Marcelo Gomes, MD
Marcelo Gomes, MD

Wednesday, April 18, 2018 | Noon


When you cut or injure yourself, your body stops the bleeding by forming a blood clot (coagulation). Normal coagulation is important during injury to help stop the bleeding and start the healing process. When your blood clots too much, it’s referred to as a hypercoagulable state which can be dangerous to your health. Marcelo Gomes, MD answers your questions about blood clotting disorders.

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Factor V Leiden

pmckee11: My number one genetic health risk (23and is venous thromboembolism and Factor V Leiden. My doctor had me do a blood test for Factor V Leiden and the results were positive. In addition, I have some blockage of plaque in my carotid arteries that has been somewhat stabilized taking 40mg/day of simvastatin and 81 mg/day aspirin for the last eight years. I also at times have restless leg syndrome. Should I be concerned about future leg blood clotting?

Marcelo Gomes, MD: Factor V Leiden is the most common genetic predisposition to vein clots. However, most individuals who have this mutation will never develop a blood clot. So - there is usually no recommendation for specific treatment just because of the Factor V Leiden. The plaque in your carotid arteries has nothing to do with the Factor V Leiden. This mutation is not considered a risk factor for heart attacks or strokes in adults.

belinda 25: I have Factor V Leiden - what is the connection with pregnancy?

Marcelo Gomes, MD: Factor V Leiden may increase the risk of vein clots also during pregnancy. There is some controversy as to whether it may also cause other pregnancy complications. Most women who are pregnant and have Factor V Leiden do not develop blood clots or pregnancy loss. Injectable blood thinners may be indicated in very select pregnant patients who have had blood clots before.

charlesH: I have Factor V Leiden, IVC filter, and atrial fib - does this have an impact on the meds that I should be on for atrial fib. Also will need surgery eventually for mitral valve - will there be precautions I need to take before having heart surgery?

Marcelo Gomes, MD: If you are already taking a blood thinner for the atrial fibrillation, then that medicine will also be preventive against vein clots that may be caused by the Factor V Leiden. Your blood thinner will have to be stopped a few days before your heart surgery and then resumed afterwards. While hospitalized, your doctors may or may not use intravenous heparin as a blood thinner while you recover from your open heart surgery.

mammaL: My son was diagnosed with factor 5. He will be doing study abroad. Should he take precautions when flying to Europe? Aspirin? Blood thinner?

Marcelo Gomes, MD: If he never had any blood clotting problems in the past, then no medications are recommended prior to long flights. What we do recommend is that he wear a knee high compression stocking, drink plenty of fluids during that trip, avoid alcoholic beverages in the airplane, and get up from his seat every couple of hours or so while he is awake in the airplane.

jennie: I was recently diagnosed blood clots in my lungs. I found out two years ago that I have Factor IX complex V Leiden. My question is: How can I have this when neither of my parents have it.

Marcelo Gomes, MD: I think the most important thing would be to have you and your parents tested for Factor V Leiden in a different and specialized coagulation laboratory. It is possible that lab errors may have occurred in previous testing.

Deep Vein Thrombosis (DVT)

su.p: Hello. I’m recently diagnosed with a complex knee to abdomen DVT. I also have ME, so i find the fatigue is very hard. Is it adequate to get up and walk every 1.45 hours to help the recovery? Thank you in advance.

Marcelo Gomes, MD: The DVT may cause leg swelling and pain, thus making it difficult for you to walk. What we typically recommend is that patients with a DVT wear compression stockings, should minimize those symptoms and be as active as they can possibly tolerate. I don't know if walking would improve your fatigue from the ME but it should over time improve the circulation in your legs.

marypat: My husband has pain in his calf and swelling. Is that a sign of blood clot?

Marcelo Gomes, MD: It certainly can be a sign of a DVT but there are many other causes for such symptoms. The best way to rule out a vein clot or DVT is to have a Doppler ultrasound of that leg.

75chevy: I am 40 years old. I was diagnosed with DVT in my calf. I am taking an injection of blood thinner twice a day. My pain is almost gone. Can I go back to running? My leg is still swollen. Will that go back to normal? Am I now prone to DVT?

Marcelo Gomes, MD: If you are taking your blood thinner consistently, then yes you can resume exercise activities such as running. You may find however, that your calf will ache and bother you more than it did before. In that case, wearing a compression stocking can minimize the symptom. I am not sure why you are on an injectable blood thinner. But, usually the symptoms of leg swelling and pain will resolve over time. How long it will take varies from person to person. Whether you are going to be more prone to future DVT will depend in part on what was the cause of your recent calf clot.

JordanV: I am thinking I have a DVT in my left leg. I went to hospital and ultrasound was performed, with no clot noted two days ago. Now my calf is painful, red, and swollen more. Is it possible that I do have a clot even though they said no?

Marcelo Gomes, MD: It is possible but not likely. It is important that other causes for the symptoms also be investigated. This may require other tests such as CT scans or MRI of the leg. When the suspicion of a DVT is very high and the first ultrasound was negative we recommend repeating the ultrasound within 5 - 7 days.

