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Video Transcript: Blood Vessel Disorders

Part One:

Ellen Beth Levitt: Welcome to Maryland Health Today. I'm Ellen Beth Levitt. Blood clots-and other types of blockages in the arteries or veins in the legs- can have serious health consequences. On the show today, we'll talk about the symptoms and treatments for deep vein thrombosis and peripheral arterial disease. My guest is Dr. Ziv Haskal. He's the chief of vascular and interventional radiology at the University of Maryland Medical Center. Dr. Haskal is also a professor and vice chairman of diagnostic radiology at the University of Maryland School of Medicine. Welcome to the show.

Ziv Haskal, M.D.: Thank you.

Ellen Beth Levitt: When we're going for a long ride in a car or on an airplane, we often hear advice that we should stand up and move around occasionally-to avoid deep vein thrombosis. For those of us who aren't familiar with it, would you explain what it is?

Ziv Haskal, M.D.: It is a blood clot that often forms or can form in your calf or even in the side from those long plane rides.

Ellen Beth Levitt: Why is the condition called "Deep vein" thrombosis?

Ziv Haskal, M.D.: Most of them happen in the leg, although some in the pelvis. And there are two sets of veins in the leg. There are the superficial ones, the ones we often think of as causing varicose veins. But the deeper system that is visible is the one that can develop the clots and those the fear complication can potentially break free, move to the lungs, and that's the pulmonary embolism.

Ellen Beth Levitt: So that's why it's dangerous?

Ziv Haskal, M.D.: It can be life threatening.

Ellen Beth Levitt: How common are these?

Ziv Haskal, M.D.: More than half a million patients who are affected by this.

Ellen Beth Levitt: You mentioned that the clot can go to the lunges. How often is it going to go to the lungs?

Ziv Haskal, M.D.: Depending on the size of the lungs, it supplies blood, and blood leaves one side of the heart to get reoxygenated and gets sent back to deliver oxygen to all organs and muscles. They are pumping against obstruction.

Ellen Beth Levitt: It could go to the heart or the brain?

Ziv Haskal, M.D.: It turns out that there are multiple plumbing systems. The arteries are the ones that can actually go or travel and can cause stroke. Heart attacks are usually blood clots as well. This is primarily on the vein side.

Ellen Beth Levitt: It doesn't go up. So it would stop in the lungs.

Ziv Haskal, M.D.:And it actually travels through a different side of the heart on the way to the lungs. So it does a drive by on the way to the pulmonary arteries.

Ellen Beth Levitt: What would be the symptoms of DVT?

Ziv Haskal, M.D.: They vary from the most dramatic ones. It can affect the entire thigh and calf. A sense of tightness in the calf that may be a symmetric. You feel like one leg is aching like you have a charlie horse or something like that. Some of these signs are actually a bit subtle, which are concerning because, as we said, this can result in a very serious illness.

Ellen Beth Levitt: Are some people more at risk to deep vein thrombosis than others?

Ziv Haskal, M.D.: Yes, they have until their first DVT an unrecognized thickening of their blood. It's more prone to blood clotting than other patients. DVT is the thing that triggers all the blood tests that try to identify the hypercoagulable conditions. But also recent operations or obesity or long immobility.

Ellen Beth Levitt: And even pregnancy can raise your risk?

Ziv Haskal, M.D.: Yes, it can depress those veins and make blood more prone to clot.

Ellen Beth Levitt: How do you diagnose this?

Ziv Haskal, M.D.: It's being aware. Getting to your doctor, and the most typical first test is actually an ultrasound.

Ellen Beth Levitt: If you have this, should you get to a doctor right away or go to a family doctor?

Ziv Haskal, M.D.: I think all those are great possibilities. I think any doctor should be able to think of this diagnosis and refer you if suspected to an ultrasound department or radiology department to have these studies.

Ellen Beth Levitt: You mentioned that about 600,000 DVT's occur every year, and people die from pulmonary embolisms that occur from these. It sounds very serious.

Ziv Haskal, M.D.: Many of them are patients who are very ill in the hospital and have that developed on top of other illnesses as well, but walking and relatively healthy, these kinds of conditions can occur as well.

Ellen Beth Levitt: How is it treated?

