Advice on travel-related DVT

About the link between long-haul air travel and DVT and how to reduce the chances of developing the condition.
Introduction
A possible link between deep vein thrombosis (DVT) and long-haul air travel was first suggested by reports in medical journals in the 1950s. These early reports generally pointed to immobility as the common underlying risk-factor. DVT may be associated with any form of long distance travel whether by air, car, coach or train and new research, largely funded by the Departments of Transport and Health, has confirmed that all forms of transport involving a journey of 4 hours or more led to an increase in the risk of blood clots forming in the veins of the legs.
This advice summarises what is known about:
travel-related DVT in air passengers
who may be at risk
how to reduce the potential risks
What is DVT?
DVT is a serious condition where blood clots develop in the deep veins of the legs. It must be distinguished from blood clots in superficial varicose veins in the legs, called phlebitis, which is much less serious.
One in every hundred people who develop DVT dies. The cause of death is usually a blood clot, travelling from the legs to the lungs. This is called pulmonary embolus or PE. When PE is severe it causes the lungs to collapse and heart failure. DVT combined with PE or other blood clots is often referred to as Venous Thrombo-Embolism or VTE.
Treatment of DVT and PE is with blood-thinning drugs or anticoagulants, including warfarin and heparin. Aspirin in low doses also acts as a blood thinning drug and is used to prevent clotting conditions in the arteries like coronary thrombosis. Its benefit in preventing DVT is debatable.
Who is at risk from DVT
Every year DVT occurs in about 1-3 in 1000 people in the general population, ranging from less than 1 in 3000 in people under the age of 40 up to 1 in a few hundred in those over 80.
The risk of DVT and PE is greater in people:
over 40 years of age
who have had blood clots already
with a family history of blood clots
suffering from or who have had treatment for cancer
with certain blood diseases
being treated for heart failure and circulation problems
who have had recent surgery especially on the hips or knees
who have an inherited clotting tendency
who are very tall.
DVT is also more common in women who:
are pregnant
have recently had a baby
are taking the contraceptive pill
are on hormone replacement therapy or HRT.
These groups make up 90 to 95% of all those who get DVT and/or PE.
The risk of DVT from air travel
There is evidence that long-haul flights, especially when passengers have little or no exercise, may increase the risk of developing DVT. Information on the proportion of people who develop DVT related to air travel has been limited until recently; new research carried out by a consortium of medical research scientists under the auspices of the World Health Organisation has found one case of DVT for every 6000 journeys that lasted 4 hours or more. Nevertheless, it is difficult to decide whether the flight itself caused the DVT/PE or whether these people were at risk for other reasons. This is because
DVT and PE are relatively common conditions anyway and
more people than ever now travel by air every year.
While it is difficult to be certain what the exact causes of travel-related DVT are, experts agree that lack of exercise or immobility are major underlying risks. They have also identified that people at increased risk of DVT/PE in general are those more likely to develop travel-related DVT/PE.
What are the signs of DVT?
You may get swelling, pain, tenderness and redness especially at the back of the leg below the knee. This is different from the mild ankle swelling that many people get during long haul flights and DVT usually though not always affects only one leg. These complaints may develop during the journey but more commonly hours or even days and up to 4 weeks later. The pain may be made worse by bending the foot upward towards the knee. In some cases there may be no signs or symptoms of DVT at all in the legs and problems only become obvious when a pulmonary embolus or PE develops from the clots in the legs. Fortunately PE is rare. PE can cause breathlessness, chest pain and in severe cases, collapse and death. Both DVT and PE, whatever the cause, are serious conditions and need urgent investigation and treatment.
How to reduce the possible risks
Simple in-flight exercises and getting up and walking around regularly are advised.
Before the trip
Consult your doctor if you have:
ever had a DVT or PE
a family history of clotting conditions
an inherited tendency to clot (thrombophilia)
cancer or had treatment for cancer in the past
undergone major surgery in the last three months
had hip or knee replacement within the last three months or
ever suffered from a stroke.
Experts advise that people who have had hip or knee replacements should postpone long haul flights for three months after surgery. If you have had this kind of surgery, talk to your family doctor, travel clinic staff or a member of the surgical team.
You may need advice on in-seat exercises, especially leg exercises to keep the circulation active and reduce the risk of developing a DVT. Some information is provided below. More information is available in literature provided by travel agents, and in the in-flight leaflets magazines and videos now produced by many airlines.
You may also need to discuss treatment with blood-thinning drugs or the use of graduated compression stockings if you are in a high-risk group. Graduated compression stockings are widely available from pharmacies and pharmacists can provide advice on use and fitting. While there is evidence that graduated compression stockings may be useful there is no evidence that aspirin is effective in preventing travel-related DVT or PE. Because aspirin can have serious side effects like bruising, bleeding from the gut and allergies you should consult your doctor before deciding to take this drug. People taking aspirin already should not increase the dose.
Women taking the 'pill' or on hormone replacement therapy (HRT) should do the exercises described in this advice to help reduce the risk. They should also discuss the use of graduated compression stockings with their community pharmacist. Women who are pregnant, or have recently had a baby should seek advice from the antenatal team or the health visitor.
Make sure you have good medical insurance for your trip. If you are travelling within the European Economic Area or Switzerland, you may be eligible for cover provided by the European Health Insurance Card (EHIC). The EHIC entitles those eligible for cover to reduced cost healthcare where treatment becomes necessary during a temporary visit to other counties of the European Economic Area or Switzerland. The card is only valid for treatment offered under the state healthcare schemes operating in these countries: it gives you access to treatment under the same terms as people that live in the country you are visiting. However, the EHIC is not a substitute for travel insurance. It may not cover all health costs and never covers repatriation costs. Further information, including a full list of countries covered along with details of their 'health systems' can be found in the booklet 'Health Advice for Travellers' available from the Post Office and on line using the link below.
During the trip
get comfortable in your seat and recline as much as possible
wear loose fitting clothing
store your hand lugguage in the overhead lockers to keep the room under the seat in front of you free
bend and straighten your legs, feet and toes while seated every half-hour or so during the flight
press the balls of your feet down hard against the floor or foot-rest to increase the blood flow in your legs and reduce clotting
do upper body and breathing exercises to further improve circulation
take occasional short walks around the cabin, whilst the aircraft is cruising at altitude
take advantage of refuelling stopovers where it may be possible to get off the plane and walk about
drink a reasonable amount of water
avoid alcohol, which in excess leads to dehydration and immobility
avoid taking sleeping pills, which also cause inertia
After the trip
For the vast majority of air passengers there will be no problems upon disembarkation. However symptoms of DVT can appear after arrival. If you develop swollen painful legs, especially where one is more affected than the other, or if you have breathing difficulties, see a local doctor urgently or go the the nearest A&E department.
Health advice for travellers
Research into travel-related DVT
More research is needed to explore effective methods of prevention of DVT.The Aviation Health Working Group (AHWG) is an interdepartmental organisation, chaired by the Department for Transport, with representatives from the Civil Aviation Authority, Health and Safety Executive and the Department of Health. It meets every two months to discuss issues relevant to aviation health and oversees research and advises the air industry. The group also helps to ensure that further research ties in with that recently carried out under the auspices of the World Health Organisation.