Tag: Blood

BLOOD THINNING MEDICATIONS PART 2: ANTIPLATELETS: PLAVIX AND ASPIRIN. WHAT ARE THEY AND HOW ARE THEY USED?

Posted on by Michael Kokinos

Last week I began a description of the medications that vascular surgeons use with a blog post on drugs used for anticoagulation.  This week, I want to describe a group of medications that also thin the blood, albeit through a different mechanism.  As discussed last week, the coagulation cascade works to turn the blood from a liquid to a solid.  A special group of cells in the blood mixed with red blood cells called platelets works simultaneously with the coagulation cascade to serve as the glue so to speak between clumps of red blood cells.  This bond that platelets facilitate with clotted blood helps clot to attach and build upon other collections of clot, thereby facilitating the control of bleeding that the clotting system was designed for.

Obviously, in the case of vascular surgery we often times want to prevent blood clotting from occurring.  The main agents we use are aspirin and plavix (clopidogrel).  In the early 2000s literature from interventional cardiology for minimally invasive heart procedures found that placing patients on aspirin and plavix together reduced the incidence of recurrent heart attacks as well as death.  This literature from cardiology has been extrapolated to the lower extremity circulation and allows the interventions we perform in the lower extremities to fix blood flow to stay open for a long period of time.  In addition to the use of aspirin and plavix for lower extremity arterial blockages, we also use it in patients who have had a stroke in order to help prevent them from having another stroke.

Aspirin is a low strength blood thinner that patients can take orally as an 81 mg tablet once a day.  In the body aspirin blocks a specific enzyme called cyclooxygenase.  When cyclooxygenase is inhibited, the enzyme cannot help to produce chemicals in the blood called prostaglandins.  Prostaglandins are normally responsible for creating an environment that stimulates the clotting of blood via complex but mild mechanisms.  Studies have shown generally that patients with cardiovascular disease have a lower incidence of death, stroke, and heart attack over time than patients who do not take aspirin.  In general, I tend to make sure that all my patients who have peripheral vascular disease take aspirin as a general preventative measure.

Plavix is a much higher strength blood thinner that binds directly to platelets and completely inhibits their function.  When used in concert with aspirin, the blood becomes thin enough to prevent the recurrent blockage of vessels that we have opened up.

Overall the large majority of my patients who receive procedures to fix blood flow to the foot are placed on aspirin and plavix.  If you think you might benefit from these medications or are in need of a procedure to fix the blood flow to your feet or brain, please do not hesitate to call my office to schedule an appointment!

 

South Bay Vascular Center and Vein Institute is Silicon Valley’s largest and most trusted Vascular Surgery practice.  Serving South Bay communities for over 26 years, Dr Kokinos and her Colleague, Dr Ignatius Lau are the region’s foremost experts in advanced vascular care and provide innovative care for patients suffering from circulation relation problems. At South Bay Vascular Center and Vein Institute our job is to understand the “Why” so that you have real solutions to living a healthy life. Call us today at 408-376-3626 or visit our website at www.southbayvascular.com to learn about what makes us the most referred to vascular surgery clinic in Silicon Valley.

CLICK ON THE LINK BELOW TO READ HOW OUR PATIENTS DESCRIBE THEIR EXPERIENCE AT SOUTH BAY VASCULAR.

https://www.google.com/search?q=south+bay+vascular+center&rlz=1C1GGRV_enUS748US759&oq=&aqs=chrome.0.69i59i450.91302019j0j7&sourceid=chrome&ie=UTF-8#lrd=0x808e34eecfbc0653:0xb9aa2de7f50ba6a5,1,,,

 

BLOOD THINNING MEDICATIONS PART 1: ANTICOAGULANTS: WHAT ARE THEY AND HOW ARE THEY USED?

Posted on by Michael Kokinos

Over the next few weeks, I want to discuss the medications that vascular surgeons may prescribe.  These medications include anticoagulants, antiplatelets, statins, and other miscellaneous agents.  This week I will discuss anticoagulants!

Anticoagulation refers to agents that STOP the clotting of blood.  The clotting of blood starts with what is known as the coagulation cascade.  The cascade refers to a series of consecutive events each involving special proteins that are needed to occur for blood to form a clot.  Different anticoagulants block specific parts of the cascade.  The main reason we usually see patients with anticoagulants are for hypercoagulable states, certain heart arrhythmias like atrial fibrillation, and deep vein thromboses otherwise known as blood clots.  Hypercoagulable states are specific genetically inherited disorders that result in the blood being more likely to clot.  Atrial fibrillation and other arrhythmias can cause blood clots to form in the heart.

