Surgery_Schwartz

Surgery_Schwartz. continually reassess if anticoagulation may be started safely at a later date.Placement of permanent IVC filters has been evaluated as an adjunct to routine anticoagulation in patients with proximal DVT.62 Routine IVC filter placement has not been shown to prolong early or late survival in patients with proximal DVT but did decrease the rate of PE (HR, 0.22; 95% CI, 0.05–0.90); however, there is an increased rate of recurrent DVT in patients with IVC filters (HR, 1.87; 95% CI, 1.10–3.20).IVC filters are associated with acute and late complica-tions. Acute complications include thrombosis or bleeding at the insertion site and misplacement of the filter. Late complications include thrombosis of the IVC, DVT, breaking, migration, or ero-sion of the filter through the IVC (Fig. 24-9). The rate of fatal complications is <0.12%.63 As a result of the increasing number Brunicardi_Ch24_p0981-p1008.indd 99122/02/19 3:01 PM 992SPECIFIC CONSIDERATIONSPART IIFigure 24-10. Autopsy specimen


Surgery_Schwartz

Surgery_Schwartz. rate of fatal complications is <0.12%.63 As a result of the increasing number Brunicardi_Ch24_p0981-p1008.indd 99122/02/19 3:01 PM 992SPECIFIC CONSIDERATIONSPART IIFigure 24-10. Autopsy specimen showing a massive pulmonary embolism.of reported complications with IVC filters, the FDA issued a warning in 2010 recommending removal of IVC filters as soon as they are no longer needed.64 This was followed by an update in 2014 where the recommendation was made to remove IVC filters within 29 and 54 days after implantation based upon a mathemati-cal model that suggested an increased risk-to-benefit ratio at this time point.65In some patients, the need for an IVC filter may be self-limited. Such patients can be treated with so-called removable IVC filters. Depending on the device, removable IVC filters are potentially removable by percutaneous endovascular tech-niques for up to several months after their initial implantation, assuming the filter is no longer required and does not have


Surgery_Schwartz

Surgery_Schwartz. IVC filters are potentially removable by percutaneous endovascular tech-niques for up to several months after their initial implantation, assuming the filter is no longer required and does not have large amounts of trapped thrombi. IVC filters that have been in place for an extended period of time may require adjunctive techniques, including laser-assisted removal or open surgical removal when they are embedded within the vena cava. All tem-porary IVC filters are approved for permanent implantation, and many so-called temporary filters end up as permanent devices with all the potential complications of permanent IVC filters.Operative Venous Thrombectomy. In patients with acute iliofemoral DVT, surgical therapy is generally reserved for patients who worsen with anticoagulation therapy and those with phlegmasia cerulea dolens and impending venous gan-grene. If the patient has phlegmasia cerulea dolens, a fasciotomy of the calf compartments is first performed. In iliofemoral DVT, a


Surgery_Schwartz

Surgery_Schwartz. and those with phlegmasia cerulea dolens and impending venous gan-grene. If the patient has phlegmasia cerulea dolens, a fasciotomy of the calf compartments is first performed. In iliofemoral DVT, a longitudinal venotomy is made in the common femoral vein, and a venous balloon embolectomy catheter is passed through the thrombus into the IVC and pulled back several times until no further thrombus can be extracted. The distal thrombus in the leg is removed by manual pressure beginning in the foot. This is accomplished by application of a tight rubber elastic wrap beginning at the foot and extending to the thigh. If the thrombus in the femoral vein is old and cannot be extracted, the vein may be ligated. For a thrombus that extends into the IVC, the IVC is exposed transperitoneally and controlled below the renal veins. The IVC is opened, and the thrombus is removed by gentle mas-sage. An intraoperative completion venogram determines if any residual thrombus or stenosis is present. If a


