A 56-year-old man undergoes surgery on his hip. He is in good overall health, but presents to the hospital because he lost consciousness. His vitals are normal, as are most of the tests performed. The treating physician is suspicious and orders a test of the blood vessels in the lung. A blood clot is found there. Could this be a potentially deadly condition?

A 78-year-old woman, a cigarette smoker with a history of angina, presents to the emergency room with chest pain and shortness of breath. She relates no pain or swelling from her legs, but does admit to minimal activity for the last five days after spraining her ankle. She relates to doing a lot of elevation of the limb because of the injury. What is causing her breathing problems?

Harry is an 81-year-old gentleman who lives alone, with a long history of venous disease. He starts to cough up some blood, after developing a sharp pain in his side. He also has recently been experiencing breathlessness with any activity, but chalks it up to a cold he had. Harry assumes it will get better, but also is too tired to go in to see the doctor right away. He passes away overnight.

Tom, a 25-year-old man, injures his left Achilles tendon playing pick-up basketball. He is put in a cast to immobilize the injury for 6 weeks. The cast was removed the prior week. He has noticed he is short of breath and is complaining of chest pain. Is there a connection?

These are just a few examples of a condition whereby a blood clot become lodged in the lungs, blocking blood flow. This clot typically originates in the deep veins of the calf, although it can come from other areas. This blockage of the lung vessels is called a pulmonary embolism (PE) and is the third most common type of cardiovascular disease. Although it can occur in individuals of varying ages, the incidence is greatest in those 60 to 80 years of age.

This blockage in blood flow through the lungs is a life-threatening condition. Studies reveal the mortality is 4% within a month of the clot forming, but may increase to 13% after 3 months. There are many risk factors for developing a PE. Orthopedic surgery is one of the most common, but there are many others. They include periods of inactivity or immobilization, an injury causing a broken bone, obesity, or smoking cigarettes. Also well-recognized is the presence of heart disease, high blood pressure, or the occurrence of a stroke.

The development of a blood clot in a deep vein of the lower leg is termed a deep vein thrombosis, but this is just one example of a wide spectrum of conditions referred to as venous thromboembolic diseases. These problems center on the development of a clot in the venous system. Because of its propensity to lead to a PE, clots in the calf are considered potentially dangerous, but are often asymptomatic.

What causes a blood clot to form and travel to the lungs? Certainly the occurrence of an injury or damage can lead to it. A broken bone or a muscle tear can damage blood vessels, leading to the clotting of blood. Alternatively, a long period of inactivity can also, since gravity causes blood to stagnate in the lowest areas of your body. Diseases which alter the clotting process can also instigate this potentially-fatal process. Additionally, cancer and chemotherapy can both stimulate the formation of a PE.

Recent studies have revealed the risk of having a potentially fatal blood clot after surgery is higher and lasts for longer than had previously been thought, especially orthopedic surgery. One of the benefits of minimally invasive surgical techniques is reduced trauma, which typically means less post-operative bleeding. This translates to a lessened risk for any VTE event. For example, a new study looked at the risk of developing a postoperative deep venous thrombosis after undergoing a minimally invasive knee procedure. The risk was significantly less as compared to patients undergoing a standard open-type technique.

Podiatry was one of the trend-setters in the development of minimally invasive surgery. Many foot and ankle procedures are now performed this way. New and advanced technologies allow various bone and joint problems to be corrected through tiny incisions, from bunion correction to hammertoes, ankle joint degenerative arthritis to bone spurs. Because many of these minimally invasive procedures are performed without a tourniquet, meaning the blood flow through the extremity is not stopped, there is little risk of these blood clots forming.

These less traumatic techniques are being learned and performed by orthopedic and podiatric surgeons around the world, due to these and other benefits. Cosmetically, these incisions often fade completely from view so one is not left with the usual “rail-road tracks” scar. Probably more important, post-op pain is dramatically less than with an “open” surgery since the surgeon is traumatizing, ie damaging, less tissue.

How does one know they have developed a pulmonary embolism? What kind of sensations or pain will the individual have? The symptoms of a PE vary depending on the individual and the severity of the blood clot. The sudden onset of shortness of breath, and difficulty breathing, are both quite typical. Chest pain may be noted. Anxiety or feelings of dread may be experienced, as well as lightheadedness or fainting. The skin can become clammy.

This blockage of blood flow through the lungs is often deadly. Survival rates for pulmonary embolism in the short term range from 77% to 94%. The risks were lower but still elevated 2 to 3 months after surgery and, in most cases, the risk remained high for at least one year. Women were almost 70 times more likely to develop some form of VTE during the first month and a half after inpatient operations. As should be expected, the risks vary considerably depending on the type of surgery.

Because most patients die within the first hours of presentation to a hospital, early diagnosis is of paramount importance. Emergency management is usually highly effective and heart failure is potentially reversible when diagnosed promptly, but PE can be missed. A number of things can alert the treating physician to the presence of a pulmonary embolism and a number of crucial tests can be performed to aid in making this critical determination.

This is not a condition to be trifled with. If you or a loved one experience any of these symptoms, have it checked out. If diagnosed in a timely fashion, a pulmonary embolism can be successfully treated with minimal risk of complications. It’s those individuals who wait and watch, thinking foolishly that time heals all wounds, that are in danger. And prevention is an even better idea, like standing and walking periodically when on a long journey (especially plane travel).

Also use of compression stockings if you have any risk factors. Early mobilization is also important post-operatively. Talk to your doctor and learn about your risk. An ounce of prevention is worth everything!

Editor’s note: Dr. Conway McLean is a physician practicing foot and ankle medicine in the Upper Peninsula, with a move of his Marquette office to the downtown area. McLean has lectured internationally on wound care and surgery, being double board certified in surgery, and also in wound care. He has a sub-specialty in foot-ankle orthotics. Dr. McLean welcomes questions or comments atdrcmclean@outlook.com.