{"id":21884,"date":"2019-02-07T09:57:12","date_gmt":"2019-02-07T16:57:12","guid":{"rendered":"https:\/\/www.uchealth.org\/today\/?p=21884"},"modified":"2022-06-03T11:04:28","modified_gmt":"2022-06-03T17:04:28","slug":"chronic-blood-clots-threatened-her-life-until-she-had-a-delicate-complex-surgery","status":"publish","type":"post","link":"https:\/\/www.uchealth.org\/today\/chronic-blood-clots-threatened-her-life-until-she-had-a-delicate-complex-surgery\/","title":{"rendered":"Chronic blood clots threatened her life until she had a delicate, complex surgery"},"content":{"rendered":"
<\/div>

Toss out the words \u201cchronic thromboembolic pulmonary hypertension\u201d at your next get-together with friends and you\u2019re likely to get a collection of blank stares. But Terrie Karp, who has the condition, can cut through the mystery with a few words.<\/p>\n

\u201cMy body is an efficient blood clot-making machine,\u201d Karp said from a bed at UCHealth University of Colorado Hospital<\/a> on the Anschutz Medical Campus in late December.<\/p>\n

The unwanted efficiency is the result of a genetic mutation \u2013 Factor V Leiden clotting disorder<\/a> \u2013 that Karp, 45, inherited from her father. The condition predisposes Karp to developing blood clots that have for more than a decade required regular treatment with anticoagulant medications. Over time, however, the medications failed to dissolve some of the clots, even as Karp\u2019s body produced new ones. Clots collected in the blood vessels of Karp\u2019s lungs, causing them to scar and narrow. This, in turn, led to pulmonary hypertension, or high blood pressure that strains the right side of the heart. The dangerous combination goes by chronic thromboembolic pulmonary hypertension<\/a>, or CTEPH.<\/p>\n

\"Terrie
Terrie Karp, shown here in her classroom during her time teaching in Lawrence, Kansas. Karp hopes to get back to teaching after a procedure that cleared blood clots from her pulmonary artery. Photo courtesy of Terrie Karp.<\/figcaption><\/figure>\n

Pulmonary house cleaning<\/strong><\/h3>\n

It was this condition that led Karp to UCH for a procedure in December with another tongue-twisting name: pulmonary thromboendarterectomy<\/a>. The surgery, performed for the first time at UCH in several years, involved opening Karp\u2019s chest, \u00a0entering the pulmonary artery of each lung and painstakingly scraping the blood vessel walls clean of clotted build-up.<\/p>\n

A couple of weeks after the procedure by a multidisciplinary team that included surgeons Jay Pal and Christopher Scott \u2013 both of whom had trained for it during separate stints at Duke University Medical Center \u2013 Karp was discharged from UCH and returned to Grand Junction to recover.<\/p>\n

The procedure required Karp to invest a good deal of trust in her providers at UCH. \u201cWe were clear with Terrie that hers would be our first case here,\u201d said Scott. However, he and Pal also reassured her that a team that included experts from pulmonology<\/a>, hematology<\/a>, radiology<\/a> and nursing had reviewed her case for months before determining surgery was the best course of treatment.<\/p>\n

More daunting, the procedure required stopping blood flow to her entire body for a total of about 50 minutes while Pal and Scott did arterial cleaning. More on Karp\u2019s trip to the netherworld later. She makes clear that, whatever the risks, giving the thumbs up to surgery was easy when she considered her alternatives.<\/p>\n

Blood barriers<\/strong><\/h3>\n

Simply put, CTEPH had laid waste to her life. In 2007, Karp was working happily as a fourth-grade teacher on a Navajo reservation in Gallup, New Mexico when the first overt signs of CTEPH appeared: a swollen leg and back pain that were the result of a blood clot. She spent her Christmas vacation in the hospital and later flew to Albuquerque, where providers threaded a catheter into her leg to suck out a clot the size of an eraser at the end of a pencil. She left the hospital with the clot cleared. With the help of a blood thinner, she resumed normal activities.<\/p>\n

