
Hi, everybody. I've Osman Ahmed. I also go by Oz. I'm a vascular and interventional radiologist. And similar to Dr. Paul, we work by doing procedures in minimally invasive methods with wires and catheters. I also, similarly, have a particular interest in treating venous disease. Specifically, deep vein thrombosis, both acute and chronic, in addition to placing and removing IVC filters.
All right, let's start off with the basics, and just what our vascular diseases? What's the difference between arterial and venous conditions?
Yeah. So I can answer that question. Vascular disease is a pretty broad term that we use. Basically, it encompasses any condition that affects the arteries and veins in our body-- the blood vessels. Arteries are the blood vessels that carry the oxygenated blood that's nutrient rich to the different tissues around our body. The veins bring the blood back to the heart when it's deoxygenated.
So I've kind of described the functions of the arteries and veins, and you can see they're quite different. And as you can imagine, the conditions that affect the arteries and veins are also quite different. So a lot of times, when we start talking about vascular disease, we often talk about coronary artery disease, which happens in the arteries, and causes people to have heart attacks. And sometimes we talk about peripheral arterial disease.
So that's what patients have poor circulation in their legs to cause them to have pain and ulcers that don't heal. We're actually really excited to be here today to talk about some of the venous conditions that patients experience. As I stated at the beginning of the show, I'm the director of the UChicago Medicine Vein Clinic, and we're in the process of kind of expanding our services there. And the three of us are actually involved in another program called the Comprehensive Venous Thrombosis and Pulmonary Embolism program. So we're really excited to talk to you about all of those.
Fantastic. So what are the most common venous conditions? Dr. Paul, if you'll take that one. So venous conditions really can present in a number of different ways. Probably, the most well known or well described venous condition would be just venous insufficiency, which is where a patient has, typically, a swollen leg, a painful, heavy leg that is sort of just always causing them some discomfort. There are always some issues with feeling soreness and heaviness, and the patient always sort of asking doc, is there anything I can do about this? That's typically due to an issue with the vein, and the ability of the vein to drain the blood effectively back to the heart, as Dr. Dorsey had described.
Oftentimes, that condition is due to a problem with the valves inside the veins. And so the valves are essentially there to help the blood make their way back up to the heart. If there's an issue with the veins becoming what we call incompetent, or have an inability to close properly, then the blood will essentially pool within the veins of the legs, and cause what we call venous insufficiency, or swelling of the leg.
Another common venous condition is deep vein thrombosis. This is a very common condition where a blood clot will form within a vein, deep down within typically the legs. Oftentimes, it happens in the legs-- lower down within the leg, but it can also happen higher up. Deep vein thrombosis can also happen within the main vein that drains back into the heart, which is called the inferior vena cava. Or else it can happen up in the arms, or in the veins in the neck. So deep vein thrombosis can happen, really, anywhere within the body.
And typically, results in a painful, swollen extremity, typically a leg. It can be a dangerous condition because deep vein thrombosis can result in that blood clot breaking off, and traveling up through the body into the heart, which causes what we call a pulmonary embolism. And that's what I have a particular interest in treating. Pulmonary embolism, as we'll talk more about in a little while, is a condition where that clot, essentially, will block blood flow within the lungs, and can be very, very dangerous. It can cause patients to come in with significant shortness of breath, trouble breathing, and chest pain, and occasionally, it can be life threatening. So if deep vein thrombosis is a serious condition.
Yeah, and I do want to talk more about that as we progress through this show, and of course, we'll tell people what to what to look for, and want to be aware of, and how to prevent these things. So is a deep vein blood clot-- is that the same thing?
It's the same thing, yeah. DVT is that is the terminology that's typically used in the medical community, but blood clot, clot, DVT, they're all interchangeable.
So Dr. Ahmed, how do you prevent blood clots? What can you do?
Yeah, that's a great question. So I would say the short answer really is to live a healthy lifestyle. So the most important thing is if you're overweight, you want to try to exercise and lose weight, and also try to remain active, and healthy as well. So just through basic exercise. In addition, you want to avoid being sedentary for too long.
So when I say sedentary, I mean you don't want to be sitting or lying down flat for a long time. In long car rides or plane trips, you want to get up and move around. And what that essentially does is it gets the blood flowing in your body, especially in your legs, where that blood tends to pool, and can form those clots. And so you really want to be able to help your body fight that gravity, and help to pump that blood back to the heart.
