Q: I am 28 years old suffering from hyperhomocysteinimia with deep vein thrombosis in the right calf. I am suffering from this disease from the last 5 years. I am taking an anticoagulant - Acitrom 5 mg - with folic acid 1 mg daily. Now my homocysteine levels are 11.12 mole/liter and the normal values are 5.00-15.00. My P.T were fluctuating between 1.45 - 1.8. I have a chronic clot in the lower limb. But from the last 3 weeks, I am having embolism in the right calf. My doctor prescribed me a treatment of low molecular heparin (fragmin) 5000 for 1 week and an oral anti-coagulant of 5 mg and then the embolism in the right calf recurred. I have searched on the Internet, a new thrombolysis technique called the New Nonsurgical Techniques Spray, Chew and Vacuum Away DVT. Is this technique available in India? Please suggest which hospital has this facility or suggest a better treatment?

A:I have read this query with great interest as I feel the condition that the person has described(Hyperhomocysteinimia with thromboembolism) is not so uncommon as one would like to believe. There are number of problems associated with this condition which makes the management even more difficult. It is ill understood, medical reports are anecdotal, and facilities to investigate and research are few due to smaller patient cohort and prohibitive cost. Given all the constrains stated above the people afflicted are young and there is no permanent cure so the recurrent episodes are not uncommon and many times with unpleasant results. However, with the current knowledge and the medical, surgical and endovascular tools available the management would be as follows: In principle the treatment remains drug treatment with some aids such as compression stockings. The vitamin therapy should include the Vitamin B12, Vitamin B6 and Folic acid the doses are slightly higher than normal therapeutic doses, more so when the level of Homocysteine is high. The doses can be moderated when the normal levels are achieved. The anticoagulant therapy (Unfractionated heparin, low molecular weight heparin and oral anticoagulants like warfarin and Acitrom) are to be decided on the basis of the frequency of the thrombosis. This condition has the propensity to recurrent thrombosis so the anticoagulants may be needed life long. The Heparins should by preference used only for a short period and a switch to warfarin made. The oral anticoagulants should be monitored with INR rather than PT time as the standardisation with INR is more reliable. Thrombolysis may some times be needed but should be restricted to salvaging life or limb as the complication rates are higher. The same goes for the surgical embolectomy, which should be only done to save the limb from impending Venous gangrene. I personally like to combine the surgical venous embolectomy with placement of Vena cava filter. One should also have low threshold for vena Cava filter As for as percutaneous Cather based embolectomies are concerned these are only recommended for life threatening Pulmonary Embolism. There is no rationale in trying these procedures for the calf DVT. These procedures are still in the experimental stages and not universally available or accepted and need considerable expertise and expensive hardware. Lastly, one has to remember that this is a metabolic error genetically transmitted which is going to stay life long and needs a treatment regimen, which gives acceptable results, is safe, cost effective and is internationally accepted. Fanciful procedures, which are good only in few hands if used randomly can have disastrous consequences. In the case of this patient I suggest that he should follow following regimen: Vitamin therapy, which is optimised and titred depending upon the Homocysteine levels. Anticoagulant therapy, which keeps the INR at 2.5 and never less than 2.0. Effective Graduated compression stocking, which should be tailormade for the patient. The venous duplex scan from time to time so that a fresh thrombosis is diagnose and treated with heparin for the syptomatic stage. Mere occlusion from a previous DVT should not be diagnosed as an acute event. Weight reduction Assessment for Hyperlipidemia and Hypothyroidism and if diagnosed to be treated at the same time. Active exercise programme and regular walking. Regular reviews with a physician or a vascular surgeon. I am sorry I have had to write a long answer, but considering this condition there are no easy answers.