Practical Phlebology: Deep Vein Thrombosis PDF

Preface

This book on acute deep vein thrombosis (DVT) is written for clinicians so that they may have a better understanding of the disease process and its etiology and a current review of optimal patient care. It is also written for the academician. The material included is based upon pertinent peer-reviewed literature and good quality clinical trials that serve to illuminate proper clinical decision making. Needless to say, this subject is fertile ground for ongoing basic and clinical research.

This book begins with the epidemiology and natural history of acute DVT, which itself may be a misnomer, as most of the observations of the "natural history" of acute DVT have been in patients receiving anticoagulation. The book ends with a strong suggestion to the reader that "not all DVTs are the same."

The etiology of DVT follows. I took the opportunity to review some of the insightful work of Dr. Gwendolyn Stewart, who I had the distinct privilege of working with early in my career. As part of the Sol Sherry Thrombosis Research Center at Temple University Health Sciences Center, we investigated venodilation and endothelial damage as etiologic factors of acute DVT in animals and appropriate clinical investigation in humans. The observations were compelling, although this element of pathophysiology is seldom recognized.

If we in the medical profession had completely effective DVT prophylaxis, and if it were used uniformly, this text would be substantially abbreviated. Current recommendations are specifically addressed in Chapter 3 on DVT prophylaxis.

Diagnosis of acute DVT is quite reliable today, although definitive diagnostic techniques are not always available 24 hours a day. Therefore, other, less definitive diagnostic and treatment algorithms need to be adopted.

The remainder of the book addresses treatment in its many forms. While anticoagulation is the mainstay, strategies of thrombus removal have been shown to be superior to anticoagulation alone for the management of iliofemoral DVT. We await the results of the ATTRACT trial to confirm those of CaVenT (for iliofemoral DVT) and to report whether catheter-based interventions and thrombolysis are more effective than anticoagulation alone in reducing postthrombotic syndrome in patients with femoropopliteal DVT. Inferior vena cava filters and heparin-induced thrombocytopenia are also covered in separate chapters. I hope the readers enjoy the "white clot" as it appears upon removal from blood vessels.

Although the final chapter, "Common femoral endovenectomy and endoluminal recanalization for chronic postthrombotic iliofemoral venous obstruction," does not formally fall under the heading of acute DVT, I thought I must include it. It illustrates to readers that the long-term morbidity of extensive thrombus that remains within the vein is due to obliteration (obstruction) of venous return from the leg by the thrombus evolving to a fibrous occlusion, which is overwhelmingly collagen. While it is possible to reduce the severe postthrombotic syndrome in these patients by this relatively new but infrequently performed procedure, it is far easier and more effective to treat the acute thrombotic event with an appropriate strategy of thrombus removal.

In closing, I acknowledge the extreme patience and support of my wife, Elsa. The dedicated editorial assistance of Marilyn Gravett has lightened the load of putting this text together. The graphic expertise of Kurt Mansor is deeply appreciated. Claire Bonnett and her expert staff at CRC Press have smoothly advanced the entire process in a professional and friendly manner.

Finally, I dedicate this book to my former mentor, the late Dr. John J. Cranley, of Cincinnati, Ohio, who had a lifelong interest in venous disease. Dr. Cranley was a mentor and inspiration to many. He was a leader by example, a man dedicated to God, his family, and friends, and a person who never took advantage of his position for self-gain. His guiding principle was "Always do what's right!" Although he mainly used this saying referring to patient care, all those who knew him understood that it was a simple motto by which he lived. I have long been and will continue to be guided by his example.