Friday, October 4, 2013

The Scary Case of Tomas Vokoun

BACKGROUND

On Saturday, September 21st, Penguins goaltender Tomas Vokoun was taken to the emergency room after leaving practice. Vokoun, 37, noticed swelling in his thigh and was diagnosed with a pelvic thrombus, or a blood clot in the pelvis. Vokoun underwent a procedure after his diagnosis to dissolve the blood clot.

In fact, this is not Vokoun's first experience with blood clots. In April of 2006, Vokoun had back pain and visited a doctor where was immediately diagnosed with pelvic thrombophlebitis. In this post, I will discuss Vokoun's injury in depth, starting with his 2006 pelvic thrombophlebitis and recovery and ending with his current condition and treatment.

THE INJURY

When Vokoun was 10 months old, he grabbed a tablecloth causing hot coffee to spill all over himself. During his treatment, doctors inserted a femoral catheter in his right groin. Presumably, this catheter is thought to have damaged the endothelium (inside lining) of one of his veins. Catheter-related thrombosis is not uncommon, but they usually don't take place 30 and 37 years after the initial damage. Essentially, blood coagulates (clots) at a wound site in order to 'plug up the hole' or fix the wound. Vokoun's old blood clot turned into scar tissue which grew into the side of his veins which explains why his clots did not break apart or get bigger when he was prescribed blood-thinning medication 7 years ago.

In 2006, after some back pain, Vokoun underwent an MRI and several blood clots were found in both his abdomen and pelvis. He was diagnosed with pelvic thrombophlebitis, a blood condition that created a multitude of blood clots presumably due to his past vein injury. After three days in the hospital and three months on blood-thinners, Vokoun returned to hockey when he was deemed to be stable.

On September 21st during a Penguins practice, Vokoun noticed swelling in one of his legs and was immediately sent to the hospital. Vokoun's foot was swollen and doctors found several blood clots ranging from his mid-thigh all the way to almost where his heart is located. This means Vokoun's clot was iliofermoral (very high and in his pelvis) which is quite unusual and the most troubling part of Vokoun's injury/condition. Most deep vein thromboses (DVTs) are usually in the lower leg and and can be treated with anti-coagulates alone.


DVTs are when a large thrombus forms in one of the deep veins of your body. The risk associated with DVTs are that the clots in your veins can break loose (embolus), travel through your blood stream and lodge into your lungs , blocking blood flow and killing you in an event known as pulmonary embolism.

THE TREATMENT

Vokoun was released from the hospital on Wednesday, September 25th.There are two options to treat Vokoun and it is undisclosed which he was treated with.

One option is called percutaneous mechanical thromectomy (PMT). During the surgery, doctors make a small incision and insert a catheter into the affected vein to break up and suck out out the clot. These catheters vary in method and range from using rotating wires, to jets of saline, and ultrasound.

A second option is a minimally-invasive procedure known as catheter-directed thrombolysis. Doctors make a small incision and insert a catheter into the vein, maneuver it to the thrombus (clot) and deliver thrombolytics, or medicines that can quickly dissolve a blood clot.

After his procedure, Vokoun is expected to be on a 3 or 6 month course of anti-coagulant therapy. Anti-coagulants are drugs that inhibit the blood's ability to coagulate, or clot. Considering this is Vokoun's second episode, it is highly likely that he undergoes a long treatment routine recommended by his hematologist. Vokoun will most like receive the best treatment that money can buy, for example, a more expensive or effective therapy than traditional anti-coagulants such as warfarin or heparin.

HOW SOON WILL VOKOUN BE BACK? 

This is completely unknown. It all depends on how Vokoun is feeling and how his doctors and hematologists evaluate him. One of the main issues is that Vokoun can not undergo and physical/sport activity while on his anti-coagulant medication. These medicines increases the risk for bleeding as your blood is not able to clot at a wound and heal. If Vokoun stopped a shot causing a severe bruise or god-forbid was accidentally cut by a skate, he could die.

For now, let's all be thankful that Vokoun is okay and is successfully undergoing treatment. I wish him a speedy recovery and hope he's on the ice at some point in the future.

UPDATE:

Redditor Ravenspike asked: "Just a quick question, couldn't the DVT also cause ishemia in other parts of the body including other organs and not just a pulmonary embolism?" 

My answer: Pulmonary Embolism is the most serious complication of proximal DVT so that's why I chose to highlight it. Also, the risk of PE is higher when clots are present in the thigh and pelvis (which were present in Vokoun's case)
As with any blood clots, ischemia is possible. This certainly occurred wkth Vokoun. As I said, his foot and leg were extremely swollen, meaning he definitely suffered from some ischemia in the tissues of his lower body.
Pelvic DVTs have also been found to cause brain ischemia in some cases, but I don't think that was present here.
Thanks for the great question!

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