We were talking a little bit before the program, and I was serious about this. I actually was on a long car trip recently. About an 11, 12 hour car trip, and I did have pain in my left leg, which was something that concerned me, and I probably should have considered. What do you do in a situation like that? Because that was the thing. After it happened, I'm home on a weekend, and thinking, I don't know if I need to do something about this or not.
I think it's a really good point. We see patients all the time that have these very nonspecific complaints. They say my leg feels funny, like you described. Having sort of a heavy feeling or a soreness in the leg. Maybe I twisted something. Maybe I slipped. Maybe I injured my leg, but there's not really a good explanation for it. If it happens acutely, or it happens right away without any sort of warning or predisposing factor, if it continues to stay there for more than a day or so, it's probably worth getting checked out.
And particularly, in those scenarios. You said you were on a long trip. You should definitely have a high degree of suspicion, for sure.
Yeah, it was it was one of those situations where I had to get from point A to point B, and it wasn't a fun trip. You just press through to the end. Probably not the smartest thing. And again, things like that can end a tragedy. We were also talking before the show. I had a colleague that I used to work with that had a situation like that, and it was fatal in that case. So something you definitely should be aware of. If you're on an airplane, what do you do if you're on an airplane for a long flight?
So there's a couple different things you can do. So I definitely recommend that patients wear compression stockings when they go on an airplane. Another thing you can do is you can get up out of your seat every now. I'd say every half an hour, get up. Walk up and down the aisle. Stay hydrated during the flight as well. Stay away from coffee and alcohol, if you can. So those are probably some of the main things. You can do exercises in your chair too, kind of with your calf, moving your legs around, and that helps as well.
So what do the compression socks do?
So the compression socks basically, just like they sound like, they cause compression on the legs to help kind of pump the blood back up out of the leg. So pretty simple, but it works.
Interesting. Dr. Paul, you mentioned a moment ago that the veins-- the valves and the veins. Explain that a little bit more for us, if you will, because I think a lot of people probably had no idea that that even exist.
Yeah. No, that's a good point. Veins are very different than arteries. So we think of arteries as basically just tubes. They're a conduit for blood to flow from point A to point B. Veins are actually very different. They're larger structures, typically. They have valves. So you can sort of think of it as a highway with those gates that sometimes close when you're getting on and off the express route, and those gates would essentially be the valves.
And the valves open when the blood is flowing, and they typically close when the blood is not flowing. And so if the valves don't work properly, then blood can pool below the valves, or blood flow can get disturbed around the valves, and that can cause issues with the blood returning up from the leg. Or it can cause blood clotting as well.
Just had our first question from a viewer. It's can flying cause blood clots? We talked a little bit about that a moment ago, but is there anything specific to flying that makes it worse? Or is it just you're trapped in a little tiny seat for an extended period of time?
Yeah, absolutely. For the most part, it's the length of time that you're staying sedentary or inactive. And so as Dr. Dorsey mentioned, really, those things, which seem relatively minor, actually could end up being lifesaving because they can kind of really prevent this large blood clots performing in your legs.
And we'll oftentimes have patients come in with a swollen leg, and they'll say I was on a recent flight. The flight was from Chicago to Atlanta. Is that a significant length of time? And typically not. It's usually the longer flights that we worry about. So transatlantic flights. Usually flights over about six to eight hours are more concerning than short hauls across the US.
And Tim, you had asked about compression stockings. It's different degrees of compression for compression stockings. So I usually prescribe 20 to 30 millimeters of mercury. That's kind of middle of the range. They get, actually, a lot tighter than that, which can be uncomfortable for some people. Once you get below that level, they're not doing as much for you. But yes, 20 to 30 millimeters mercury is what I typically prescribe.
And is that something you just pick up at a drugstore?
So usually, you have to go to a kind of medical device companies, where they'll measure your leg, and make sure that you have the proper size. But you can't go to Target, Walgreens, CVS, Amazon, and order some as well.
I think a lot of sporting good companies are selling compression socks for elite athletes that run marathons. So you may see these runners that have these bright green socks, and those are usually compression socks.
That makes sense. Well, any other pieces of advice too. If you're in your car and you've got a long trip, pullover on occasion, and get out of the car and walk around. That alone can make a pretty significant difference, I would imagine. So if you do have a situation where you do have a blood clot, is that always deadly? Or is that something that can be treated?
It's not always deadly. Blood clots are common. They happen for a number of different reasons. Blood clots can happen for the issues we already discussed, such as immobility. However, some patients are more predisposed to forming blood clots, in general. Patients that have cancer, for example, are more prone to forming blood clots. Patients that have genetic abnormalities that sometimes affect how blood clots can be more prone to forming blood clots. And there's a number of other potential causes, but they're not-- by far, not always deadly. I don't want to give that impression at all.
