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Practical Phlebology
Series Editors: Lowell S. Kabnick, Neil S. Sadick
Deep Vein Thrombosis
Anthony J. Comerota
Practical Phlebology
Deep Vein Thrombosis
Practical Phlebology
Series Editors: Lowell S. Kabnick, Neil S. Sadick
PUBLISHED
Practical Phlebology: Starting and Managing a Phlebology Practice
Marlin Schul; Saundra Spruiell; Clint Hayes
2010 • ISBN 9781853159404
Practical Phlebology: Venous Ultrasound
Joseph Zygmunt; Olivier Pichot; Tracie Dauplaise
2013 • ISBN 9781853159404
Practical Phlebology: Deep Vein Thrombosis
Anthony J. Comerota
2014 • ISBN 9781444146480
Practical Phlebology
Deep Vein Thrombosis
Anthony J. Comerota
Series Editors: Lowell S. Kabnick
Associate Professor of Surgery, New York University, Langone Medical Center, New York; and Director, NYU Vein Center, NY, USA
Neil S. Sadick md faad faacs facph
Clinical Professor of Dermatology, Weill Cornell Medical College, Cornell University, New York, NY, USA
Boca Raton London New York
CRC Press is an imprint of the Taylor & Francis Group, an informa business
md facs
CRC Press
https://t.me/med1917
Taylor & Francis Group 6000 Broken Sound Parkway NW, Suite 300 Boca Raton, FL 33487-2742
© 2014 by Taylor & Francis Group, LLC CRC Press is an imprint of Taylor & Francis Group, an Informa business
No claim to original U.S. Government works Version Date: 20130919
International Standard Book Number-13: 978-1-4441-4610-3 (eBook - PDF)
This book contains information obtained from authentic and highly regarded sources. While all reasonable efforts have been made to publish reliable data and information, neither the author[s] nor the publisher can accept any legal responsibility or liability for any errors or omissions that may be made. The publishers wish to make clear that any views or opinions expressed in this book by individual editors, authors or contributors are personal to them and do not necessarily reflect the views/opinions of the publishers. The information or guid­ance contained in this book is intended for use by med ical, scienti fic or health-c are professionals and is provided strictly as a supplement to the medical or other professional ’s own judgement, their knowledge of the patient’s medica l history, relevant manufacturer’s instructions and the appropriate best practice guidelines. Because of the rapid advances in medical science, any information or advice on dosages, pro­cedures or diagnoses should be independently verified. The reader is strongly urged to consult the drug companies’ printed instructions, and their websites, before administering any of the drugs recommended in this book. This book does not indicate whether a particular treatment is appropriate or suitable for a particular individual. Ultimately it is the sole responsibilit y of the medical professional to make his or her own professional judgements, so as to advise and treat patients appropriately. The authors and publishers have also attempted to trace the copyright holders of all material reproduced in this publication and apologize to copyright holders if permission to publish in this form has not been obtained. If any copyright material has not been acknowledged please write and let us know so we may rectif y in any future reprint.
Except as permitted under U.S. Copyright Law, no part of this book may be reprinted, reproduced, transmitted, or utilized in any form by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying, m icrofilming, and recordi ng, or in any information storage or retrieval system, without written permission from the publishers.
For permission to photocopy or use material electronically from this work, please access www.copyright.com (http://www.copyright. com/) or contact the Copyright Clearance Center, Inc. (CCC), 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400. CCC is a not-for­profit organization that provides licenses and registration for a variet y of users. For organizations that have been granted a photocopy license by the CCC, a separate system of payment has been arranged.
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Dedication
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“Tony … ALWAYS DO WHAT’S RIGHT!”
John J. Cranley
1918–2003
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Contents
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Series Preface xi Foreword xiii Preface xv About the Author xvii
1 Natural history of acute DVT 1
Overview 1 DVT and mortality 1 rombus resolution 2 DVT, valve function, and recurrence 2
Pathophysiology of postthrombotic morbidity 2
Not all DVTs are the same 3
Calf vein thrombosis 4 Femoral vein thrombosis 4 Popliteal vein thrombosis 4 Iliofemoral DVT 4
References 5
2 Etiology 9
Overview 9 Etiology 9
Stasis 9
Hypercoagulability 10 Vein wall injury 11 References 14
3 DVT prophylaxis 17
Overview 17 Risk stratication 17 Prophylaxis guidelines 20 References 23
4 Diagnosis of acute DVT 25
Overview 25 Clinical evaluation 25 Ascending phlebography 26 Venous duplex ultrasound 26 Computerized tomographic venography 31 Magnetic resonance venography 31 D-dimer tests 31 References 33
vii
viii Contents
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5 Anticoagulants 35
Overview 35 Unfractionated heparin 35 Low-molecular-weight heparins 38 Fondaparinux 38 Direct thrombin inhibitors 39
Lepirudin 39 Argatroban 40
Bivalirudin 40 Warfarin compounds (Vitamin K antagonists) 41 Danaparoid 43 References 43
6 New oral anticoagulants 47
Overview 47 Clinical trial development 48 VTE prophylaxis in orthopedic patients 48
Dabigatran 48
Apixaban 49
Edoxaban 50
Rivaroxaban 50 VTE prophylaxis in medically ill patients 50 Treatment of acute VTE 51
Dabigatran 51
Apixaban 52
Edoxaban 55
Rivaroxaban 55 Reversal of the anticoagulant eect of NOACs 55 References 57
7 Management of acute DVT: Anticoagulation 61
Overview 61 Initial anticoagulation 62 Duration of anticoagulation 62
Four weeks versus three months 62
Six weeks versus six months 63
ree months versus indenite 63
Indenite subtherapeutic anticoagulation versus placebo 63
Indenite subtherapeutic versus indenite conventional anticoagulation 64
Aspirin to prevent recurrent VTE 64 Recurrent DVT 64 DVT and malignancy 65 Tailoring duration of anticoagulation 66
Residual venous obstruction on ultrasound 66
Randomized trials 67
rombus activity: D-dimer 68
Ambulation and compression 69 References 70
Randomized trial 68
Contents ix
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8 Strategy of thrombus removal 73
Background 73 Rationale for thrombus removal 73
Postthrombotic morbidity of iliofemoral DVT 74 Acceptance of thrombus removal 76
Treatment options for thrombus removal 77
Contemporary venous thrombectomy 77
Technique of venous thrombectomy 77 Preoperative care 77 Operative technique 78
Postoperative care 83 rombolytic therapy: Systemic 83 Intrathrombus catheter-directed thrombolysis 84
National venous registry 84
Patient evaluation 88
Technique 89 Pharmacomechanical thrombolysis 90 Endovascular mechanical thrombectomy 90 Ultrasound-accelerated thrombolysis 91 Isolated segmental pharmacomechanical thrombolysis 91
Recurrent DVT 92 References 96
9 Inferior vena cava filters 101
Overview 101 Indications 101 Filter types 102 Clinical decision making 102 Randomized trials 102 Hemodynamic performance 103 Decision matrix 103
Indication for placement 104 Management of thepatient with a lter 104 Conditions for removal 104 Patient evaluation before removal 105 Patient management aer lter removal 105
Summary 105 References 106
10 Heparin-induced thrombocytopenia 109
Overview 109 Clinical presentation 109 Diagnosis 110 Management 111
Lepirudin 112 Bivalirudin 112 Argatroban 112 Danaparoid 112