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Three Phases of Blood Clot Management of the Lower Extremity:

STP to Popliteal Vein Figure 7.STP extending into the popliteal vein at the SPJ

Dr. Schul is board certified in venous & lymphatic medicine and a leader in the field. He and his staff’s passion in helping patient’s with blood clots is unprecedented in the Greater Lafayette area. He has published peer review articles, book chapters, and has been a lead investigator in 3 FDA sanctioned clinical trials. Your visit today encompassed a tremendous amount of information. This document is a supplement to your visit, designed as an educational tool so that you understand the process of managing your blood clot over time. This is not an easy process to cover, yet it is our sincere hope that this document stimulates thought and helps you gain a greater understanding of how your life has changed and what things must now become a priority over the coming months and years.

Types of Blood Clots:

Superficial – Isolated tributaries

Superficial – Combined saphenous vein and tributaries

Calf Vein Thrombosis

Proximal – Fem/Pop Thrombosis

Pelvic Vein Thrombosis


The guidelines for treatment vary depending upon many factors. The higher the clot is in the leg, the greater the need to have a surgical intervention. The larger the burden of clot the greater the need for full doses of a blood thinner. The smaller and more superficial the event, we have many more options to consider. This is a living document and will continue to change as management paradigms change.


Phase I – Blood Clot Prevention


You may have a blood clot, yet we may or may not know why at this time. If you have loved ones who are concerned, you may help educate them in healthy vein habits outlined below:

  • Walking is better than sitting/standing;
  • Wear compression stockings when in occupations involving prolonged sitting or standing;
  • Target walking 10,000 steps/day – this is a standard philosophy. This is not always easy, but you should start tracking steps and assure you are getting ample activity;
  • Maintain a normal weight if possible. If your body mass index is over 40, your risk of developing a blood clot is three times the normal weight person all other things being equal.

This phase does not help you at this time, but you could help influence the risk factors for loved ones currently caring about your condition. Keep in mind that the risk of developing blood clots is an INDIVIDUAL risk. You cannot look at someone and see his/her risk. There is a free app at the Apple App Store called the Caprini DVT score. Dr. Caprini has studied patients with deep vein thrombosis for over thirty years and has developed a validated tool to assess an individual’s blood clot risk. Upon completing this simple tool that asks a detailed set of questions, a score is generated that is accompanied by potential options should you be hospitalized or need surgery.


We see so many people that have their lives turned upside down with a blood clot. We will be working to determine the exact cause of your problem over the coming months. At this time, however you have the opportunity to empower others to help prevent what you are experiencing. We want everyone to know healthy vein habits and encourage those we care for to help other understand this importance as well.


Phase II – Acute Management

The three principles of blood clot management have been proven in randomized trials to arrest the clotting process, and help to limit complications. These involve walking, compression, and either anti-inflammatories/blood thinners.

  • Walking & Compression therapy – Randomized clinical trials have proven that patients subjected to compression and walking do better than when placed at bedrest and elevation. The benefits include, less pain, swelling, and complications when compared to the bedrest population. Walking enhances blood flow while bedrest allows for stagnation of flow. When we think about what leads to blood clots, three factors are known:   injury to a vessel, stasis/stagnant flow (immobilized limb), and blood chemistry such as a clotting disorder that shifts the curve toward clotting. The combination of walking and compression is widely accepted and many believe it speeds recovery. We’ll learn more about the role of compression when it comes to reducing the risk of long term complications.
  • Anticoagulation – This depends largely upon two things, the burden of clot and the risk of bleeding. The chart below combines the current guidelines as reported by the American College of Chest Physicians (ACCP). The ACCP studies the world literature regarding deep and superficial thrombosis, and updates their guidelines ever 4 years.


The choice of approach is guided by your burden of disease. When options are evident, we will discuss them with you, including the benefits and risks. The importance of this phase is simply to halt the clotting process. The outcomes however are tied to the intensity and duration of anticoagulation. The guide below is what we will typically follow for patients with a given thrombosis or blood clot.


Clot Burden Drug/Surgical Management Duration
Iliofemoral/CFV ·      Mechanicopharmacological catheter based treatment to open the obstructed lesion.·      Anticoagulation vs. IVC filter 6 months or longer
Unprovoked Fem/Pop ·      Anticoagulationo   Xa inhibitorso   Heparin/Coumadin 6 months
Provoked Fem/Pop ·      Anticoagulationo   Xa inhibitorso   Heparin/Coumadin 3 months
Calf Vein Thrombosis ·      Option A – Duplex study in 2 weeks and use aspirin·      Option B – Anticoagulationo   Xa inhibitorso   Heparin/Coumadin If anti-coagulated, patients should be treated as if they have a Fem/Pop DVT
Superficial Thrombosis involving saphenous veins >10cm in length ·      Prophylactic doses of blood thinnero   Xa inhibitorso   Heparin/Coumadin 4-6 weeks with repeat duplex study immediately should symptoms worsen
Superficial Thrombosis involving branch veins at the surface of the skin only ·      Anti-inflammatories. If unable to tolerate anti-inflammatories, use prophylactic doses of blood thinners as shown in cell above. 6 weeks