Surgery_Schwartz

Surgery_Schwartz. below the renal veins. The IVC is opened, and the thrombus is removed by gentle mas-sage. An intraoperative completion venogram determines if any residual thrombus or stenosis is present. If a residual iliac vein stenosis is present, intraoperative angioplasty and stenting can be performed. In most cases, an arteriovenous fistula is then created by anastomosing the great saphenous vein (GSV) end to side with the superficial femoral artery in an effort to main-tain patency of the thrombectomized iliofemoral venous seg-ment. Heparin is administered postoperatively for several days. Warfarin anticoagulation is maintained for at least 6 months after thrombectomy. Complications of iliofemoral thrombec-tomy include PE in up to 20% of patients67 and death in <1% of patients.68One study followed 77 limbs for a mean of 8.5 years after thrombectomy for acute iliofemoral DVT. In limbs with suc-cessful thrombectomy, valvular competence in the thrombecto-mized venous segment was 80% at 5 years and


Surgery_Schwartz

Surgery_Schwartz. limbs for a mean of 8.5 years after thrombectomy for acute iliofemoral DVT. In limbs with suc-cessful thrombectomy, valvular competence in the thrombecto-mized venous segment was 80% at 5 years and 56% at 10 years. More than 90% of patients had minimal or no symptoms of PTS. There were 12 (16%) early thrombectomy failures. Patients were required to wear compression stockings for at least 1 year after thrombectomy.69Survival rates for surgical pulmonary embolectomy have improved over the past 20 years with the addition of cardio-pulmonary bypass. Emergency pulmonary embolectomy for acute PE is rarely indicated. Patients with preterminal massive PE (Fig. 24-10) for whom thrombolysis has failed or who have contraindications to thrombolytics may be candidates for this procedure. Open pulmonary artery embolectomy is performed through a posterolateral thoracotomy with direct visualization of the pulmonary arteries. Mortality rates range between 20% and 40%.70-72Percutaneous catheter-based


Surgery_Schwartz

Surgery_Schwartz. artery embolectomy is performed through a posterolateral thoracotomy with direct visualization of the pulmonary arteries. Mortality rates range between 20% and 40%.70-72Percutaneous catheter-based techniques for removal of a PE involve mechanical thrombus fragmentation or embolec-tomy using suction devices. Mechanical clot fragmentation is followed by CDT. Results of catheter-based fragmentation are based on small case series. In a study in which a fragmentation device was used in 10 patients with acute massive PE, frag-mentation was successful in 7 patients with a mortality rate of 20%.73 Transvenous catheter pulmonary suction embolectomy has also been performed for acute massive PE with a reported 76% successful extraction rate and a 30-day survival of 70%.74ProphylaxisPatients who undergo major general surgical, gynecologic, urologic, and neurosurgical procedures without thrombopro-phylaxis have a significant incidence of perioperative DVT. An estimated one-third of the 150,000 to


Surgery_Schwartz

Surgery_Schwartz. major general surgical, gynecologic, urologic, and neurosurgical procedures without thrombopro-phylaxis have a significant incidence of perioperative DVT. An estimated one-third of the 150,000 to 200,000 VTE-related deaths per year in the United States occur following surgery.75 The goal of prophylaxis is to reduce the mortality and morbidity associated with VTE. The first manifestation of VTE may be a life-threatening PE (Fig. 24-11), and as indicated earlier, clinical evaluation to detect DVT before PE is unreliable.Effective methods of VTE prophylaxis involve the use of one or more pharmacologic or mechanical modalities. Cur-rently available pharmacologic agents include low-dose UFH, LMWH, synthetic pentasaccharides, and vitamin K antago-nists. Mechanical methods include intermittent pneumatic com-pression (IPC) and graduated compression stockings. There is insufficient evidence to consider aspirin alone as adequate DVT prophylaxis. Methods of prophylaxis vary with regard to