JimfromAK: I had a DVT and was put on Warfarin. I will be coming off of Warfarin next week - and then they will put me on aspirin. What is the normal dose of aspirin? Is that for life?

Marcelo Gomes, MD: Aspirin may help reduce the risk of future DVT in some patients. In those situations after warfarin is stopped, the aspirin dose that has been typically prescribed is anywhere between 81- 162 mg. Which means 1 - 2 baby aspirins per day. The duration of the aspirin therapy really depends on your doctor's recommendation but it may have to be for life.

benlomondeast: I have a remote history of Hodgkin’s Lymphoma treated with 8200 cgy total nodal RT. Subsequently I have all the cardiopulmonary earmarks including complete heart block requiring a pacemaker. My first UEDVT followed soon after the pacer placement in 2015 and was treated short term with Xarelto. A second more severe UEDVT, same side, revealed itself recently for which Warfarin therapy was implemented. I have long questioned occult malignancy vs. pacer wires as the sole provocateur. How would you respond to a second unprovoked UEDVT considering my medical history? Thank you for your time.

Marcelo Gomes, MD: Both the ongoing presence of pacemaker wires and malignant diseases can cause recurrent upper extremity DVT. In these situations it is important that your doctors and you discuss what the appropriate work up should be in order to establish the cause of your recurrent DVT.

Antiphospholipid Syndrome

tina88: How is antiphospholipid syndrome treated? My mother told me she was diagnosed with this. Does it go away with time or is it lifelong?

Marcelo Gomes, MD: This syndrome is caused by antibodies called antiphospholipid antibodies that tend to cause an increased risk of blood clots. So, patients with APS are typically treated with anticoagulation therapy (blood thinners) indefinitely. But it is important to make sure that the diagnosis has been made with certainty. Many of the current blood thinners on the market may cause false positive tests, so it is critical that the diagnosis be confirmed beyond doubt before committing a patient to long term anticoagulation.

Antithrombin Deficiency

CMcD: Hello, I am a 55-year-old a/a female, with hx of multi PE. Had an IVC filter placed, threw clots x2 after. Most recent was last month. I've been on all types of anticoagulants until now.  I'm back on Coumadin. One nephew had the similar history. When his hypercoag screen was done it was found the he has thrombin 3 deficiency. I have had multiple screen, and still undetermined. My nephew died two weeks ago from a PE. First and only. We know it has to be genetic. Since my first PE in 2004, I have tried to have my family take this serious and get a hypercoag screening. How can I get them to understand its hereditary? Also, is there any suggestions as to how I can find out what mutation or deficiency is causing the PE? I know the clots are damaging my heart and lungs each time. Last month was the fourth PE. Thank you.

Marcelo Gomes, MD: Coumadin seems to be an effective blood thinner to prevent recurrent DVT or PE in patients with antithrombin deficiency provided that the INR level is in therapeutic range. Testing for antithrombin deficiency involves a simple blood test but such tests should be done in a specialized laboratory. Having said that, about 1 out of 6 patients with recurrent DVT or PE do not have any detectable clotting disorder despite extensive testing. In these situations, it is indeed recommended that they remain on indefinite blood thinner treatment. Coumadin is the choice of blood thinner when patients have recurrent clots despite taking the newer blood thinners. We typically do not recommend that relatives be tested for clotting disorders unless those individuals also have had clotting problems themselves. But testing asymptomatic relatives is no longer standard of care.

Mmiller: Briefly: First clots one in arm and leg. They said probably from birth control- went off blood thinners- got very long clot up my arm, shoulder and chest when I later had an IV- back on Warfarin for life this time. Genetic testing showed anti thrombin 3 deficiency. No PE's either time (all started in 2016-I am 49) Looking for any info on AT3 Blood clot disorder - what are the " must knows" when you have this? I just know that it is rare and from what I've read one of the more serious ones to have. Any additional precautions when having surgery? - I am petrified just thinking what might happen if I need any kind of surgery. Is there anyone to contact who has studied AT3? Is there a blood thinner that is better to be on than another?

Marcelo Gomes, MD: Warfarin is the preferred blood thinner for patients with AT deficiency and recurrent blood clots. It is one of the most rare genetic predispositions to clotting affecting approx. 0.01% of the population. But, it is also a strong risk factor for blood clots. Your history seems to match what we know about AT deficiency. Because warfarin would have to be interrupted for surgery, the most important evaluation prior to undergoing any surgery in your case, is to review what the AT level in your blood is soon before the surgery. There are AT concentrates which can be administered to you during hospitalization as needed. Cleveland Clinic staff physicians both in vascular medicine and hematology have taken care of patients with AT deficiency.

Klippel-Trenaunay (K-T)

ClaudeG: Do you see patients with Klippel-Trenaunay?

Marcelo Gomes, MD: Yes - here in the Section of Vascular Medicine at Cleveland Clinic, we do see patients with that syndrome. We are happy to see you.


JaniceG: If someone is having blood clots over and over - what type of testing should be done to find out why?

