John is a 54-year-old man who had a blood clot in his right leg 3 years ago. Since then his leg has gotten progressively more swollen. He does not wear compression stockings since they are too hot for him. At the end of the day if he takes his shoes off he won’t be able to get them back on due to swelling. He gets home and immediately gets into a recliner for the evening. After waking up in the morning the swelling has improved some but not much. He has noticed a red-brown patch over the inside of his ankle which has been getting darker, and it is very tender there. He came to see me because he was worried that his circulation is getting worse and wondered if vein treatment could help.
Swelling is a very common symptom for people and is associated with vein disease. I see swelling in my practice every day, and here are some thoughts to help you understand what this problem involves.
Pay attention to the location of the clot in your leg, as the swelling depends on where the blood clot was. If it occurred in your upper thigh, swelling will involve the entire leg. If the clot is behind your knee, the swelling involves the calf. Then, after a DVT blood clot, there are three potential outcomes: it can dislodge, it can dissolve completely, it can partially dissolve.
One possibility, and the scarier of the three, is when the clot dislodges and travels through the veins to the lungs. The result is a pulmonary embolus or PE, which can be life-threatening. It’s important to see your healthcare provider with a blood clot so that he/she can take precautionary measures.
As the clot dissolves, it can leave the thin and fragile vein valves damaged and nonfunctional. These valves are important because they prevent the blood in the legs from backing up into the ankle and foot area. After a DVT, I often see patients who have developed vein reflux as a result. Vein reflux is when the valves don’t close completely and blood pools in the legs and ankles and, when the result of DVT, is a more severe condition than the usual form of vein reflux that we treat. It is called post-thrombotic syndrome (PTS) and is medically diagnosed using a venous reflux ultrasound. For DVT-related vein reflux, there is no specific treatment except the use of compression stockings.
An especially severe form of post-thrombotic syndrome occurs when the clot does not completely resolve. In this case, the vein valves do not work allowing vein reflux to occur, but because the clot hasn’t completely dissolved, the remaining clot leaves the vein permanently narrowed and constricted. This narrowing makes it difficult for blood to flow and increases venous hypertension even more. This combination is associated with more dramatic swelling, leg discomfort, and a higher risk of developing a skin sore. This too is diagnosed with a vein ultrasound. To treat this, you’ll need to wear compression stockings at the highest level of strength you can tolerate, such as 30-40 mmHg or higher.
People who have post-thrombotic syndrome suffer from debilitating leg discomfort, leg swelling, and poor quality of life. They are frustrated and aren’t sure what can be done to help them. They develop skin discoloration and tenderness due to stagnant blood flow and they often develop skin sores. The best way to get this sorted out is with a vein ultrasound and evaluation by a vein specialist. The best treatment is regular compression stocking use. I advise people with this condition to wear them from first in the morning to bedtime, and on a daily basis. The use of stents or surgery has not been very successful and is not recommended.
In the example of John, he had an ultrasound and was found to have an old scarred DVT with related vein reflux and a narrowed vein. I, therefore, did not recommend any vein treatments for him. I advised him to try using a wide mesh compression stocking to improve ventilation and comfort and to wear them daily.
A prior DVT blood clot can cause significant swelling and, even worse, lead to a skin sore that does not heal. The best approach is to get a venous ultrasound and evaluation with a vein specialist. Wearing compression stockings daily is the smartest way to relieve symptoms and prevent complications.