Surgery_Schwartz

Surgery_Schwartz. pneumatic com-pression (IPC) and graduated compression stockings. There is insufficient evidence to consider aspirin alone as adequate DVT prophylaxis. Methods of prophylaxis vary with regard to efficacy, and the 2012 ACCP Clinical Practice Guidelines strat-ify their uses according to the patient’s level of VTE risk, bleed-ing risk, and the values and preferences of individual patients (see Table 24-3).Venous Thromboembolism Prophylaxis in Nonorthopedic Surgery. The risk for VTE associated with a surgical procedure depends on the type of operation, type of anesthesia, duration of surgery, and other risk factors, such as patient age, presence of cancer, prior VTE, obesity, presence of infection, and known thrombophilic disorders. VTE risk can be stratified according to Brunicardi_Ch24_p0981-p1008.indd 99222/02/19 3:01 PM 993VENOUS AND LYMPHATIC DISEASECHAPTER 24Figure 24-11. Computed tomography angiogram showing mul-tiple pulmonary embolisms (arrows). (Used with permission from Dr.


Surgery_Schwartz

Surgery_Schwartz. 99222/02/19 3:01 PM 993VENOUS AND LYMPHATIC DISEASECHAPTER 24Figure 24-11. Computed tomography angiogram showing mul-tiple pulmonary embolisms (arrows). (Used with permission from Dr. Scott Ambruster.)Table 24-5Risk assessment model from the Patient Safety in Surgery StudyRISK FACTORRISK SCORE POINTSOperation type other than endocrine Respiratory and hernia Thoracoabdominal aneurysm, embolectomy/thrombectomy, venous reconstruction, and endovascular repair Aneurysm Mouth, palate Stomach, intestines Integument Hernia9744432ASA, physical status classification 3,4, or 5 2 Female sex211Work RVU >17 10–1732Two points for each of these conditions Disseminated cancer Chemotherapy for malignancy within 30 days of operation Preoperative serum sodium >145 mmol/L Transfusion >4 units packed RBCs in 72 hours before operation Ventilator dependent2One point for each of these conditions Wound class (clean/contaminated) Preoperative hematocrit ≤38% Preoperative bilirubin >1 mg/dL Dyspnea Albumin


Surgery_Schwartz

Surgery_Schwartz. in 72 hours before operation Ventilator dependent2One point for each of these conditions Wound class (clean/contaminated) Preoperative hematocrit ≤38% Preoperative bilirubin >1 mg/dL Dyspnea Albumin ≤3.5 mg/dL Emergency1Zero points for each of these conditions ASA physical class of 1 Work RVU <10 Male sex0ASA = American Society of Anesthesiologists; RBCs = red blood cells; RVU = relative value unit.Reproduced with permission from Rogers SO Jr, Kilaru RK, Hosokawa P, et al: Multivariable predictors of postoperative venous thromboembolic events after general and vascular surgery: results from the patient safety in surgery study, J Am Coll Surg. 2007 Jun;204(6):1211-1221.the previously mentioned risk assessment models, the Caprini score and Rogers score. These risk assessment models are included in the prophylaxis guidelines for nonorthopedic sur-gery (Tables 24-5 and 24-6). A composite score is created using assigned values for each risk factor. The cumulative score for each patient is


Surgery_Schwartz

Surgery_Schwartz. in the prophylaxis guidelines for nonorthopedic sur-gery (Tables 24-5 and 24-6). A composite score is created using assigned values for each risk factor. The cumulative score for each patient is then used to predict thrombosis risk and provide recommendations regarding VTE prophylaxis.Patients at very low risk (<0.5%; Rogers score <7; Caprini score 0) who undergo general or abdominopelvic procedures do not require pharmacologic or mechanical pro-phylaxis; however, early ambulation is required. Patients at low risk (<1.5%; Rogers score 7–10; Caprini score 1–2) should receive mechanical prophylaxis. Patients at moderate risk (3%; Rogers score >10; Caprini score 3–4) should receive LMWH at recommended doses, low-dose UFH, or mechanical pro-phylaxis. Patients at high risk (6%; Caprini score ≥5) should receive LMWH at recommended doses or low-dose UFH and mechanical prophylaxis. Thromboprophylaxis should con-tinue until discharge, except in select high-risk patients with malignancy in whom