Blood clots happen in the legs quite commonly. They do travel to the lungs, occasionally. And when they do travel to the lungs, about 5% of the time, they cause a serious problem. The big problem is that patients don't always make it to the hospital when they have a major blood clot in the lungs, and those are the ones we never find out about. So if a patient makes it to the hospital with a big blood clot in the lung, we can usually treat it pretty effectively, and make it so that they're not going to have long-term problems.
So what about people who are on blood thinners? If you've got a heart condition, you're on a blood thinner, does that make you more or less susceptible?
Yeah, sure. I'll take that one. So actually, the foundational treatment for blood clots is blood thinners. And so, really, if we can get somebody on a blood thinner if they have a blood clot, really, the majority of the time, that's going to be enough. A lot of the treatments that we'll probably talk about today won't be needed, but it's really for those patients who have a very large amount of blood clot, or actually cannot be on a blood thinner. Then we have to talk about different things that we potentially have to do to kind of intervene, and help prevent further consequences of that.
And I think most people, when they think of these venous conditions, they think of conditions with your legs, but it's not just your legs. Is that accurate?
Yeah, absolutely. So unfortunately, blood clots can occur anywhere throughout the body. Today, we're specifically talking about the veins. And within the veins itself, we've already talked about how those blood clots in your legs can break off and travel to your lungs. They can actually just propagate up, and go into your abdomen, or into your pelvis. Unfortunately, they can also occur in your neck, in your arms. A large variety of different places that they can occur, unfortunately. And we're actually showing a screen image here of a patient with a CT scan who has a very large clot in there. What we call the IVC, which is the largest vein in your abdomen that kind of drains all the blood from your legs.
And so this is actually very similar to a case we just did recently where a patient had a large amount of blood clot like this. And as you can imagine, when you have this significant amount of clot, that's life threatening because if that breaks off and goes to your lungs, those are the people that Dr. Paul's mentioned that might not make it even to the hospital. So those are the types of situations where we want to try to get in, and intervene, and try to take care of that blood clot.
So what kind of symptoms would somebody be showing if they had something like this happening? What would people need to look for?
So this is a pretty extreme case here, but if someone had this issue, they would present with swelling, pretty significant pain in the lower extremities as well. Again, we don't want everyone at home to think that they might have a clot that big just looming in their abdomen. If this were going on, you'd know it.
Sure. Pretty unusual situation. That's good. Let's talk about varicose veins for a moment, if we can. I think that's, again, a fairly common thing that people think of. How serious is that, Dr. Dorsey? And can people live with varicose veins?
That's a great question, and that's a question that I often get in clinic when I'm talking to patients. So just to back up a little bit. Varicose veins are kind of those bulging veins that you can see on the surface of your skin, and can also feel if you're kind of touching your leg. Varicose veins, spider veins, they usually come about because of the issue that we talked about earlier, which is venous insufficiency.
To answer your question, yes, you can live with their varicose veins. People can be kind of anywhere on a spectrum with respect to their varicosity. So some patients have no symptoms whatsoever. Some patients really, get a lot of aching, throbbing, fatigue, heaviness in their leg because of this issue, and that can affect them if they're on their feet a lot during the day as a caregiver or for work. And then some patients don't like the appearance of the varicose veins too. So at the vein clinic, we really try to take each person individually, and try to figure out a management plan that's appropriate.
So whether that's sitting down and just kind of talking about the severity of the condition. In some patients, it's just kind of preventing things from getting worse. But we also do a lot of minimally invasive procedures as well for patients who are a little bit more symptomatic, or if they don't like, again, the appearance. So the photo that they're showing you now is a patient in our procedure room as they're about to get an ablation procedure for venous insufficiency.
Interesting. And so what is the ablation procedure? What does that do?
Yeah. So basically, the kind of thought there is that you close off the superficial veins that aren't working as well, as Dr. Paul was saying. So that's that issue the venous insufficiency, where the valves are kind of pumping properly to get the blood up and out of the leg. So the idea is you close off those veins that aren't working well to reroute blood to veins that are working a bit better.
Interesting. We've got another question from a viewer. And this is how common is vascular disease in people in their 20s and 30s?
