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DVT and Saddle Pulmonary Embolism
Posted February, 2014
At the time I was a 48-year old, divorced mother of three grown children. On July 25, 2012 I had surgery on my right foot. I was back at work five days after the surgery, only missing three days of work. I had to wear a boot to protect my foot for 4 weeks after the surgery and was advised to keep my foot elevated as much as possible. About 2 or 3 weeks after the surgery, I began having an occasional feeling in the back of my leg, like the tendon was overextended or strained, and thought it was from elevating my leg on a chair at work. This sensation continued to increase but wasn’t terribly painful to cause me to be alarmed.
Then on Wednesday August 22, 2012, a little after lunch, I was walking down a hallway at work when I suddenly felt my heart beating erratically, shortness of breath, pulse racing and like I might pass out. I debated about having someone take me to the ER, but instead waited the 15 minutes for my doctor’s office to open at 1:30, and called there. They told me to come in at 3:00 p.m. that afternoon. I told my doctor my symptoms, and he told me to increase the medication I take for an irregular heartbeat (premature ventricular contractions or PVC’s), which I did. I continued with shortness of breath but it wasn’t so severe that it stopped me from doing anything, so I thought it was from the PVC’s. He didn’t ask, and I didn’t know it was an important symptom at that time, that my leg was hurting down the back.
Six days later, by Tuesday August 28th I noticed swelling at the back of my ankle and the pain in my right calf and thigh had increased to where it was concerning me. I was still wearing the boot from my foot surgery so at this point I was afraid of a blood clot. I called my doctor’s office, and was told to come in right after lunch. My doctor felt on my ankle and lower calf, but didn’t have me lift my pant leg to look at my leg. Because my ankle and lower calf were not extremely painful when he felt them, he didn’t think I had a blood clot, but wanted me to have a blood test to check my clotting factor which would show if I had blood clots. I told him it was hurting up above my knee, but he did not check that area, he just had me go for blood tests and said he would call me if there was a problem with my clotting factor. I did not hear from my doctor that afternoon, so I figured there wasn’t a problem with my blood clotting. Later that evening after I arrived home, at about 8:30 p.m., I was changing out of my work clothes, and when I took off my pants I saw that it wasn’t just my ankle that was swollen, my calf was swollen. I looked on the Internet to read about blood clots and because my leg didn’t seem hot or red, and also because I had not heard from my doctor’s office to say I had a blood clot, I went to bed and elevated my leg.
On Wednesday August 29th when I got up at to get ready for work, the swelling in my leg was down. I got ready for work, but the pain in my right leg was getting increasingly worse. I went to work and was anxiously waiting for doctor’s office to open at 9 to call. The pain in my leg was bad enough that I wanted to cry any time I would get up and walk around. Thirty minutes seemed like two hours. After 9 a.m. I called my doctor’s office to let them know about the pain being worse, and the nurse said my blood work from the day before was normal. I told her my leg was hurting so much that I wanted to cry and there had to be something wrong. So the nurse said she would check with the doctor and call me back. About an hour later she called back and said the doctor had ordered a venous doppler scan for 1:00 p.m. at the hospital. Upon doing the scan, the tech did find blood clots in my right leg from the mid to distal femoral vein extending into the popliteal and posterior tibial veins, and I was immediately admitted to the hospital. After being admitted, a CT scan was done on my chest and clots were found in both my lungs. (After being discharged, I got a copy of the CT scan results and it stated I had a “saddle pulmonary embolus with additional more distal involvement of the lobar, segmental, and subsegmental branches.”) I was then told by my doctor to not get out of bed, not even to go to the bathroom, I was to use a bed pan, and to keep my right leg still, because the clots were very bad, but at this point I still didn’t understand or know how bad they were.
On Friday my doctor went on vacation so a different doctor took over my care and she called in a pulmonary specialist. When the pulmonary doctor came to see me Friday evening about 8:00 p.m., he told me that I had a large saddle pulmonary embolism, that I should not be alive, and he didn’t know why I was alive - which was very shocking to hear to say the least. The pulmonary doctor explained that he wanted to do an injection to
break the clot in my lungs which had to be done within 3 days, however, when I explained it had apparently happened the week before, I was not a candidate for that procedure. Because I had a massive femoral clot which could cause instant death if it dislodged, my doctors then decided to see if I was a candidate for a vena cava filter. They called in a tech to do an ultrasound on my heart that night and a cardio-thoracic surgeon was consulted about placing the vena cava filter. Thankfully my heart was not damaged. I was told the procedure was going to be scheduled for the filter to be placed possibly on Saturday, but maybe not until Tuesday because it was a holiday weekend. Because I now realized how serious my condition was, I called in my children on Saturday morning in case I didn’t survive. I did not want them to be mad at God and if I passed I had to stress to them to become closer to God. I will always be grateful to the doctor who took over my care that Friday, the surgeon, and the staff, because even though it was a holiday weekend, they arranged for staff to come in Sunday morning so that I could have the vena cava filter placed.
I am now 9 months down the road and so very thankful to God for sparing me. I have been told the vena cava filter will be removed and I should expect to be on warfarin for one year, which is now only three months away. Am anxious to find out at my next doctor’s appointment if this is still the plan. I am apprehensive about having the filter removed and not being there for security, but trust my doctors, and most of all trust God.
Even though I know I should be joyful every single day and not let anything get me down, I have been through a range of emotions from high to low in dealing with what happened. I still get nervous when I have pain in my leg, tightness in my chest, or feel like something might be going wrong again, but what has gotten me through every day without letting fear consume me, is knowing that God is in control. I am in awe and humbled of how God spared me, and thankful for the healing that takes place every day, physically and mentally. God is great & life is good.
Editor's Note from Henry I. Bussey, Pharm.D.: There are at least 3 points in this case that deserve comment. First, because clot-preventing research has focused so much on hip or knee replacement, clinicians do not always fully appreciate the extent to which milder forms of injury or foot surgery may increase the risk of deep vein thrombosis (DVT) - especially if the foot is immobilized as in this case. Something as "minor" as a strain of the achilles tendon can increase the risk of DVT several fold. Second, although a negative d-Dimer test usually eliminates blood clotting from the diagnosis, this is not true in all cases. Up to 2% of patients with active clotting may have a normal d-Dimer test and a positive d-Dimer may become negative after the clot has stopped forming. Also, the d-Dimer test is reported in different units so that it is important to be sure to compare the reported results with the normal range for the specific lab. If the symptoms and clinical circumstances strongly suggest a blood clot, then further testing should be considered even if the d-Dimer is normal (not elevated). Third, placement of an inferior vena cava (IVC) filter helps protect against blood clots going to the lungs (pulmonary embolism or PE), but these devices increase the risk of having another DVT by as much as 10 fold in one recent study. Until fairly recently, placement of an IVC filter (which could not be removed) meant that the patient would be a candidate for life-long anticoagulation because of the increased risk of DVT. Removable IVC filters are now available which can be taken out after the period of risk has passed so that life-long anticoagulation may be avoided.
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