Surgery_Schwartz

Surgery_Schwartz. should receive LMWH at recommended doses or low-dose UFH and mechanical prophylaxis. Thromboprophylaxis should con-tinue until discharge, except in select high-risk patients with malignancy in whom extended-duration prophylaxis (up to 4–6 weeks) may be beneficial. Patients with significant risk for bleeding should receive mechanical prophylaxis until this risk subsides.75Overall, low-dose UFH and LMWH reduce the risk for symptomatic and asymptomatic VTE by 60% to 70%. The risks for bleeding differ, depending on the dosage. Lower dosages of LMWH appear to be associated with less bleeding risk than low-dose UFH, but the latter produces less bleeding risk than higher prophylactic dosages of LMWH.76 Other advantages of LMWH include once-daily dosing protocols and a lower rate of heparin-associated antibody formation.Fondaparinux has been compared with the LMWH dalte-parin in patients who undergo high-risk major abdominal sur-gery. It also has been compared with IPC alone in patients


Surgery_Schwartz

Surgery_Schwartz. antibody formation.Fondaparinux has been compared with the LMWH dalte-parin in patients who undergo high-risk major abdominal sur-gery. It also has been compared with IPC alone in patients undergoing non–high-risk abdominal surgery.77,78 Fondaparinux demonstrated rates of VTE prevention, bleeding complications, and mortality similar to those of LMWH. It was more beneficial than IPC alone in reducing VTE but with a higher rate of bleed-ing (1.6% vs. 0.2%).Prophylactic insertion of IVC filters has been suggested for VTE prophylaxis in high-risk trauma patients, bariatric surgical patients, and some patients with malignancy who have contraindications for LMWH therapy.79 A 5-year study of prophylactic IVC filter placement in 132 trauma patients at high risk of PE (head injury, spinal cord injury, pelvic or Brunicardi_Ch24_p0981-p1008.indd 99322/02/19 3:01 PM 994SPECIFIC CONSIDERATIONSPART IITable 24-6Caprini risk assessment model1 POINT2 POINTS3 POINTS5 POINTSAge 41–60Age 61–74Age


Surgery_Schwartz

Surgery_Schwartz. injury, pelvic or Brunicardi_Ch24_p0981-p1008.indd 99322/02/19 3:01 PM 994SPECIFIC CONSIDERATIONSPART IITable 24-6Caprini risk assessment model1 POINT2 POINTS3 POINTS5 POINTSAge 41–60Age 61–74Age ≥75Stroke (<1 month)Minor surgeryArthroscopic surgeryHistory of VTEElective arthroplastyBMI >25 kg/m2Major open surgery (> 45 minutes)Family history of VTEHip, pelvis, or leg fractureSwollen legsLaparoscopic surgery (> 45 minutes)Factor V LeidenAcute spinal cord injury (<1 month)Varicose veinsMalignancyProthrombin 20210A Pregnancy or postpartumConfined to bed (>72 hours)Lupus anticoagulant History of unexplained or recurrent spontaneous abortionImmobilizing plaster castAnticardiolipin antibody Oral contraceptives of hormone replacementCentral venous accessElevated serum homocysteine Sepsis (<1 month) Heparin-induced thrombocytopenia Serious lung disease, including pneumonia (<1 month) Other congenital or acquired thrombophilia Abnormal pulmonary function test Acute myocardial


Surgery_Schwartz

Surgery_Schwartz. (<1 month) Heparin-induced thrombocytopenia Serious lung disease, including pneumonia (<1 month) Other congenital or acquired thrombophilia Abnormal pulmonary function test Acute myocardial infarction Congestive heart failure History of inflammatory bowel disease Medical patient at bed rest BMI = body mass index; VTE = venous thromboembolism.Data from Bahl V, Hu HM, Henke PK, et al: A validation study of retrospective venous thromboembolism risk scoring method, Ann Surg. 2010 Feb; 251(2):344-350.long bone fractures) reported a 0% incidence of symptom-atic PE in patients with a correctly positioned IVC filter.80 In 47 patients with a malpositioned IVC filter (strut malposition or filter tilt), there was a 6.3% incidence of symptomatic PE with three deaths. DVT occurred at the insertion site in 3.1% of the patients. IVC patency was 97.1% at 3 years.Fatal and nonfatal PE can still occur in patients with vena cava interruption. As noted earlier, long-term complications