 

Anticoagulant agents are given to prevent the formation of clots in the heart that can then break off and go to the brain, hands, feet, kidneys, or any other part of the body and cause problems. 

 

Deep vein thrombosis or blood clots mandate the prescription of anticoagulant therapy to ensure that more blood clot does not form.

 

Anticoagulants can be broken up by many different classification schemes.  For the purposes of this blog, I will limit our discussion here to agents that are appropriate for the OUTPATIENT (Outside of the hospital) setting.  Please speak with you private physician to answer any additional questions you may have regarding Anticoagulation medication of feel free to reach out to me directions for more information on how anticoagulation is used. Anticoagulation agents that are used during hospitalization or in the IN-PATIENT setting in patients are outside the scope of this article.

 

Up until the 2010’s the mainstay of anticoagulation therapy was with a drug called warfarin (Trade name: Coumadin).  Warfarin, though effective, requires the weekly or biweekly measurement of a specific lab for the blood called the prothrombin time.  The active monitoring of the prothrombin time facilitates modulation of dosing to always allow for safe levels of effective therapeutic anticoagulation.  Since the beginning of the 21st century new agents have come to market that require only taking one or two pills a day.  They include Xarelto or Rivaroxaban and Eliquis or apixaban.

If you have a question about how your medications may be affecting your vascular disease, please do not hesitate to call and schedule an appointment today!

South Bay Vascular Center and Vein Institute is Silicon Valley’s largest and most trusted Vascular Surgery practice.  Serving South Bay communities for over 26 years, Dr Kokinos and her Colleague, Dr Ignatius Lau are the region’s foremost experts in advanced vascular care and provide innovative care for patients suffering from circulation relation problems. At South Bay Vascular Center and Vein Institute our job is to understand the “Why” so that you have real solutions to living a healthy life. Call us today at 408-376-3626 or visit our website at www.southbayvascular.com to learn about what makes us the most referred to vascular surgery clinic in Silicon Valley.

PART 1: WHY DO MY TOES, ANKLE, AND FEET HURT AT NIGHT? VENOUS DISEASE

Posted on by Michael Kokinos

One of the many questions I receive as a vascular surgeon is why do my feet hurt at night?  Though this question may seem simple, every person is different. Before I can provide you with “real” solutions to what’s causing this pain and what can be done to stop it, I need to evaluate multiple factors to understand “Why” this pain exists.  Over the next few weeks, I am going to explore the most common reasons for foot pain at night and why people can have pain in their feet at night caused by venous disease.

For the majority of patients Raynaud’s syndrome, Arterial disease, and Diabetic foot disease explain most of the reasons why people experience pain in their feet at night.  Though pain from problems with bones and muscle can play a role, pain due to these causes usually worsens during the day and with use, not when a patient is resting or lying flat.

In part one of this four-part series, I am going to discuss pain at night caused by VENOUS DISEASE.

Let’s start with a refresher on our bodies “plumbing” (Specifically, how does blood circulate around my body.)

  • Veins are blood vessels that bring blood BACK from the feet to the heart.
  • Arteries on the other hand are the blood vessels that bring blood FROM the heart to the feet.

Veins have specialized structures called one-way valves that allow blood to go up towards the heart but not back down towards the feet.  As we age, veins become dilated (start to leak) because the valves no longer seal properly. These leaky valves allow blood to fall back towards one’s feet which results in an increase in pressure within the veins at the ankle and just above the legs. Gravity tugs on the blood in our veins bringing it down to our feet which causes this increase in pressure

Interestingly, because of the curve that the veins take at the level of the ankle to enter the foot, the increase in pressure is not transmitted directly to the foot and toes.  The increase in venous pressure at the ankle typically results in

  • Varicose veins,
  • Swelling,
  • Dark skin discoloration from the leaking of red blood cells into the skin, and, in the worst cases
  • Ulceration.

Even without ulceration, however, the pain related to swelling and discoloration can be very severe.

People during their normal daily lives spend most of their days either standing or sitting.  Because of this, during the day gravity works in both positions to facilitate the pooling of blood around one’s ankles.  When patients come to me with pain in their feet, I always ask specifically if the pain is localized in the calves and ankles.  When pain is localized to the calves and ankles, I confirm a venous etiology by performing a physical exam and finding varicose veins, swelling, dark skin discoloration and/or ulcers between the ankle and the knee.

