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Had surgery to repair torn labrum and bicep tendon. Having pain in veins. Taking caoumadin. Suggest

Apr 2013
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General Surgeon
Practicing since : 2009
Answered : 5517 Questions
Hi..I'm a 41 yr old male in good health. I take lipitor for high cholesterol. I work out 4+ times per week with cardio and weights. I recently had surgery to repair a torn labrum and bicep tendon. A few days after the surgery I noticed some pain alon the veins in my forearm. I thought it may have been from wearing the sling so I tried icing and stretching it a little. This did not help. having had a prior blood clot in the calf I wanted to get it checked out and sure enough it was a clot. I am now on coumadin again. The doctor was puzzled because a clot in the arm for this type of surgery is extremely rare. There was no reason found for the clot i had in the calf in 2009. The hematologist ran all the genetic tests, etc and found nothing. The only thing they could "try" to attribute it to was i had injured my SI joint playing basketball the prior month. however, I was not laid up or inactive from this injury. so my question is, where do I go from here? The hematologist is saying I don't need to be on coumadin for life, but now this is the 2nd time around; one w/o cause and one due to surgery, but shouldn't have happened. so there does appear to be something going on, but no one can pin point it. My question is, given what has happened, twice now, do you think I need to be on coumadin for life? My hematologist suggests no, because the clots werent in "life threatening organs" and all the blood work looks good. However, because of all the anomoly behind this, I would think you'd error to the side of caution and put me on it. any thoughts you could provide would be greatly appreciated.
Posted Sat, 8 Jun 2013 in Bones, Muscles and Joints
Answered by Dr. Ivan R. Rommstein 15 hours later
Hi and thank you for your query.

Well, actually, every surgery increases the risk of clotting, especially localized clotting in area of surgical manipulation. So this isn’t so rare and you shouldn’t be concerned.

First it should be evaluated: is it clot at all by Doppler ultrasound or this is just a haematoma, muscle pulling or something else. Secondly, if this is clot it can be in deep or superficial vein. If you don’t have arm swelling and pain then this is probably superficial venous clot and in this case even short term Coumadin isn’t necessary. You should just keep your arm elevated and do isometric biceps exercises and watch for signs of thrombophlebitis such as redness, pain, swelling and fever.

Deep venous thrombosis is bit more serious and in this case you should be treated by Coumadin but only till this clot passes. Even deep venous clot in arms almost never cause serious consequences such as pulmonary embolism or brain ischemic attacks as we can see in deep legs clots. Also these clots rarely affect arterial blood flow.

So, there is no need for lifetime anticoagulant therapy except you have heart disease, overweight, deep legs vein clots or clotting factor abnormalities. Since you said that your prothrombin time, thrombocytes and other hematologic tests were fine then there is no need for specific treatment and this is probably caused by surgery or hit you have mentioned. Clot should subside in 1-2 weeks and it this persists after this or happens again you should do more detailed hematologic tests for clotting function.

So you really have no reason to worry. This is often seen and it heals spontaneously. If you notice pain, swelling, loss of sensation and pulsations distally to this clot then you should visit ER as there can be blood flow insufficiency.

Wish you good health. If you have any questions I will be glad to help.
Above answer was peer-reviewed by
Follow-up: Had surgery to repair torn labrum and bicep tendon. Having pain in veins. Taking caoumadin. Suggest 2 hours later
Thanks for your reply. when I went to the ER they did ultrasound and found multiple clots in the arm (deep Vein), thus the coumadin I am on now. I guess my concern take me back to the fact there was no "real" reason for the leg clot, and now I have this arm clot due to surgery..this one has a cause, but I'm wondering what the underlying cause could be (aside from surgery) as I have had surgeries in the past and no blood clot.

Given the unfounded cause for the leg clot, and this arm clot due to surgery (where no clots before with prior surgeries) it makes me wonder what could be going on; and if now, after 2 clots, not taking coumadin for life puts me at risk of other unfounded clots which could cause stroke, PE, etc...

you also mentioned you are at more risk of clotting with surgery. Given the fact that I was not bed ridden in the hospital or inactive for a period of time, i'm not sure why a clot would have developed.

Any further thoughts you could provide would be appreciated.
Answered by Dr. Ivan R. Rommstein 1 hour later

Well, of course that surgery is the first thing to think of. In such cases, prolonged bed rest isn’t the only cause of thrombosis. Surgical procedure includes venous trauma and damage, hemostasis, vessel compression, possibility of subcutaneous infection, also there could be too tight bandaging and many other risk factors which leads to formation of clot inside blood vessel. So I don’t think it is likely that clot was not caused by surgery.

Deep leg vein thrombosis sometimes occurs for no apparent reason; true, this is more likely to happen in women and in elderly, but can be found in any age and gender.
Of course there are certain risk factors:
-     Hypercoagulability,
-     Prolonged sitting (even after 8-12 hours which can be seen during airplane and car traveling),
-     prolonged bed rest or immobility,
-     recent surgery,
-     recent trauma to the lower body,
-     obesity,
-     smoking
-     Dehydration
Some of these people don’t even notice.

There are some more serious but very rare causes such as cancer and rare inherited genetic changes in blood clotting factors, but this would have much more intensive and different symptoms.

I have seen several deep vein clots where we didn’t find cause and it was successfully treated with heparin and anticoagulants and most of them never occurred again. So I am sure this isn’t anything serious in your case if your prothrombin time and other blood findings were normal. This one blood clot in past and second one after surgery isn’t significant for some hematologic disease. You can do tests to check those rare genetic disorders but I don’t think this is necessary.
Also, I wouldn’t suggest long term coumadin therapy as it can cause more problems than benefit.
Above answer was peer-reviewed by
Follow-up: Had surgery to repair torn labrum and bicep tendon. Having pain in veins. Taking caoumadin. Suggest 4 hours later
A couple more questions:
1) you mention long term use of coumadin can cause more problems than benefit. What type of problems, (aside from bleeding risk)?

2) Going forward, if I were to have future surgeries what precautionary measures would you take as a doctor and which ones should I take as a patient so this does not happen again?

3) What are your thoughts of taking a baby aspirin once off the coumadin? I had been taking one ever since the first clot back in 2009, then stopped a few days prior to this surgery and then started back up right after surgery, and yet, still developed a clot.

Thanks again for follow-up. very helpful.
Answered by Dr. Ivan R. Rommstein 1 hour later

Risk of bleeding can be significant problem and you ll have to do frequent and annoying prothrombine time measurements. There are also some dermatologic, gastrointestinal and cardiovascular side effects. I wouldn't recommend taking it if there is no clearly verified risk factor for trombosis especially in such young people. If there would be any sign of unexplained trombosis again then you should consider taking it.

2. In future surgeries you should inform your doctors about your "clotting history" especially in urologic and abdominal ones. You should visit anaesthesiologist and surgeon 2 weeks before surgery and plan pre- and postoperative coagulation management. Considering the risk of bleeding during the surgery your doctors can assess optimal PV/INR for you. Of course, you ll need early mobilization and adequate physical therapy in bed. But you dont need to be afraid of future procedures; doctors are aware of trombosis and embolus risks and this is easily prevented today.

3. Yes, you can take aspirin 100mg daily, this is better idea than coumadin if you ask me, but consult your GP about it.

I see that you consider clot as something very rare and serious, but trust this isn't actually true. Many clots in our body aren't even recognized and results from any trauma or inflammation. It comes and goes leaving no consequences and this is normal reaction of our body to vessel damage or blood-foreign agent contact. I am sure everything s fine with your coagulation and wish you fast recovery.

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