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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
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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
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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
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Dedication
https://t.me/med1917
“Tony … ALWAYS DO WHAT’S RIGHT!”
John J. Cranley
1918–2003

https://t.me/med1917

Contents
https://t.me/med1917
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 stratication 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
https://t.me/med1917
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 eect 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 indenite 63
Indenite subtherapeutic anticoagulation versus placebo 63
Indenite subtherapeutic versus indenite 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
https://t.me/med1917
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 thepatient with a lter 104
Conditions for removal 104
Patient evaluation before removal 105
Patient management aer 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
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