On a warm Sunday evening in September 2015, Cheryl Violante felt a jolt of pain in her right instep when she stood up from a chair. It went from her toe to heel. Her first thought was that she’d pulled something. “I thought, ugh, I just got new knees and now I’ve hurt my foot,” says Violante, who is 64 years old and lives in New Haven.
For the last two months, she’d been recuperating from a double knee replacement. She was now looking forward to returning to work. But when she saw her physical therapist the next day, the plan changed.
Her foot still hurt and her calf had become swollen and warm to the touch. “My physical therapist said: ‘This doesn’t look right. I think you should go to the emergency room,’” says Violante, who works as a senior administrative assistant and publications web coordinator at Yale School of Medicine’s Office of Communications.
Her husband drove her to the emergency department at Yale New Haven Hospital, where an ultrasound revealed a blood clot in her leg—not an uncommon complication after a major surgery such as her knee replacements. “They said it was quite large,” Violante says. “And I was thinking it might be the size of the tip of your finger. I figured they would give me some intravenous drugs and send me on my way.” But, instead, she was admitted to the hospital for treatment, and, because it was getting late, she sent her husband home to get some rest.
Before she was settled in her room, she heard a knock at the door. On the other side was Young Erben, MD, a vascular surgeon at Yale Medicine. She had alarming news. The clot wasn’t merely large. It extended all the way from the ankle to a vein in her belly. This type of clot can cause a potentially fatal condition called pulmonary embolism.
“This shouldn’t wait,” Dr. Erben told Violante. “We should intervene immediately.”
A rush to the operating room
Each year, two million Americans receive a diagnosis of deep vein thrombosis (DVT). The condition arises when a clot develops in a vein surrounded by dense connective tissue, typically in the arms or legs, and begins to block blood flow. It may be caused by a medical condition, or by enforced inactivity, such as recuperation after surgery or a long flight or train ride.
About a third of the time, a piece of the clot breaks off and travels to the lungs, where it becomes a pulmonary embolism that interferes with breathing or causes worse problems. In this country, pulmonary embolisms kill about 60,000 people a year. Violante’s condition was “significantly dangerous,” Dr. Erben says, adding, “I knew we had to break down the clot right away."
Hearing that shocking news, Violante burst into tears. “I realized I had this humongous clot that at any moment could break off and go to my lungs,” she says. Her husband was at home, and her adult daughters didn’t even know she was in the hospital. “I didn’t want to call and wake them up and get them upset,” Violante says.
Dr. Erben comforted her with a hug and a promise: “Don’t worry, I will take good care of you,” she said.
Indeed, the surgeon stayed to answer all of her questions about the procedure and the medication she’d be given. “If you have to get bad news, Dr. Erben was the perfect person to deliver it,” Violante says. “She was calm, personable, caring and reassuring.”
The doctor then phoned Violante’s husband, who, after a phone call from his wife, was already on his way back to the hospital. He went to the family waiting room, where he texted updates to his daughters and anxiously awaited news on whether the surgery would save his wife.
Though it was now past midnight, Dr. Erben started scrubbing for the procedure.
By the time Violante was rolled into the operating room, the swelling in her leg was at its peak. “Her artery was pushing blood into her leg, but the whole vein was plugged up,” Dr. Erben recalls. The blood couldn't circulate from the leg to the rest of her body. If the Yale Medicine team didn’t act quickly, the cells in Violante's leg would begin to die, which could lead to the loss of the limb. Under the circumstances, it was hard to predict what would happen. Some people end up with a leg that is just severely swollen. Others develop a more serious problem called phlegmasia cerulea dolens, when the leg becomes painful, swollen and blue–a precursor to gangrene.
Yale Medicine’s modern clot-busting techniques
Twenty years ago, doctors only had a few ways to handle a clot. In a case such as Violante’s, they would have administered anticoagulants (drugs such as heparin and warfarin, which keep blood from clotting), wrapped the leg tightly and hoped for the best. But Dr. Erben had a much more sophisticated plan.
Called thrombolysis, the procedure is done with the patient under conscious sedation. It takes about an hour and the clot quickly starts to melt away.
Through small, puncture incisions, one in Violante's ankle and the other behind her knee, the doctor pushed long, plastic catheters into the clogged vein. One was a sheath to run from her ankle. A second catheter, running from the back of her knee to her groin, was dotted with tiny holes along the sides, like a miniature irrigation system. Once that catheter was in place, Dr. Erben started a 24-hour drip of a powerful clot-dissolving medication called tissue plasminogen activator (tPA). It would seep out of the holes, coating every bit of the blockage.
Violante's circulation began to improve immediately. Nurses pulled a compression stocking over her calf to boost the blood flow even more. In the early morning hours, Violante awoke as the anesthesia wore off. She was relieved to learn that her surgery had been a success. “I looked up at my husband dozing at the side of the bed and told him, ‘Please go home and get some sleep,”’ she says.
Violante was not out of danger. Catheters can jostle clots, potentially leading to a pulmonary embolism. Also, tPA is a potent drug that can cause bleeding in the brain. So, like all Yale Medicine patients who undergo thrombolysis, Violante was moved to the intensive care unit (ICU), where nurses monitored her closely. “Those are the patients you worry about when you go home at night,” Dr. Erben says.
A complete recovery
Violante spent the next two days in her bed in the ICU. “While the catheters were in, I could only walk if I was supported by a person on either side,” she says. On Tuesday afternoon, she went back to the operating room to have the clot checked and start another 24-hour infusion of tPA (clots as large as Violante’s always require multiple days of the drug). Wednesday required the same routine. By Thursday, Dr. Erben was satisfied with the clot’s dissolution and she carefully removed the catheters. Violante’s body would take care of what remained.
Violante then moved from the ICU to a private hospital room, where she could safely complete her recovery. Though she was foggy from the repeated sedations, her leg pain and swelling were gone. With the help of physical therapists, she quickly regained her strength and the ability to walk. A week later, she went home and was welcomed by a giant hand-lettered sign that her daughter had made: “Welcome Home, Mom!” She was overjoyed to eat meals her husband cooked and sleep in her own bed. “Just being surrounded by family and friends, and having peace and quiet,” she says.
It was hard to believe that a routine physical therapy appointment had morphed into a 10-day hospital stay. But Violante knew, by now, that a deep vein thrombosis ends far worse for many others. When Violante’s sister came to visit from New Hartford, an hour and a half away, the two spent the day catching up on family news over tea, her sister’s homemade zucchini bread, and raspberries from her garden. “Then, at the end, she was hesitating to tell me something, shuffling her feet like a little kid,” Violante says. “She finally told me that within the past few weeks, two people from her church had the same condition. Both passed away from pulmonary embolisms.”
With DVT, a quick diagnosis and expert treatment can make all the difference. “I knew I was in good hands at Yale,” Violante said. “My youngest daughter, Carissa, said the same thing. She was very upset at first, then peace came over her, and she said: ‘I know mom’s going to be okay. I don’t have to worry.’” Carissa also works at Yale School of Medicine, in Women’s Health Research, so she’s well aware of the institution’s high quality of care.
Despite her dramatic, near-death experience, Violante was able to return to work a few weeks later. At a follow-up with Dr. Erben in January, she and her husband brought a white rose and a chocolate bar as thank-you gifts. “My husband is 6’2” and she’s teensy-tiny, and he gave her a great big bear hug,” Violante says. “She was so caring and compassionate–and she’s an amazingly skilled vascular surgeon. I’m very fortunate. I had good people all at the right place at the right time.”