Go ahead, Ahmed
Sure. Yeah, so again, the short answer is it's not very common. But when we do see it, it's usually related to we have specific pathologies that we want to rule out. And pathologies is just sort of another word for a specific disease that we want to rule out. So you might hear things like thoracic outlet syndrome, or May-Thurner Syndrome. And what these are these are actually anatomic compressions in your body that actually-- where the veins are getting squeezed, and causing the blood flow to be inhibited. And so we commonly see things like this in younger patients, and so when we do see blood clots or vascular disorders in those patients, we want to rule out something more than just kind of a plain, old blood clot from sitting on a plane too long.
Yeah, and I might add, also with regard to DVT or blood clots within the legs, we typically see these in younger patients that are on oral contraceptive medications. That's a risk factor for forming deep vein thrombosis. So women on birth control. Sometimes we see younger patients that are smokers, or obese, or sort of live sedentary lifestyles that develop these deep vein clots as well.
We also see venous insufficiency and varicose veins in the young female patient. So women are at increased risk for developing this issue. Having multiple pregnancies also puts you at increased risk for getting varicose veins.
So let's get back to-- let's talk a little bit more about various veins. The symptoms, obviously, you can see them, but what are some of the other symptoms that somebody might notice.
Sure. As I kind of described before, a lot of times it's aching, throbbing, heaviness. A patient will just say that their leg feels really tired, and that's particularly after they've been on their feet for long periods of time. Some patients will describe burning or itching overlying their varicosities. So those are kind of the typical complaints, and then swelling is also involved.
And these are things you'll take care of in the vein clinic. What other things happen at the vein clinic? Is that fairly new?
Lots of exciting things. So we've had a vein clinic for a while, but we're expanding outpatient procedures to Orland Park in South Loop now, but we do it all. We'll focus on conservative management for some patients. So that's making sure they've got good compression stockings, leg elevation, maintaining a healthy weight. Those are all really important things for vein health.
We also do sclerotherapy for spider veins. So that's more about cosmetic procedure that we do in the office for patients with that issue. Then we do those minimally invasive ablation procedures, which you saw that photo a bit earlier. And then we do some surgical procedures as well, including phlebectomies, which is where you basically make little tiny incisions to remove the varicosities directly.
Great. Dr. Ahmed, how do you diagnose a venous condition? And I think we have some images that maybe we can-- some looped images that may work with what you're going to talk about.
Sure. Well, you're asking the radiologist. So of course, I'm going to say the answer is imaging. The workhorse imaging modality that we use to diagnose DVT, specifically clot in the legs, is going to be ultrasound. It's cheap, it's fast, and it doesn't utilize radiation as well. So this picture that we're showing you here is a picture of an abnormal vein in your leg.
Essentially, what that's showing you is clot there. And the way to really see this is that there's no flow. So the next picture we're going to show you is a normal vein, and it's going to be very obvious, as you can see there. There's that bright blue color that actually signifies that there is blood flow within the vessel returning towards the heart, and so that vessel is wide open with good blood flow, as opposed to the other one where there was no blood flow detected.
The additional modality that we use when we can't image-- so if a patient is very large, or we want image other places where ultrasound can't reach, really is we like to use CT. And so specifically, also for Dr. Paul who is treating a lot of the PE patients, is we utilize what we call CT or CAT scan.
Great. More questions from our viewers coming in. How do you remove a blood clot? Throw that up to anybody.
Well, I'll take that. That's one of my favorite questions. So all three of us, we have a bunch of great options available to us to try to help patients who, when indicated, to remove that blood clot. So the main way that we try to take care of a blood clot, especially when it's fresh or acute, is to infuse medications that essentially dissolve the blood clot like a clot-busting medication, and that's called TPA is the most common medication that we use. If needed, or if we don't want to give the TPA, we can actually use devices.
Again, we're sort of like glorified plumbers. It's just basic plumbing. Meaning, we go in there, we roto-rooter the clot out. So we have devices that actually will manually extract that clot, and Dr. Dorsey could probably speak a little bit more to that, especially from a surgical perspective. When blood clot sticks around for a very long time, it's kind of hard to explain to patients, especially, because the vein actually starts scarring and kind of disappearing. So we actually have to open that back up, again, using minimally invasive methods to either balloon open the blood vessel, or actually place a stent, like a metal stent.
So the last thing I'll say also about that is if patients can't have the blood clot removed or there is a large amount of blood clot, but can't get any medications to dissolve it, we also place a device called IVC filters. There's a lot of misinformation out there about these devices, but the reality is that when they're used appropriately, they actually do help patients, and we place them when indicated to kind of help those clots from actually physically traveling from the legs to the lungs.
