Recognize a venous thrombosis

Acute venous thrombosis is often noticeable by a feeling of tightness and one-sided leg swelling in the case of venous thrombosis of the leg or arm swelling in the case of venous thrombosis of the arm.

Venous thrombosis of the calf is the most common form, accompanied by a usually acute pain in the calf. The dull pain in the lower leg can therefore be the first sign of venous thrombosis. Typical triggers of venous thrombosis are any kind of immobilization: long distance flights, long train or car rides, hospitalization with bed confinement, etc. However, venous thrombosis can often occur without a clear trigger, “out of the blue” so to speak. Acute venous thrombosis of the arm often occurs after a blood sample has been taken or an indwelling venous cannula has been inserted: via an initially superficial venous thrombosis, the thrombotic clot material grows into the deep venous system and causes acute venous thrombosis here. In order to detect a venous thrombosis, an ultrasound examination is necessary. It can be used to reliably detect or rule out venous thrombosis.

Venous thrombosis treatment must be initiated immediately if venous thrombosis is detected. Venous thrombosis treatment is intended to prevent further growth of the venous thrombosis. Another danger is concomitant pulmonary artery embolism. This arises from acute thrombosis in the deep venous system, usually venous thrombosis of the leg, due to thrombotic material in the deep conducting veins, which travels back to the heart via the venous system with the blood flow and then becomes entrapped in the lungs. Venous thrombosis treatment is started with blood thinning. Here, either heparin or an oral blood thinner as a tablet is given. This is accompanied by the fitting of an appropriate compression stocking or, in the case of pronounced leg swelling, the leg is first bandaged with a compression bandage.

A frequent cause for the development of acute venous thrombosis is varicose vein disease of the superficial skin veins. Initially, superficial venous thrombosis also occurs here, which then passes into the deep venous system via connecting veins / so-called bridging veins and can cause acute venous thrombosis. If varicose veins have already caused superficial phlebitis, varicose vein treatment is recommended. In contrast to the almost obvious superficial venous thrombosis, acute venous thrombosis of the deep veins can only be recognized clinically in a more unspecific way: e.g. by a difference in circumference of the affected extremity or by leg swelling. However, there is also an increased risk of thrombosis after any vein intervention, be it surgical varicose vein removal or spider vein treatment. Therefore, in the follow-up treatment of patients who have undergone vein surgery or other manipulations of the superficial leg veins, in addition to regular checks, it is necessary to wear a compression stocking as a prophylaxis to prevent the development of venous thrombosis. Under certain circumstances, drug treatment with heparin may also be necessary for the prophylaxis or treatment of venous thrombosis.
Lymphedema should also be considered if leg swelling is present. In this case, the swelling is predominantly in the forefoot. Lymphedema treatment is primarily based on physical treatment procedures. In addition to lymphatic drainage, this includes the fitting of a special compression stocking, similar to the treatment of venous thrombosis. Drug therapy with a blood thinner is not necessary here.

Arteriosclerosis treatment, on the other hand, also often involves the use of blood thinning drugs. Therefore, if acute venous thrombosis is present at the same time as PAOD, venous thrombosis treatment must be adapted accordingly and determined on an individual basis.

In summary, if there are signs of venous thrombosis, a medical presentation must be made immediately to confirm the suspicion and venous thrombosis treatment can be initiated promptly.

How long does a leg vein thrombosis last?

The duration of venous thrombosis treatment depends on various aspects and must be determined individually by the treating physician. Venous thrombosis treatment of the calf is usually carried out over 3 months with a medication for blood thinning and a lower leg compression stocking. If the venous thrombosis of the leg is localized above the knee joint or even in the pelvis, the venous thrombosis treatment must accordingly be longer, usually over 6 months. The acute phase of venous thrombosis is then over and the venous thrombosis has healed. Whether the venous thrombosis treatment must be continued over a longer period of time depends on the origin of the venous thrombosis: If there is a clear trigger (immobilization, previous knee or hip joint surgery, etc.), drug therapy can often be stopped.