Surgery_Schwartz

Surgery_Schwartz. the insertion site in 3.1% of the patients. IVC patency was 97.1% at 3 years.Fatal and nonfatal PE can still occur in patients with vena cava interruption. As noted earlier, long-term complications associated with permanent IVC filters include IVC thrombo-sis and DVT. Currently, the ACCP recommends IVC filters be placed only if a proximal DVT is present and anticoagula-tion therapy is contraindicated. Placement of an IVC filter in the setting of severe pulmonary embolism development while anticoagulated remains controversial. IVC filter insertion is not recommended for primary prophylaxis.75Removable IVC filters may be placed in patients with a temporarily increased risk of PE.81 The best patient groups for retrievable filter placement may include young trauma patients with transient immobility, patients undergoing surgi-cal procedures associated with a high risk of PE, and patients with hypercoagulable states who cannot receive anticoagula-tion therapy for a short period of time.


Surgery_Schwartz

Surgery_Schwartz. patients undergoing surgi-cal procedures associated with a high risk of PE, and patients with hypercoagulable states who cannot receive anticoagula-tion therapy for a short period of time. Careful follow-up is required to assure all potentially removable filters are in fact removed.OTHER VENOUS THROMBOTIC DISORDERSSuperficial Vein ThrombophlebitisSuperficial vein thrombophlebitis (SVT) most commonly occurs in varicose veins but can occur in normal veins. When SVT recurs at variable sites in normal superficial veins, thrombophlebitis migrans, it may signify a hidden visceral malignancy or a systemic disorder such as a blood dyscrasia and/or a collagen vascular disease. SVT also frequently occurs as a complication of indwelling catheters, with or without asso-ciated extravasation of injected material. Upper extremity vein thrombosis has been reported to occur in 38% of patients with peripherally inserted central catheters; 57% of these developed in the cephalic vein (Fig. 24-12).82


Surgery_Schwartz

Surgery_Schwartz. material. Upper extremity vein thrombosis has been reported to occur in 38% of patients with peripherally inserted central catheters; 57% of these developed in the cephalic vein (Fig. 24-12).82 Suppurative SVT may occur in veins with indwelling catheters and may be associated with generalized sepsis.Clinical signs of SVT include redness, warmth, and ten-derness along the distribution of the affected veins, often asso-ciated with a palpable cord. Patients with suppurative SVT may have fever and leukocytosis. DUS should be performed in patients with signs and symptoms of acute SVT to confirm the diagnosis and to determine if any associated DVT is present. Concomitant lower extremity DVT may be present in 5% to 40% of patients with SVT; most occur in patients with greater Brunicardi_Ch24_p0981-p1008.indd 99422/02/19 3:01 PM 995VENOUS AND LYMPHATIC DISEASECHAPTER 24Figure 24-12. Duplex ultrasound of a brachial vein containing thrombus and percutaneously inserted central catheter


Surgery_Schwartz

Surgery_Schwartz. 99422/02/19 3:01 PM 995VENOUS AND LYMPHATIC DISEASECHAPTER 24Figure 24-12. Duplex ultrasound of a brachial vein containing thrombus and percutaneously inserted central catheter (PICC).Figure 24-13. Upper extremity venogram showing stenosis of the right subclavian vein at the first rib (arrow).saphenous vein SVT within 1 cm of the saphenofemoral junction. A follow-up DUS should be performed in 5 to 7 days in patients with SVT in the proximal GSV but without deep vein involvement. Approximately 10% to 20% of patients with SVT involving the proximal GSV experience progression to deep venous involvement within 1 week.83,84Treatment of SVT is quite variable. A Cochrane Review reported that LMWHs and nonsteroidal anti-inflammatory drugs both reduce the rate of SVT extension or recurrence.85 Addi-tionally, a multicenter, randomized, blinded trial comparing use of fondaparinux to placebo in lower extremity SVT found use of fondaparinux reduced the rate of VTE formation by 85%, though the