And then I'll add. From a surgical perspective, we have a few options. We obviously try to stick with the minimally invasive methods, if possible, but sometimes you need a more immediate fix. And so in those circumstances, we'll actually do a surgical procedure, either a thrombectomy or an embolectomy, where we, essentially, visualize the vein directly, and make a small incision in it to try to remove as much of that clot as possible.
With the thrombolysis, which was just described, sometimes that can take 24 to 48 hours for you to really see improvement in patients. So for some people, doing a surgical procedure is what's necessary. When there's large, extensive blockages, we'll also do some venous reconstructions on patients. That's a little bit more rare, but we can do reconstructions or bypasses around large blockages, if necessary, as well.
And I think maybe, if I could add also, I think what's really nice and unique about our program is that we work together. We like each other, and we have we have specialists in a number of different specialties. We have vascular surgeons, we have radiologists, we have cardiologists and others that discuss this. This is a complicated issue. There's no one size fits all solution to any of these problems. And so we often will discuss patients from a multidisciplinary standpoint, and try to figure out how we can work together to really take the best care of patients possible.
That's fantastic. More questions coming in from viewers. So I want to get to as many as these as we can. Does losing weight to make vascular disease go away?
So maintaining a healthy weight is definitely helpful for the health of your veins. So that's definitely easier said than done. So in most of my patients, I'm recommending a heart healthy diet. So the quick answer to that question is yes, maintaining a healthy weight can help significantly.
Perfect. Another question from a viewer. Would the pain feel like leg cramps?
It definitely can. Pain from a deep vein clot-- I'm assuming that's what the question is, is about a deep vein thrombosis-- can definitely feel like leg cramps. It can feel like a heaviness, a soreness, sometimes there's redness or tenderness of the leg, but cramping is a common complaint.
We're getting close to the end of the time for the program, and there's one thing I want to touch upon because I'd like for you to talk to us a little bit more about the comprehensive venous thrombosis and pulmonary embolism program. Don't know who wants to kick that one off, but if you can just kind of--
I can take us down that one.
That would be great.
Yeah. So as I was sort of alluding to just a minute ago, we have a nice group of physicians and specialists here at the University of Chicago that help to diagnose, treat, and follow these patients with any of these conditions, and in particular, with the venous condition, such as DVT and pulmonary embolism. We have a group of physicians that will take care of patients in the hospital. I'm particularly interested in pulmonary embolism. So we have a group of physicians that are part of what we call the Pulmonary Embolism Response Team or the PERT program.
When a patient comes in with a life threatening PE or otherwise, we get together very quickly, whether it's the middle of the night or the middle of the day. We discuss the patient. We discuss the best management for the patient. And oftentimes, we'll come into the hospital, and take care of the patient the middle of the night. We also discuss these patients in follow up. So we'll have patients that come into the clinic several months after they have their DVT or PE event.
We'll discuss blood thinners. We'll discuss IVC filter removal, if necessary. We'll discuss genetic testing for potential underlying conditions that make folks more predisposed. This is all under the umbrella of what we call the Comprehensive Venous Program or the Comprehensive Venous Thrombosis and Pulmonary Embolism program. We all work together. It's a great program. I think it's a unique thing we have here at UChicago Medicine, and we're growing every day.
Fantastic. Well, you three were fantastic.
Thanks for having us.
Appreciate it. That's all the time we have for the program. Please remember to check out our Facebook page for future programs, and helpful health information. Also, if you want more information about UChicago Medicine, please take a look at our website at uchicagomedicine.org. If you need an appointment, give us a call at 888-824-0200. Thanks again for being with us today and I hope you have a great week.
Chelsea Dorsey, MD
Chelsea Dorsey, MD, provides comprehensive care for individuals with arterial and venous conditions. Her treatment algorithms involve medical management, minimally invasive interventions and open surgery.Learn more about Dr. Dorsey
Jonathan Paul, MD
An interventional cardiologist, Jonathan D. Paul, MD, uses minimally invasive, catheter-based techniques to diagnose and treat cardiovascular diseases. In particular, he provides care for patients with coronary artery disease, peripheral vascular disease, aortic disease, and structural heart disease.Learn more about Dr. Paul
Osman Ahmed, MD
Osman Ahmed, MD, is an expert vascular and interventional radiologist who diagnoses and treats a wide range of conditions. Using image-guided technology and small, sophisticated instruments, Dr. Ahmed performs minimally invasive procedures for acute and chronic deep vein thrombosis, benign prostatic hyperplasia, peripheral vascular disease and more.Learn more about Dr. Ahmed