Pain that is reported in the foot and/or toes without the physical exam findings of varicose veins, swelling, dark skin discoloration, and/or ulcers between the ankle and the knee is NOT likely to be from a venous cause!  Though vein problems may sound or seem like a rare disease for those who have never had venous disease, patients with vein problems are one of the most common consults I see as a vascular surgeon.  Does foot pain wake you up at night? If you have any of the symptoms or appearance of the leg that I described above, please do not hesitate to call our office on 408-376-3626 to schedule an appointment.

One Final Note:

Though causes from the bones and muscles can play a role, foot pain that worsens at night is rarely due to these causes.  Often pain related to problems with bones and muscles worsen during the day and with use, not when any given patient is resting or lying flat.

Clues that can guide me as a vascular surgeon to the cause include throbbing and aching pain versus numbness and tingling associated with tenderness or pain located in the toes versus pain located in the ankle or just above the ankle in the leg.

 

Dr. Ignatius H. Lau

Vascular Surgeon

Dr. Ignatius Lau grew up in Portland, Oregon. He attended the University of Washington in Seattle for college and Stony Brook University in Long Island for medical school. He then went on to train in vascular surgery at Mount Sinai Hospital in New York City. During his time in New York, he performed over 1600 cases involving aortic, peripheral, venous, and carotid surgery. He has a special interest in limb salvage and treating patients with peripheral arterial disease and has extensive training and experience in treating the full spectrum of vascular diseases. Dr Lau was also very active in medical research during his training, ultimately finishing with twelve peer reviewed manuscripts. During his training in New York he met his wife, Lisa, who is a practicing endodontist. Together they love to hike, try new restaurants, and travel.

YOU HAVE A BLOOD CLOT. NOW WHAT?

Posted on by Michael Kokinos

One of the most common consultations that we as vascular surgeons receive is for deep vein thrombosis, otherwise known as blood clots.  Deep veins refer to the location of the vein that has the problem.  In the legs we have two main sets of veins: Deep and superficial.  Deep veins are within the muscle and close to the bones whereas superficial veins are close to the skin; hence their names!

Thrombosis refers to the process of the blood turning from a liquid into a solid form.  Normally, thrombosis occurs in response to an injury to stop bleeding from a wound.  However, when thrombosis occurs in the deep veins, it stops blood from being transported from the foot back to the heart.  The obstruction of flow results in swelling and pain below where the thrombus, or clot, has formed.

There are many causes of blood clots, but the most common causes include:

  • Traveling for extended periods of time in a sitting or resting position.
  • Trauma, including accidents which cause broken bones or bruises.
  • Narrowing of the veins of the pelvis, and
  • Specific genetic mutations that increase the likelihood of the blood forming clots. 
  • In older patients, another potential cause of blood clots without any other cause is cancer.  Cancer, unfortunately, can result in the release of chemicals and hormones within the body that make clotting more likely.

For patients who develop a blood clot in the context of traveling, narrowed pelvic veins, or having a traumatic injury to the affected leg, treatment involves a 3-month course of blood thinning medication followed by ultrasound tests to determine the stability of the clot.  If the symptoms improve and the clot remains stable, then the medication to thin the blood can be stopped at 3 months.

For travelers who are forced to sit for extended periods without being able to move, making an effort to walk around intermittently throughout the traveling can be helpful.  For example, on the plane, every 30 minutes stand up and walk up and down the aisle 3-4 times.  For patients who have a traumatic injury to their leg, the best choice would be to avoid, if possible, situations that led to the particular accident.  Finally, in patients with narrowed pelvic veins, I as a vascular surgeon can help relieve the narrowing with a special minimally invasive procedure called a venogram.  In the procedure, I place a self-expanding tube called a stent into the compressed vein via a small 2 mm puncture site in the groin to make sure the compressed vein remains open.

For those patients who did not have a traumatic accident, narrowed pelvic veins, recent travel, or a high suspicion of cancer, referral to a hematologist, or a doctor who specializes in disorders of the blood, can be helpful.  The hematologist can help order special genetic tests to determine if there is a genetic predisposition to forming clots.  In patients who do end up having genetic mutations, long-term placement on blood thinning medications can help prevent further events.

If you are anyone that you know is suffering from a blood clot, please do not hesitate to call our office on 408-376-3626 to schedule an appointment!  The expertise that vascular surgeons have in this area of medicine is critical to ensure a good outcome!