Ziv Haskal, M.D.: First is preventing the pulmonary embolism, the pulmonary blood clot that has moved to the lungs. Preventing the second one if you survive the first, and minimizing the symptoms to the actual leg. So blood thinners work very well at reducing the risk of having a second pulmonary embolism or more blood clots forming in that leg.

Ellen Beth Levitt: How long would someone be on blood thinners then?

Ziv Haskal, M.D.: Three to six months.

Ellen Beth Levitt: That's a long time.

Ziv Haskal, M.D.: It is. It hardens and eventually heals to some degree. That's very effective at reducing it dramatically. It doesn't entirely though, affect the limb, and that's been a change in how we have been thinking of DVT in years.

Ellen Beth Levitt: Will taking aspirin help if someone thinks they might have this condition? Popping a couple of aspirin?

Ziv Haskal, M.D.: It's very important if you think you're having a heart attack, but i don't think there's any indication that that would be the first treatment. You brought up a first and early suspicion and reaching your emergency department or doctor is the way to go.

Ellen Beth Levitt: And in terms of treatment, the blood thinner takes care of the clot, but people can still have continuing symptoms in the leg that should be checked out?

Ziv Haskal, M.D.: Our medical term for that is postthrombotic syndrome. What a blood thinner does is prevents development of moving the blood clot, but it doesn't in fact dissolve a blood clot, and that may take weeks. What we have realized is that the weeks it may take, if you're lucky, actually wreak havok on the veins. The veins become damaged and often permanently scarred. And that results in the symptoms of the postthrombotic syndrome.

Ellen Beth Levitt: That's where you as a radiologist would come in?

Ziv Haskal, M.D.: Yes. They're far more common and occur faster than many of us would realize. Legs are swollen, fatigued, and behaves differently with prolonged standing. You might not stand in a long line to buy tickets for it because that leg feels different and permanent. As an interventional radiologist, it's a different term. We're the specialty that does image-guided treatments with tiny little tubes. We treat a lot of conditions ranging from diseases to fibroids to targeting cancers to DVTs using tiny tools and imaging instead of operation and incisions.

Ellen Beth Levitt: You watch what you're doing on different imaging --

Ziv Haskal, M.D.: An X-ray camera, or in some occasions, even under MRI guidance.

Ellen Beth Levitt: So what are we seeing here? Is this the typical setup for an interventral radiology laboratory?

Ziv Haskal, M.D.: Yes, we're looking at a fluoroscopy suite. We measure their blood pressure and make sure that they're relaxed. Our patients are typically awake, they don't need to be asleep, but there's a very large camera that allows us to see what's inside. We can move something with a very small tube in another location in the body so we can do very large treatments with very tiny pencil-tipped size holes.

Ellen Beth Levitt: So how do you treat these clots in the deep veins. You go in there and break them up?

Ziv Haskal, M.D.: Right. So the object really is to not have to wait those many months for the blood clot to dissolve and have the damage to the vein walls and prevent it from going back wards in our legs. We have a number of devices, we're seeing an animation of it on the screen, a tiny tube with some balloons on the end with clot-dissolving medication. It will break it up into little things, and that, with a clot-dissolving medication, TPA, allows us to then suck it out actually and dry it out through a tube.

Ellen Beth Levitt: I was wondering if there was little pieces of a clot left behind, but it looks like this system sucks the pieces of the clot into the tube and whisks it away.

Ziv Haskal, M.D.: And it turns out that veins are tolerant of having little clots like that. You can see how small it is, and we can put this in as if it were a small iv, and it has a giant pump that is connected to the very back of it that allows it to spray and suck the blood clot out of it. Here's a newer device that's come out. If you can see this little brow string wire. This is actually an ultrasound vibrating wire, and ultrasound vibrations, too fast to see, it will actually create shock wave bubbles. This starts from behind the knee. We go upstream in this and use these devices to clean out that vein and after one session, or possibly two, a band aid on the back of the leg and then, of course, the blood thinners. You still need the blood thinners to prevent the return of the blood clot. But the idea of getting rid of it early on, you prevent the damage of that that leads to that disabled formality.

Ellen Beth Levitt: How would someone know if they need to have this radiology procedure in addition to the blood thinners? Are there certain people -- who are advised that they should have it more than others?

