For decades, patients with deep vein thrombosis -- a potentially serious condition in which blood clots form in the deep veins -- had hope as long as their blood clots were fresh, meaning symptoms were present for a month or less. These acute and subacute clots were relatively easy to remove because they were soft.
Things were trickier for patients with chronic clots, in which symptoms lasted a month or longer, because the clots were hard, making them difficult to break apart and remove. As a result, treatment was aimed at preventing the clots from enlarging and breaking loose, and preventing new ones from forming. Options included blood thinners, clot busters, filters and compression stockings.
With deep vein thrombosis, it's important to try to remove all clots because not only can they be painful, but they can break off and enter the lungs -- an event known as a pulmonary embolism, which can kill.
Today, Christiana Care's Vascular Interventional Radiology department is providing more hope to people with chronic clots, too. For the past 18 months, Dr. Mark Garcia and his team have been working to eliminate chronic clots, a time-consuming and cumbersome procedure. He has removed chronic clots in dozens of patients, recalling only one case that was unsuccessful.
Garcia, who has been an interventional radiologist for 14 years, credits the new generation of clotbusting devices on the market. The devices are designed to remove acute blood clots, but he is using them to remove chronic clots.
"There is no treatment for chronic clots, but these patients are severely hampered and it dawned on me that maybe [this kind of device] would work and it did -- it opened up hard, chronic clots," he said.
"If we are successful in getting across the chronic clot," Garcia added, "we can do you some good."
Focusing on chronic clots So far, patients who suffer from painful chronic blood clots
have come from as far as California and Utah to see Garcia, who routinely gives presentations about the techniques that can be used to break up chronic clots at meetings for the Society of Interventional Radiology.
Dr. Suresh Vedantham, who is on the executive council for the society, said there are interventional radiologists at other hospitals removing chronic clots, but he knows of no other place where eliminating chronic clots is the focus.
At this time, there are no published randomized controlled trials on outcomes of the techniques being used to remove chronic clots. That would be needed to drive major changes in the treatment of deep vein thrombosis, said Vedantham, an interventional radiologist at Washington University School of Medicine in St. Louis.
Garcia said that as clot-removal techniques evolved -- and his experience grew -- chronic clots became his focus. "If you're a patient and it's really affecting your life and we don't have any other options, look, we can give it a shot," he said. Plus, by removing chronic clots, a patient's time in the hospital and the costs associated with it are
reduced.
For years, clot-dissolving drugs were delivered through a catheter to eliminate acute clots. The drugs were highly effective but took two to four days to work while the patient was in the intensive care unit.
The new generation of devices came onto the market about a decade ago. They use clot-dissolving drugs in combination with the devices themselves, which also work to break up the clots. In this type of procedure -- known as pharmacomechanical catheter-directed thrombolysis -- imaging is used to guide a catheter and the device directly into the vein with the blood clot.
There are a few devices on the market. One such device sprays a clot-dissolving drug onto the clot and uses high-velocity saline jets to further break up and vacuum out the clot. Another device uses ultrasound waves to enhance the effectiveness of the medicine in breaking up the clot. Yet another device uses a catheter with two balloons that are inflated to initially prevent the clot from breaking off. While this is happening, a clot-dissolvint drug is released onto the clot and the catheter oscillates to disperse the medicine while breaking up the clot.
Surgeries involving these devices are considered safe. The biggest potential risk is excess bleeding as a result of the clot-busting drugs. Some people may also suffer an allergic reaction to the dye that is used with the devices. Both risks are rare.
Like mud or cement in a pipe 
Small, initial studies have shown that these treatments remove acute clots effectively and result in patients experiencing less chronic leg pain. But there are still no published data on the clinical outcomes of these techniques, Vedantham said. It is also still unknown whether these new procedures can have adverse effects.
Not surprising, there are no such data on the use of these techniques to remove chronic clots either, he said. "But there's a tremendous need out there, and it would be the Holy Grail for the field if we could find something to treat those patients with chronic clots," Vedantham said.
Garcia believes he has already found the answer, using the devices designed for acute clots to break up chronic clots. Removing an acute clot is like trying to remove mud from a pipe, Garcia said, whereas removing a chronic clot is like trying to remove cement from a pipe. Eliminating acute clots in an entire leg can take one to two hours. For chronic clots, the process can last twice as long. But Garcia said it's worth it -- interventional radiologists just need to be willing to put in the work.
"We have catheter skills that are there, you just have to be a little more patient and work a little harder at it," said Garcia, who is a paid consultant for the company that makes the device with the saline jets.
Mark Sullivan, 47, of Malvern, Pa., is thankful that Garcia has focused his efforts on removing chronic clots. Because of his deep vein thrombosis, Sullivan's left thigh was 10 centimeters larger than his right thigh and his left ankle was 7 centimeters larger than his right ankle.
Garcia performed surgery on Sullivan only a week ago, so it's too soon to tell what his long-term outcome will be. But he is hopeful that eliminatiing his chronic clots will bring relief.
"On the basis of my age and my level of activity, I just really felt that taking this approach was best," said Sullivan, who was surprised to learn he had deep vein thrombosis because he bikes up to 150 miles a week.
It may be several years before research shows how effective and safe the new devices are for removing blood clots of any type. Vedantham is the lead investigator in a study, funded by the National Institutes of Health's National Heart Lung and Blood Institute, that aims to evaluate catheterbased treatments for acute clots.
From there, more effort may be put toward evaluating the effectiveness of using the new devices to eliminate chronic clots.
"What has to be kept in mind is that if someone has a chronic blood clot in their leg, there already aren't good treatment options," Vedantham said. "So this can be an alternative."
