Currently the diagnosis of deep vein thrombus is primarily done by duplex venous ultrasound. You would think that all ultrasounds of the venous system would be performed the same way, however they are not. Many duplex ultrasounds don’t assess all of the veins in the leg, some only evaluate half of the leg. Very few venous ultrasound assess the abdominal and iliac veins. Deep vein thrombus starts in the calf of the leg 98% of the time, however the American College of Radiology (ACR) does not require imaging below the knee! It is estimated that up to 54% of DVT’s are missed when using this protocol. Even though Mr. Bosh was diagnosed with a pulmonary embolism, we do not know how well his leg was evaluated for thrombus. He may have had a high quality exam or a very poor exam (he nor his physicians would know the difference).
I think it is fair to say that Chris Bosh is seeing the best known doctors in the country for his medical condition. Seeing the best doctors does not guarantee that the testing being done at that facility is of the highest quality. Similarly doctors that are well known don’t always have the best reputation within a facility or even within the local community (it is complicated). It is very common for large institutions to pay their sonographers significantly less that for profit and private institutions. In reality the patient regardless of financial or social standing does not know what kind of testing they are getting. Ultrasound is very technical and the sonographer not the reader determines the quality of the exam. For this reason the variability from sonographer to sonographer and facility to facility is very high. Highly accurate testing can be found at the smallest of facilities and a very poor testing found at a large nationally recognized hospita. Several years ago, I performed a training at an internationally known neuro diagnostic facility and the sonographers did not know the basic anatomy! Did the physicians, staff, researchers know that the quality was beyond poor? As a result I don’t trust any of the research that is coming from this prestigious hospital. Large institutions do provide quality testing, I just know from over 20 years of experience consulting and providing hands-on training that the variability of testing is very high regardless of reputation or size. Even though there are great vascular sonographers, the quality of venous testing across the country is very low. The patient regardless of stature has no idea what they are getting and the physician themselves often don’t know that the facility has significant deficiencies in testing.
Let’s get back to Chris Bosh and his situation. Let’s assume he is seeing a top physician at a large hospital in Miami and has had a battery of tests including: venous ultrasound, CAT scan, etc. I do not know the extent of his previous DVT or Pulmonary Embolism. I also don’t know who performed these tests and what protocols they follow. There is a high probability that if a radiology department performed the ultrasound, his entire venous system may not have been evaluated. They may have missed deep vein thrombus in the calf and his treatment may have been based solely on above the knee thrombus and the PE. It is common for the patient to have a number of venous exams before coming off of blood thinners, again if the entire leg was not evaluated he may have been taken off of anticoagulants prematurely. Chris may also have a genetic disorder and should have had a workup to see if he has any clotting disorders that would increase his risk of DVT.
Not all treatment for DVT is the same. In the case of pulmonary embolism there are treatments available today that were not available even 5 years ago. These include removal of large ilio-femoral deep vein thrombus via thrombectomy, iliac vein stenting and use of new oral anticoagulant drugs. The health care providers may also recommend thrombolysis, using an intravenous agent that dissolves clots. With this procedure, a catheter is threaded up through the clot, and one of the clot-dissolving drugs is injected to dissolve it. The clot buster is injected slowly through a catheter with many tiny holes into the area of the DVT, much like a soaker hose. Sometimes a tiny vacuum cleaner is used to suck out the softened clot. Once the clot is gone, balloon angioplasty or stenting may be necessary to open the narrowed vein, but this is common only in the iliac veins, located in the pelvic area. With this approach, the patient will also need anticoagulant medication (heparin) to prevent new blood-clot formation while the existing clot is being dissolved. This treatment is revolutionary, however again due to Mr. Bosh’s stature such aggressive treatment may not have been offered or suggested. Dr. Charles Ross at Piedmont Atlanta is an expert in the area of iliac stenting, however someone of his caliber may not have been sought in Chris’s case.
These decisions regarding treatment are complex and given that Mr. Bosh is a high profile athlete agreement among specialists may be difficult to ascertain. Again, I don’t know the details on the diagnosis or treatment but in my experience Bosh was probably treated very conservatively and this may be one of the reasons for his conflict with Heat doctors and management.
Exercise is not harmful for patients with a history of DVT, in fact it is actually very beneficial. The Vascular Disease Foundation has an excellent flyer explaining what you can and cannot do when you have been diagnosed with a DVT. Travel and the contact that is involved playing professional basketball I would think to be the biggest risk factors for Mr. Bosh. Even though he is not known as a bruiser, Chris is a physical player and life in the NBA is hard on the body. His greatest risk may not be from another clot but from the risk associated with taking a blood thinner.
I hope that the average person learns something regarding the diagnosis, treatment and management of deep vein thrombosis due to Chris’s unfortunate situation. There is a need for systematic changes in the evaluation of thrombus from an ultrasound stand point. Chris if you read this article, I offer my services free of charge to evaluate your venous system in its entirety.