Surgery_Schwartz

Surgery_Schwartz. Addi-tionally, a multicenter, randomized, blinded trial comparing use of fondaparinux to placebo in lower extremity SVT found use of fondaparinux reduced the rate of VTE formation by 85%, though the incidence of VTE formation was low in both groups (0.2% vs. 1.3%, P <.001). The number needed to treat to prevent one episode of VTE was 88 patients. There was no difference in mortality between the two arms of the trial.85Topical medications appear to improve local symptoms. Surgical treatment, combined with the use of graduated com-pression stockings, is associated with a lower rate of VTE and SVT progression.86 The treatment is individualized and depends on the location of the thrombus and the severity of symptoms. In patients with SVT not within 1 cm of the saphenofemoral junction, treatment consists of compression and administra-tion of an anti-inflammatory medication such as indomethacin. In patients with suppurative SVT, antibiotics and removal of any existing indwelling catheters


Surgery_Schwartz

Surgery_Schwartz. consists of compression and administra-tion of an anti-inflammatory medication such as indomethacin. In patients with suppurative SVT, antibiotics and removal of any existing indwelling catheters are mandatory. Excision of the vein may be necessary but is usually reserved for patients with systemic symptoms or when excision of the involved vein is straightforward. If the SVT extends proximally to within 1 cm of the saphenofemoral junction, extension into the com-mon femoral vein is more likely to occur. In these patients, anticoagulation therapy for 6 weeks and GSV ligation appear equally effective in preventing thrombus extension into the deep venous system.87,88Upper Extremity Vein ThrombosisAxillary-subclavian venous thrombosis (ASVT) is classified into two forms. Primary ASVT occurs in only a small minority of all patients with ASVT. In the primary form, no clear cause for the thrombosis is readily identifiable at initial evaluation. Patients with primary ASVT often give a


Surgery_Schwartz

Surgery_Schwartz. in only a small minority of all patients with ASVT. In the primary form, no clear cause for the thrombosis is readily identifiable at initial evaluation. Patients with primary ASVT often give a history of performing prolonged, repetitive motion activities, which results in damage to the subclavian vein, usually where it passes between the head of the clavicle and the first rib in association with the subclavius muscle. This condition is also known as venous thoracic outlet syndrome, effort thrombosis, and Paget-Schroetter syndrome. Secondary ASVT is more common and is associated with an easily identified cause such as an indwelling catheter or a hyper-coagulable state. Over 30% of patients with tunneled subclavian vein access devices develop ASVT.89A patient with ASVT may be asymptomatic or may pres-ent with varying degrees of upper extremity edema, tenderness, and conspicuous superficial venous enlargement. DUS can be performed initially to confirm the diagnosis, but limitations to


Surgery_Schwartz

Surgery_Schwartz. or may pres-ent with varying degrees of upper extremity edema, tenderness, and conspicuous superficial venous enlargement. DUS can be performed initially to confirm the diagnosis, but limitations to the exam by the clavicle and collateralization can lead to a false-negative study. Venography is recommended when there is nonconcordance between the duplex study and clinical suspi-cion. Anticoagulation therapy should be initiated once ASVT is diagnosed to prevent PE and decrease symptoms.Treatment of patients with primary upper extremity venous thrombosis is controversial because the natural history of the disease may vary from minimal to no symptoms to significant symptoms with vigorous upper extremity activities. In recent years, patients presenting with acute symptomatic primary ASVT are often considered candidates for CDT therapy with the goal of minimizing long-term symptoms of venous congestion. Venography is performed through a catheter placed using an ultrasound-guided