Marcelo Gomes, MD: It depends on what blood clots, where they were, and what the circumstances were around the time when the blood clots were diagnosed. There are multiple different tests that can be done to find out the possible cause or causes for blood clots. But, the tests will be different depending on the answers for the questions that we mentioned before.

sally1958: If one has a gene mutation that is causing increased blood clots, should all their kids be tested - or do you wait for blood clots to occur before testing?

Marcelo Gomes, MD: It is my opinion that children should not be tested for clotting disorders unless those children have had blood clotting problems themselves. Most genetic clotting disorders pose only a very small risk of future blood clots. Even if a child inherited a blood clotting disorder from a parent, if the child has never had blood clots before, then no treatments would be recommended. The most important thing is for the children's pediatrician to know the parent's medical history. At times, special consultations for family counseling are preferred prior to doing such tests in children. These consultations can usually be done by a vascular medicine specialist, like me or by a hematologist.

Blood Thinners

lar2003: I have a St. Jude aortic valve and have been on Warfarin since 2002. I have a bad knee that needs to be replaced. I had arthroscopic surgery in 2014 and ended up with DVT. I have had multiple surgeries with post-operative bleeding issues. Doctors do not want to do the knee replacement because I have a history of post-surgery bleeding issues and they say I am high risk. My ACL is severed and I have arthritis. I have tried numerous options but the pain is increasing. I am overweight and am having difficulty losing it. Is there a safe way to have the surgery? Is there a diet that you would recommend for someone on Warfarin?

Marcelo Gomes, MD: Patients taking Warfarin should minimize the amount of vitamin K that they eat. Broccoli, spinach, brussels sprouts, kale are the foods with the highest content of vitamin K. So, you should minimize the portions that you eat of these foods. But, the risk of bleeding does not have anything to do with the vitamin K intake. I suspect that your doctors have in the past started you on blood thinners sooner than they normally would have preferred after surgery. The reason for that is the mechanical heart valve. So, future surgeries will always pose that challenge to your doctors because in order to prevent clots in the valve, they have to start you on blood thinners sooner than they would prefer.

lar2003: Is the knee surgery something that Cleveland Clinic would consider doing? Other hospitals are hesitant to do it because of the bleeding issues?

Marcelo Gomes, MD: Yes - you would have to be evaluated both by one of our orthopedic surgeons and one of our vascular medicine specialists. We would evaluate the indications for the procedure, what type of procedure that would be best for you and we would work together to agree on a treatment plan that would minimize your risk of blood clots while not increasing the risk of bleeding excessively.

mickeyJ: I was on Pradaxa post DVT and then had a PE. Obviously the drug did not work for me. Does that mean other meds like this will not work? My doc put me on Coumadin - is that the only option?

Marcelo Gomes, MD: It depends on what was the cause of the PE. The new blood thinners (not Coumadin) may not be as effective for blood clots related to malignant diseases or chronic inflammatory or autoimmune diseases. Without knowing what the cause of your PE was I cannot really say whether Coumadin is the only option. But, when we are in doubt about whether new blood thinners may or may not be effective, Coumadin has been a proven blood thinner treatment in many of these clinical situations for decades.

V1668: I have a significant history of clotting related disorders. 1) Received AKT treatment from Apr. 2015 - Apr. 2016.  2) Left renal vein thrombosis + left nephrotomy in June 2016. To our surprise all thrombotic profile tests came out as negative. Took Warfarin therapy for six months until Dec. 2016. Repeated tests protein C, protein S and serum homocysteine in Jan. 2017, which were again negative. Hence stopped Warfarin therapy. 3) Deep vein thrombosis in left leg / left and right arm in Feb 2018. With the above history, now I am on Warfarin therapy for my entire lifetime. I was hoping you could answer my doubts on the long term effects of Warfarin therapy. Are these some side effects of long term consumption of Warfarin: a) Low / High blood pressure b) Changes in quantity of vitamins other than ‘K’ in blood, due to which supplements may be needed? c) Back ache and feeling tired  d) Any possibility of inducing fatal blood disorders like Leukemia or similar e) Any blood gene mutations, which may be passed on to the future generations. Would really appreciate it if you could answer my queries.

Marcelo Gomes, MD: Other than the risk of bleeding, the only proven long term or potential side effect related to Coumadin is hair loss. Most of my patients who are on Coumadin for many years and had hair loss - the symptom was not due to Coumadin after they were seen by a dermatologist. Coumadin does not seem to cause increase in the risk of bone loss, or cancers after long term use. The risk of bleeding is minimized by good monitoring and frequent blood tests. The vitamin K contents in your diet should be kept as consistent as possible. Your primary care doctor or nutritionist could review what you the types of foods that have more vitamin K.


Abhipillai1683: Am suffering from stroke past eight months.

Marcelo Gomes, MD: Usually a stroke is an acute event and if symptoms continue to linger on for many months, it is because of sequelae or scarring in the brain, caused by the stroke. A neurologist should be able to determine if you are having recurrent strokes or suffering from the chronic consequences from a previous stroke.

Reviewed: 04/18

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