Ziv Haskal, M.D.: Well, Iâve been looking for ways to make this faster and easier on patients and not what it used to be, which was a much longer procedure. It's really a one-day, probably go home the next day, procedure. There's a gap between primary physicianses and emergency rooms and the knowledge of the availability. To be honest, many of the patients have come to me over the past few years, and they've been self preferred. With 80 other million americans who use the internet for information. They don't necessarily have physicians that are aware of this. Part of this is just being aware of what your options are.

Ellen Beth Levitt: We have to take a break, but when we come back, we'll talk about peripheral arterial disease. So stay with us, we'll be right back.

Part Two:

Ellen Beth Levitt: Welcome back to Maryland Health Today. I'm Ellen Beth Levitt. On the show today, we're talking about some common conditions that cause blockages in blood vessels in the legs and ways to treat them. My guest is Dr. Ziv Haskal. He's the chief of vascular and interventional radiology at the University of Maryland Medical Center. Dr. Haskal is also a professor and vice chairman of diagnostic radiology at the University of Maryland School of Medicine. An estimated 10 million people in the U.S. have a condition known as peripheral arterial disease. It's also sometimes called claudication. What is it?

Ziv Haskal, M.D.: Claudication is a small piece of peripheral arterial disease. We have a lot of arteries. We have arteries in our legs and arms. That's what we call peripheral and blockages or some people include kidney arteries as well get included in this diagnosis of peripheral arterial disease. It's pain in the calves or thighs that come from having a blocked artery. It's like traffic. You exercise when means you demand more blood from that muscle, and that can't supply more blood flow to it. People get pain. People take a rest, and they start to walk again and may hit another point at which that returns. That clot, that's a very typical symptom.

Ellen Beth Levitt: So the symptoms are when you're walking and things, you get more pain, and you feel like you need to rest? Your legs might feel cold; is that right? Or you might feel some numbness occasionally?

Ziv Haskal, M.D.: With chronic peripheral arterial disease, you may notice the loss of hair on the leg. Very often, patients will not describe it as pain but an actual tightening in the thigh or pain around the knee in some cases. There are a lot of things that may mimic arthritis. We underdiagnose pad because we think it might be the other things when, in fact, it really is pad.

Ellen Beth Levitt: What's causing these blockages? Is it blood clots or more of the fatty deposits?

Ziv Haskal, M.D.: It's that western diet. That cholesterol-rich diet that we enjoy that causes these.

Ellen Beth Levitt: Are some people more at-risk than others?

Ziv Haskal, M.D.: The same types of risk factors include heart attack and smoking and high blood pressure as well can be associated with pad.

Ellen Beth Levitt: And people who have diabetes as well?

Ziv Haskal, M.D.: Very much so.

Ellen Beth Levitt: What kinds of tests do you do to confirm someone has pad? Why is it important to diagnose pad early?

Ziv Haskal, M.D.: Well, there's a very simple test called the abi which is actually a comparison of blood pressure in the thigh to blood pressure in the arm. The ratio between that can tell us, in fact, whether you have some reduced blood flow in the legs. The american heart association published some guidelines which i was the co-chair of a few years ago that made some recommendations with patients over 50 that have risk factors. Everyone over 70 should have this test to look for pad.

Ellen Beth Levitt: It's just a simple ultrasound test, right?

Ziv Haskal, M.D.: With a blood pressure cuff, yes. This year, we'll be rolling out a national program to get front line physicians to be able to use knees tests to screen their patients. So you can get that screening information from your doctor and perhaps not have to figure out on your own that you need to see a physician.

Ellen Beth Levitt: How is this treated?

Ziv Haskal, M.D.: It really depends on the symptoms. We break it down into lifestyle limiting pain or tissue loss. Some people have a leg at-risk for amputation, and an average of months of delayed before there's potential limb loss to a vascular specialist. The first thing if you've got that, make sure you're in touch with somebody to treat it. We do have a lot of very potent, less invasive surgeries than we had years ago. Ones that don't require surgery that can be done with catheters.

Ellen Beth Levitt: And you actually brought some stents along. We've heard about stents that are used in angioplasties, are these stents also able to be used in people who have this problem?

