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Cardiovascular System - Arteries / Veins

Dr Jules Eden, dive medicine specialist and founder of e-med, answers divers' questions - as published in Sport Diver magazine:
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Q - My family has a history of Hereditary Haemorrhagic Telangiectasia (HHT), with my mother currently suffering from nose bleeds and stomach bleeds, as well as other symptoms such as blood spots on her fingers etc. I have nose bleeds but not to the same degree as my mother. I recently read some info on the condition and about the effects sometimes causing Pulmonary Arteriovenous Malformations (PAVM's). As far as I am aware my mother has never been tested for this. I am obviously concerned about the effects that this could have on my diving especially as the symptoms of HHT are expected to worsen as I reach 30. Could you tell me any more info on PAVM? Is my diving career over before it has even started?

A - Hereditary Haemorrhagic Telangiectasia: a fine phrase to roll around the tongue, but a hugely inconvenient condition to live with. About 1 in 5000 people do, and almost all are afflicted with recurrent nosebleeds. Telangiectasias are malformations that cause the walls of small blood vessels to become fragile, and hence bleed easily. Arteriovenous malformations (AVM’s) occur if larger vessels are affected; in HHT they can be found in the lungs, liver and brain. Lung (or pulmonary ) AVM’s are a problem for divers as essentially they do the same thing as a PFO – bypass the normal filtering action of the lungs on bubbles, allowing them to cross into the systemic circulation. The big difference is that pulmonary AVM’s are normally multiple, so rather than deploying an umbrella over a hole in the heart, they are treated by embolisation. A catheter is advanced into the heart, similar to the approach used in PFO closure. Dye is then used to highlight the AVM’s, and tiny coils deployed into them, which cause the blood within to clot off and the lesions to regress. It’s a complicated technique but in the right hands, good success rates are achievable. However, AVM’s can recur, so I would counsel anyone with this condition to think very carefully before considering diving, even if they don’t appear initially affected.

Q - i have burgess disease. out of the 3 artery running down my calfs i have half remaining in one leg and almost two in the other i get intermittent claudication in feet and hands. does this mean i cant learn to dive

A - Honey, if I don’t tell you, then no one will. The next book you read will not be the PADI Open Water course book. It has to be “Ant and Bee Learn Basic Grammar and Spelling”. I get the odd typo from you lot, but this is my finest one yet. So…capitalise your I’s and caps after a full stop please. That’s enough pedantry!

It’s called Buerger’s disease, named after some German bloke no doubt, as opposed to the coke fuelled author of A Clockwork Orange. It is also known as thromboangiitis obliterans and is a rare disease characterized by a combination of acute inflammation and thrombosis (clotting) of the arteries and veins in the hands and feet. The obstruction of blood vessels in the hands and feet reduces the availability of blood to the tissues, causes pain and eventually damages or destroys the tissue. It often leads skin ulcerations and gangrene of fingers and toes. And as you do have clogged up arteries in your legs, and you get this “claudication”, or angina of the legs then it is a real issue with diving. If you were to fin at all, then you would get searing cramps and pains up your legs, whilst at depth. This would result in the sight of you bend double in agony, desperately pulling the tip of a fin to release a cramp, but with no result as your blood supply would be so bad.

So sad news I am afraid. But you could at least see the inside of a dive chamber, as hyperbaric oxygen is used a lot for the treatment of this condition.

Q - Wondering if there are any problems with diving if I have varicose veins - any risk to worsening the condition, or whether it could impact my ability to dive.

A - I can't see any real issue here. Sure they're ugly, sure they may cause a bit of aching and discoloration, but as long as they are not really severe, you can dive. By severe imagine great thick wriggly blue worms, trying to bust out from under the skin on your legs. If these are knocked or pricked on something spiky, the column of blood above them can dump out quicker than a Texan oil strike. The only way of taming this wildcat is to lie on your back and get a passer by to put pressure on the point of the bleed with your leg raised.

But to let the varicosities get to that stage would be criminal, so as you are smart enough to take up diving, I assume the problem is a minor one.

In fact, if you're wearing a full length nice tight neoprene wettie, then the pressure might even act to improve the condition temporarily. And be a darn site more fashionable than one of those grotty NHS pressure stockings, that seem to slip down to the ankle, especially in the elderly obese Richard and Judy watching care home resident types. An image still burned into my brain from early years working voluntarily in old folks homes. Ever been a bingo caller to people with Alzheimer's? The longest of all games.

Q - I am 54 years old and have been diving for some 6 years now. Most of this is in either tropical waters or temperate areas with water temps of 18 deg C or more. Two years ago I underwent varicose vein surgery to both legs and veins were removed from both lower limbs. The ops. were completely successful. The only discomfort I now suffer is occasional cramp, which happens during the night.

My diving activity over the last two years has all been in Tropical waters at 25 deg plus with no cramp effects. I have however just returned from Western Australia and among other dives, we enjoyed the inaugural dive on the HMAS Perth in Albany. Water temp was 18 deg and I was "crippled" during the last 10 minutes of each dive, causing some concern to myself and diving buddies alike. The two layers of 5mm neoprene kept the rest of me quite warm enough in the water.

Is there any drug treatment that I can use to alleviate this inevitable consequence, or any physical treatment to be advised.

A - I assume that "crippled" was with the cramps you experience at other times.

I think there are a few things you can do to make sure it doesn't happen again.

Cramps result after the build up of lactic acid, a by product of the burning of other elements apart from the glucose that is the normal stuff the tissues need to give them energy.

If you dive dehydrated or do not eat properly before you dive then the chances of getting cramps are greatly increased. As we know as well in diving the muscles we use most are those in the legs when finning, so if you are going to cramp then the legs are probably where you will get it.

Again keeping warm is important as cold legs and arms will result in cramps fairly soon into a dive if you are having to fin a lot.

So the lesson here is plenty of fluids, energy drinks may be the best for you and perhaps a set of ergonomic fins so you use your leg muscles less.

If you do cramp underwater, depending on the situation your buddy could pull the muscle for you by flexing the leg. But if it's a serious one just come up slowly and try this manoevre during a deco stop, but if it is too painful just get back to the boat.

The varicose vein surgery is a red herring as it doesn't necessarily contribute to causing cramps, but what you can use for any night cramps is a tablet called quinine sulphate. This is the same compound used as an antimalarial and also found in tonic water. So if you're stuck for the tablets, a few bottles of this may help. Gin is optional.

(other dive medical questions)



   


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