But Karp\u2019s body continued its clot-making efficiency, and the toll increased. In 2010 she had a new teaching job in Lawrence, Kansas when clots in her leg and arm felled her again. Treated with blood thinners, she recovered, but the next year, during a Christmas break visit to her parents\u2019 home near Elko, Nevada, Karp suffered a sudden painful attack that turned out to be a blood clot in the lung. The following summer, she was back in Elko, watching President Obama accept his party\u2019s nomination for a second term when a violent headache struck. She called 911 and was airlifted to the University of Utah, where she was treated for a stroke caused by a blood clot in her brain. She was just 39 years old and her life was in shambles.<\/p>\n

\"Dr.
Dr. Jay Pal. Photo by UCHealth.<\/figcaption><\/figure>\n

 <\/p>\n

\u201cThe disease derailed my teaching career,\u201d Karp said. It took four arduous years of recovery, including treatment to control epileptic seizures, to land another teaching position, this one at a school serving the Navajo Nation in Yatahey, New Mexico. However, her hopes for a successful return to the classroom were sabotaged by multiple clots in both lungs. She missed the first four days of class and required oxygen around the clock after she returned. She struggled through fatigue, shortness of breath and pain to finish the year, but the school didn\u2019t renew her contract because she\u2019d had too many absences.<\/p>\n

New hope<\/strong><\/h3>\n

Following this disappointment, Karp moved to Grand Junction to live with a friend. She says her medical providers there told her that there was little they could do for her other than attempt to manage her disease with blood thinners. But one of them referred her to UCH pulmonologist Dr. James Maloney<\/a> for the evaluation that eventually led to the pulmonary thromboendarterectomy.<\/p>\n

Maloney said the multidisciplinary team\u2019s consideration of Karp\u2019s case included reviewing her extensive medical records and an echocardiogram. A pulmonary angiogram that yielded images of the blood vessels on the right side of her heart helped the team quantify the severity of her pulmonary hypertension and decide on medications to manage the condition. The imaging also revealed Karp\u2019s \u201chigh clot burden,\u201d which made it unlikely that medications alone could restore her quality of life, Maloney explained.<\/p>\n

\u201cOne of Terrie\u2019s goals was to get back to teaching, and it\u2019s something she simply couldn\u2019t do, not only because of her oxygen levels, but because she had frequent hospitalizations related to her CTEPH,\u201d he said. \u201cWe knew that she would have not only a shorter life but also that the quality of life she had was not consistent with what she viewed as acceptable.\u201d<\/p>\n

Pal and Scott traveled in October to UC San Diego Health, which developed the pulmonary thromboendarterectomy procedure. Colleagues from San Diego later journeyed to UCH to support Pal and Scott during Karp\u2019s surgery.<\/p>\n

The razor\u2019s edge<\/strong><\/p>\n

The procedure begins with the surgeons opening the sternum, reaching the pulmonary artery, and using a sharp knife to delicately scrape away and suction out clotted debris pressed into the wall lining. Success or failure balances on a razor\u2019s edge.<\/p>\n

\u201cThe most important thing is to identify exactly where the clot begins and ends because it is embedded in the walls of the artery,\u201d Pal said. \u201cIf we take too little of the clot out, we haven\u2019t really helped the patient. If you take too much, you risk rupturing the artery, which is universally fatal.\u201d<\/p>\n

\"Dr.
Dr. Christopher Scott. Photo by\u00a0UCHealth.<\/figcaption><\/figure>\n

Then there\u2019s the matter of eliminating blood flow and movement from the artery. That requires lowering the patient\u2019s body temperature to about 65 degrees Fahrenheit and stopping the heart, creating a state Scott described as \u201cfunctionally dead.\u201d<\/p>\n

At that temperature, the body requires little oxygen to remain functional, Pal said. \u201cIt\u2019s analogous to when a kid falls in a frozen lake in Michigan,\u201d he said. \u201cThe body gets so cold that the heart stops. An hour later they warm up and they\u2019re fine because their body was so cold it didn\u2019t matter that they had no blood flow.\u201d<\/p>\n

The removal of the blood clots \u2013 first on one lung artery, then the other \u2013 takes only about 50 minutes total, but the entire procedure takes many hours. That\u2019s because after about 20 minutes, the super-chilled body begins to warm up, requiring the work to stop so that the process of gradual cooling can begin again in preparation for another round of clot removal.<\/p>\n