However, if there is no clearly identifiable trigger for venous thrombosis or if there is a permanent trigger (e.g., an underlying malignant disease), venous thrombosis treatment must usually be continued over the long term. In this case, the dose of medication can usually be reduced in the maintenance phase. The compression stocking should also be worn for 3-6 months during the acute phase of venous thrombosis treatment. The goal is always the complete regression of the venous thrombosis. However, if leg swelling persists in the course of treatment or if damage to the deep venous valves or residual clots on the vein wall have occurred as a result of the thrombosis, it is advisable to continue compression therapy permanently. Furthermore, physical measures should be considered in the treatment of venous thrombosis, such as sufficient drinking volume (blood thinning), exercise, sporting activity, elevation of the legs, weight reduction, etc., if necessary.

How do I behave or what can I do in terms of exercise when I have thrombosis?

If venous thrombosis has been diagnosed and venous thrombosis treatment has been initiated, there is no reason to stay in bed. Moderate exercise such as walking is beneficial for the healing process when the blood is thinned and a compression stocking is worn on the leg. However, strength or endurance sports should be avoided for a short time during the acute phase of venous thrombosis treatment. The increased risk of bleeding during venous thrombosis treatment must also be taken into account. Extreme sports with an increased risk of injury should be avoided throughout the venous thrombosis treatment. Prolonged sitting or standing puts increased stress on the venous system, so we recommend elevating the legs and regular exercise during venous thrombosis treatment. The compression stocking should be worn consistently, i.e. daily during the day and washed out and dried in the evening for the next day. The stocking can be taken off overnight.

What should be avoided in case of thrombosis?

In principle, active nicotine consumption, especially in combination with hormone use (“the pill”), can promote the development of thrombosis. If an acute venous thrombosis has occurred, nicotine consumption should absolutely be discontinued. If necessary, the type of hormonal contraception must be changed or discontinued in the long term together with the treating gynecologist. In the acute phase, a continuation of hormone therapy is temporarily possible under the ongoing venous thrombosis treatment / blood thinning until a further concept is developed in cooperation with the gynecologist or similar. If venous thrombosis has already occurred under hormone therapy, for example, prophylactic venous thrombosis treatment with low-dose heparin must always be given if pregnancy occurs. Obesity and a lack of exercise can also promote the development of venous thrombosis. Moderate exercise, even in the case of an already existing venous thrombosis, is important in order to positively influence the healing success.

Prolonged sitting, on the other hand, promotes swelling of the leg due to failure of the calf muscle pump/venous pump. It is important to activate the calf muscle pump: this is activated, for example, when walking or performing venous gymnastics. Prolonged sedentary activity should therefore be regularly interrupted during venous thrombosis treatment or the legs should always be elevated. Wearing loose-fitting, comfortable clothing and flat shoes is also recommended. Exposure to direct sunlight, warm baths or saunas is also not recommended in the early phase of venous thrombosis treatment. If venous thrombosis treatment has already been initiated, continued immobilization (e.g. postoperative or due to illness) is more likely to be tolerated, since the venous thrombosis is treated by the initiated therapy and can heal.

What are the symptoms of thrombosis in the veins (venous thrombosis)?

The leading symptom of acute venous thrombosis is painful swelling of an extremity with a difference in circumference compared to the opposite side. Especially if a triggering event has occurred in advance (long car/bus journey, long-distance flight, inpatient hospitalization, previous operations, febrile infections, bed confinement). The occluded vein prevents blood from flowing back to the heart and backs up into the leg. The limb then feels painful and extremely bulging and swollen, as if it were going to burst. There may also be a bluish discoloration or so-called warning veins may appear in the superficial venous system due to the bypass circulation.