Phase III – Preventing Long term complications (Recurrent DVT & Post-thrombotic syndrome)


Of all things to consider after the acute event has been managed, it is the prevention of a new event that could bring the same risk. Long-term management involves the safe transition from full anticoagulation to aspirin, and acquiring healthy vein habits to help reduce the incidence of post-thrombotic syndrome. Generally speaking, the amount of additional testing for someone with a DVT varies on whether it was provoked vs. unprovoked. A patient with a provoked blood clot (something triggered the event like total replacement knee surgery, long car ride, etc.) does better than when compared to the patient with an unprovoked event. Unprovoked events mean that the clot was not formed by anything particular, it just happened. These are managed differently and the workups are often quite dissimilar.

  • Importance of Provoked vs. Unprovoked events
    • Provoked Events simply far better in near term mortality and in long term limb health. If we know there was a cause (surgery, long plane ride) for the blood clot, very little work up or additional testing is needed. The important part becomes stopping anticoagulation after the appropriate duration in a controlled manner. More on this in next segment.
    • Unprovoked events fare more poorly and are commonly associated with an underlying condition including blood disorders and malignancies or cancer. Depending upon age, comorbidity, family history, and additional detailed questioning, a plan will ultimately need to be developed to help determine what incited the potentially limb threatening event.
      • Thrombophilia testing – testing the blood for acquired and inherited factors that cause blood clots are commonly performed. Acutely, or when the clot has just happened is not the time to test for these changes. When a blood clot initially occurs, it uses up many of the proteins we would otherwise test. If we test at this time, we will find misleading and unreliable results that could fail to address the true problem. This is difficult to understand for many yet the three most common disorders may be tested at any time, e.g. homocysteine level, prothrombin gene mutation, and Factor V Leiden. We generally do not advocate for immediate assessment of blood disorders. We prefer an organized approach timed with plans to remove patients from blood thinner, or soon thereafter.
    • Preventing Recurrent DVT
      • Discontinuing anticoagulation – The duration of anticoagulation is generally established by current guidelines. If the reason for developing a clot is ever present, e.g. malignancy, it is often continued until the underlying process is resolved.
        • Step #1 – The risk of recurrent blood clot is dependent upon the intensity and duration of anticoagulation. At the time we wish to discontinue Coumadin or one of the Xa inhibitors, we will check a D-Dimer test, a sensitive yet nonspecific test seeking any signs of an ongoing clotting process. If this test is negative, we transition to aspirin therapy, recommending 162 mg (two baby aspirin) per day. If the test is (+), we will continue anticoagulation for another 6-12 weeks. And repeat Step#1.
        • Step #2 – Studies have shown that patients with an elevated Factor VIII activity or a positive D-Dimer that turns (after bing normal) at one month are at greater risk of developing another blood clot. IF the Factor VIII and D-Dimer are negative, transition to aspirin is recommended and is proven to help reduce recurrence.
      • The role of Aspirin therapy – Aspirin actsby making platelets less sticky. One platelet causes a 5% effect on your circulating platelets. When patients with blood clots were randomized to aspirin vs. placebo (sugar pill) those receiving Aspirin had significantly reduced risk of developing another blood clot. This is important as it is a new way to manage blood clots and a critical step in helping prevent recurrent events. Interestingly, taking aspirin routinely will do nothing to protect you from developing the first blood clot. The key here is recognizing it is a proven means to help reduce recurrence.
    • Preventing Post-thrombotic syndrome – Post thrombotic syndrome is a common condition that occurs after a significant blood clot. The bigger the clot burden and more proximal the obstruction, the higher the incidence of this condition. Characterized by painful, swollen, discolored, and often ulcerated limb, the incidence may be reduced by 50% by simply wearing calf high 30-40 mmHg compression garment.
      • Role of compression – each of these is a proven benefit in the medical literature
        • Promotes healing in cases of venous leg ulcer
        • Reduces occupational swelling
        • Reduces the incidence of post-thrombotic syndrome by 50%
        • Increases the blood flow velocity of the deep venous system
        • Helps distinguish whether superficial veins are a cause of symptoms
        • Reduce the pain and swelling after acute blood clot
          • If considering anticoagulation, consider compression immediately


You should have unlisted phone numbers to contact Dr. Schul if necessary. We take the management of blood clots very seriously and blood-thinning agents are an important part of therapy, yet these drugs do not come without risk. Should you develop chest pain, shortness of breath, cough up blood, experience a fainting spell, or begin to have bleeding as indicated by black or blood stools, gum bleeding or blood in the urine, you should seek immediate help.

Call today to learn how Dr. Schul and his staff can help you and your vein concerns at (765) 807-2770,  email at, or visit to learn more.