For her part, Karp said she was concerned about \u201closing her intelligence\u201d if the procedure went wrong, but was also hoping to experience and remember a near-death experience.<\/p>\n

\u201cI wanted to see what it\u2019s like on the other side,\u201d she said. No such luck: the procedure was a blank. When she regained consciousness she was intubated and so upset that she was restrained that she threatened to inform the Southern Poverty Law Center that she\u2019d been subjected to inhumane practices.<\/p>\n

\u201cI knew the restraints would happen, but I was in delirium,\u201d Karp recalled, chuckling.<\/p>\n

She recovered her faculties in a day or so and began a recovery that included a brief bout of atrial fibrillation and pain from implanted drains she described as \u201cgarden hoses.\u201d<\/p>\n

Karp said she appreciated the careful explanations Pal and Scott gave her of the procedure and its risks, but she had little trouble making her decision.<\/p>\n

\u201cI said, \u2018Let\u2019s do it,\u2019\u201d she recalled. \u201cI was ready to get my life back. I was ready to start teaching. I was ready to be able to take a shower without needing oxygen, to got to Walmart and shop without getting short of breath.\u201d<\/p>\n

Arteries cleared, on with life<\/strong><\/h3>\n

With the wreckage of the old clots removed from her lungs and her pulmonary hypertension relieved, Karp now has reason for optimism. She\u2019s set her sights on returning to teaching, first in a substitute role, as soon as possible. Her body will continue to form clots, but Maloney said she has a good chance of controlling them with consistent anticoagulant treatment.<\/p>\n

\"Karp
Dr.\u00a0James Maloney.\u00a0Photo by UCHealth.<\/figcaption><\/figure>\n

\u201cShe has a very good prognosis,\u201d he said. \u201cShe can be more physically active, which increases her cardiac output and helps to scrub clots away.\u201d<\/p>\n

She\u2019s the first of what the multidisciplinary team hopes will be a steadily growing list of CTEPH patients to receive the procedure. Maloney estimates that about 40 people in Colorado each year could benefit from the surgery. The team, led by Dr. Todd Bull<\/a>, medical director of UCH\u2019s Comprehensive Lung and Breathing Program<\/a>, now meets regularly to review cases and select the most appropriate candidates.<\/p>\n

Scott said it is important in building the program to increase awareness of CTEPH among the public and community providers. He noted that ventilation-perfusion (VQ) scans, which measure air flow and blood flow in the lungs, are relatively inexpensive yet reliable early screens for the disease and thus could help to spur referrals.<\/p>\n

Whatever the number of cases, the team\u2019s goal is not only to repair the physical damage caused by CTEPH but to restore hope for the future, Maloney said.<\/p>\n

\u201cThat\u2019s always a motivator for anything we do: not only to extend life with a certain therapy, but to improve the quality of life,\u201d he said.<\/p>\n","protected":false},"excerpt":{"rendered":"

Toss out the words \u201cchronic thromboembolic pulmonary hypertension\u201d at your next get-together with friends and you\u2019re likely to get a collection of blank stares. But Terrie Karp, who has the condition, can cut through the mystery with a few words. \u201cMy body is an efficient blood clot-making machine,\u201d Karp said from a bed at UCHealth […]<\/p>\n","protected":false},"author":2143,"featured_media":22518,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"_relevanssi_hide_post":"","_relevanssi_hide_content":"","_relevanssi_pin_for_all":"","_relevanssi_pin_keywords":"","_relevanssi_unpin_keywords":"","_relevanssi_related_keywords":"","_relevanssi_related_include_ids":"","_relevanssi_related_exclude_ids":"","_relevanssi_related_no_append":"","_relevanssi_related_not_related":"","_relevanssi_related_posts":"","_relevanssi_noindex_reason":"","footnotes":""},"categories":[5],"tags":[223,2597,1242,1497],"class_list":["post-21884","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-innovative-care","tag-cancer-care-and-hematology","tag-comprehensive-lung-and-breathing-program","tag-radiology","tag-uchealth-university-of-colorado-hospital"],"acf":[],"yoast_head":"\nComplex surgery saves woman from chronic, 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