A superficial vein thrombosis has not yet penetrated the deep vein system and usually causes only a local, very painful reddening and palpable hardening of the affected vein. The swelling tendency is much less pronounced here. The thrombosed vein, associated with superficial phlebitis, is then palpable as a hard, coarse strand, painful to the touch and overheated.

How are patients with thrombosis treated?

If acute venous thrombosis has been diagnosed, venous thrombosis treatment must be initiated immediately. This is usually done with drugs to thin the blood. In addition to heparin, which is available as an injection, there are modern drugs that can be taken orally as tablets. In contrast to Marcumar, the direct oral anticoagulants (DOAKs) no longer require laboratory monitoring of the prothrombin time or individual dose adjustment in venous thrombosis treatment. However, blood count, liver and kidney values should be checked regularly during the course of therapy. Otherwise, direct oral anticoagulants are superior to marcoumar in terms of the benefit-risk ratio. In particular, they can be administered at half the prophylactic dose in the long-term treatment of venous thrombosis, which is not possible with Marcumar. The disadvantage is the still significantly higher treatment costs.

In the acute stage of venous thrombosis treatment, the full therapeutic dose of blood thinner must initially be administered. Depending on the extent of the venous thrombosis and the trigger mechanism, the dose can then be reduced or even completely discontinued in the further course of venous thrombosis treatment. A compression stocking is also used. This is intended to reduce the swelling tendency in acute venous thrombosis and to protect the venous valves in the further course of venous thrombosis treatment, since the thrombotic material that accumulates on the vein wall in venous thrombosis can permanently damage the vein valves and thus the vein function.

What is the goal of thrombosis treatment?

The aim of venous thrombosis treatment is primarily to prevent further spread of the thrombotic event. If there is an acute leg or pelvic vein thrombosis, there is a risk of pulmonary artery embolism. The thrombotic material is then transported from the leg toward the heart via the venous circulation. The blood clots then become entangled in the lungs, leading to acute pulmonary artery blockage/pulmonary embolism with acute restriction of oxygen exchange. In venous thrombosis treatment, the initiated blood thinning interrupts the procoagulant processes so that further carryover or further growth of thrombotic material is interrupted. This is the initial goal of acute venous thrombosis treatment. Once the material has stabilized in the first 3-6 weeks, the thrombosis must heal. Complete dissolution of the thrombotic material would be desirable, but the long-term result or the desired recanalization of the diseased vein varies greatly from individual to individual.

In venous thrombosis treatment, the compression stocking exerts pressure on the vein wall from the outside, so that the blood can flow back better from the leg towards the heart and the tendency to swell consequently decreases. Furthermore, the venous thrombosis treatment is intended to prevent valve damage to the affected vein wall, which in the further course can lead to a so-called post-thrombotic syndrome, which among other things becomes noticeable in a permanently existing tendency to swell.

After the initial thrombosis has healed, the question arises as to how to proceed with blood thinning in further venous thrombosis treatment. There are situations in which a prolonged continuation of venous thrombosis treatment, often not limited in time, makes sense. For example, if there is a permanent trigger (active tumor disease, coagulation disorder), venous thrombosis treatment should be continued. The aim here is to prevent a new thrombosis, the so-called thrombosis recurrence. However, the prolonged venous thrombosis treatment then takes place in a lower dosage, a prophylactic dose. If the trigger of the thrombosis is clearly defined (surgery, long-distance flight), the venous thrombosis treatment can usually be terminated after about 3 months, depending on the recanalization achieved.

Subsequently, in the risk situations described, it is recommended that consistent prophylactic medication be administered. Wearing a medical compression stocking is considered a prophylactic measure that can significantly reduce the risk of developing a new thrombosis. Likewise, consistent prophylactic blood thinning should subsequently be carried out in risk situations for the rest of the patient’s life. If there is already manifest venous valve damage in the sense of post-thrombotic syndrome, there is a permanent indication for compression therapy in order to prevent the development of serious secondary damage, up to and including open leg (ulcus cruris).

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