Ziv Haskal, M.D.: Absolutely. There are lots of different kinds of stents, and they are one of the more important inventions of the last century. I use tiny little tubes the size of a tip of a pencil to move x-ray cameras to be able to fix things like a abnormal arteries and veins. There are many different types of stents, and you can make it into something really small. Everything goes in without surgical incisions. This is actually a very interesting one. You can see that it's white, and this particular one has gortex, the same one we have on clothing. It's called a stent graft, and we can put this liner to prop it open and prevent those fatty tissues from getting through. It's really a compelling and advanced tool to treat pad.

Ellen Beth Levitt: And that just stays right in the vessel?

Ziv Haskal, M.D.: It does, the stent actually supports and presses open. When you have the surrounding graft, it may have some role in pad. We can do some more local therapies to that than just push it back?

Ellen Beth Levitt: When people have this, do they usually have just one area of deposits or multiple ones, and you can you treat multiple ones as well?

Ziv Haskal, M.D.: The extent of the disease certainly affects the type of treatment that we have, and more extensive type of treatment may lead to more symptoms as well. We do have newer abilities to treat different types of arteries. They are really the arteries in the thigh from the groin to the knee. That's called the sfa. We've got a lot of tools to keep these open after these operations.

Ellen Beth Levitt: What's the recovery like when you have these treatments?

Ziv Haskal, M.D.: It's often an overnight stay. There's no surgical cutting or sewing. The opening might be the size of a pencil tip, but there's lying in the bed afterwards, and hopefully, you're up the next day and testing out your leg.

Ellen Beth Levitt: All right. Iâve heard that peripheral arterial disease might be signs of heart attack or stroke. Is that true?

Ziv Haskal, M.D.: That's a really important point. We have far more patients that have peripheral arterial disease than necessarily should have treatment for it. Just because you have it, it doesn't mean you need to have it treated. It is a marker for having heart disease or possibly it has in the arteries or the corroded arteries. You can see from that graft, the blue one is heart disease, the yellow one is peripheral arterial, and they all meet in the middle.

Ellen Beth Levitt: They overlap.

Ziv Haskal, M.D.: It means that having pad sets you at higher risk. It's a marker for coronary disease, and we'll often use that for your cholesterol-lowering drugs. Those stats that have been in the news the last several days are as important for pad patients. If you've got peripheral arterial, you potentially have them everywhere.

Ellen Beth Levitt: You could have them system wide, and that could be a good alert for you to know that you need to have further investigation treatment and so forth. Prevention, of course, is the key, right?

Ziv Haskal, M.D.: And diagnosis has become a much less-invasive one. We talked about a screen tool, but we also have magnetic resisence and geography. The days in which i did invasive angiograms to find out how extensive the blockage was before treating it are gone. We can go in and fix something and know exactly what weâre going to face.

Ellen Beth Levitt: That's really interesting. Technology has just gotten so sophisticated, hasn't it?

Ziv Haskal, M.D.: Yes.

Ellen Beth Levitt: For preventing these problems, lifestyle things, what would you recommend?

Ziv Haskal, M.D.: Get with your regular doctor. Make sure your risk-factors are controlled. Quit smoking. Think about fish oil, perhaps, if it's appropriate. Talk with your doctor.

Ellen Beth Levitt: Exercise maybe?

Ziv Haskal, M.D.: Exercise is critical.

Ellen Beth Levitt: Keeping a normal weight. Eating lots of fruits and veggies.

Ziv Haskal, M.D.: Perhaps.

Ellen Beth Levitt:There's lots of things we can do to prevent these problems. Thank you very much.

Ziv Haskal, M.D.: Thank you for having me.

Ellen Beth Levitt: My guest has been Dr. Ziv Haskal. He's chief of vascular and interventional radiology at the University of Maryland Medical Center. Dr. Haskal is also a professor and vice chairman of diagnostic radiology at the University of Maryland School of Medicine. If you have any comments or questions about this program, please contact me by e-mail at eblevitt@umm.edu. If you'd like to reach Dr. Haskal or any other University of Maryland Physician, call 1-800-492-5538. Or, visit the web site, where you'll find a great amount of health information and be able to see other Maryland Health Today programs: the address is www.umm.edu. Take good care of yourself -- we'll see you next time for Maryland Health Today.

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This page was last updated on: December 18, 2008.

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