Surgery_Schwartz

Surgery_Schwartz. ASVT are often considered candidates for CDT therapy with the goal of minimizing long-term symptoms of venous congestion. Venography is performed through a catheter placed using an ultrasound-guided percutaneous basilic vein approach to docu-ment the extent of the thrombus (Fig. 24-13). A guidewire is traversed through the thrombus, and a catheter is placed within the thrombus. Typically, tissue plasminogen activator is admin-istered through a multi–side-hole infusion catheter. Various catheter-based mechanical techniques may also be employed to speed thrombus removal. Heparin is administered concurrently with the thrombolytic infusion. After completion of thrombo-lytic therapy, a follow-up venogram is obtained. Correctable anatomic abnormalities may then be considered for treatment. Adjuvant procedures after thrombolytic therapy may include Brunicardi_Ch24_p0981-p1008.indd 99522/02/19 3:01 PM 996SPECIFIC CONSIDERATIONSPART IIcervical or first rib resection for thoracic outlet


Surgery_Schwartz

Surgery_Schwartz. procedures after thrombolytic therapy may include Brunicardi_Ch24_p0981-p1008.indd 99522/02/19 3:01 PM 996SPECIFIC CONSIDERATIONSPART IIcervical or first rib resection for thoracic outlet abnormalities, scalenectomy, surgical venous reconstruction, and balloon angioplasty of residual venous stenosis.90 The ACCP guidelines recommend the same intensity and duration of anticoagulant therapy in patients who undergo thrombolysis as in patients who are treated with anticoagulation alone.Mesenteric Vein ThrombosisFive percent to 15% of cases of acute mesenteric ischemia occur as a result of mesenteric vein thrombosis (MVT). Mortality rates in patients with MVT may approach 50%.91 The usual present-ing symptom is nonspecific abdominal pain and distention, often accompanied by nausea, vomiting, and diarrhea.92 Perito-neal signs, suggesting intestinal infarction, are present in fewer than half of MVT patients. MVT is more common in patients with a hypercoagulable states, malignancy, and


Surgery_Schwartz

Surgery_Schwartz. and diarrhea.92 Perito-neal signs, suggesting intestinal infarction, are present in fewer than half of MVT patients. MVT is more common in patients with a hypercoagulable states, malignancy, and cirrhosis. MVT also occurs as a rare complication of laparoscopic surgery.92,93Most cases of MVT are diagnosed with contrast-enhanced CT scanning or magnetic resonance imaging (MRI) in the course of an evaluation for abdominal pain. The sensitivity and speci-ficity for CT and MRI approach 100% and 98%, respectively.94 Ultrasound can also be used and has reported sensitivity and specificity of 93% and 99%, respectively.Patients with MVT are treated with fluid resuscitation, heparin anticoagulation, and bowel rest. Once the patient’s clinical status improves, oral intake can be carefully started. The patient is transitioned to oral anticoagulation over 3 to 4 days and, depending on the etiology of the MVT, continued for 3 to 6 months or indefinitely. Most patients with MVT can be treated


Surgery_Schwartz

Surgery_Schwartz. The patient is transitioned to oral anticoagulation over 3 to 4 days and, depending on the etiology of the MVT, continued for 3 to 6 months or indefinitely. Most patients with MVT can be treated nonoperatively, but urgent laparotomy is indicated in patients with peritoneal findings. Broad-spectrum antibiotics are admin-istered perioperatively. Operative findings consist of edema and cyanotic discoloration of the mesentery and bowel wall. In more advanced cases, thrombus involves the distal mesenteric veins. The arterial supply to the involved bowel is usually intact. Nonviable bowel is resected, and primary anastomosis can be performed. If the viability of the remaining bowel is in question, a second-look operation is performed within 24 to 48 hours.VARICOSE VEINSVaricose veins are common and are present in at least 10% of the general population.95 The findings of varicose veins may include dilated and tortuous veins, telangiectasias, and fine reticular varicosities. Risk factors for


Surgery_Schwartz

Surgery_Schwartz. and are present in at least 10% of the general population.95 The findings of varicose veins may include dilated and tortuous veins, telangiectasias, and fine reticular varicosities. Risk factors for varicose veins include obesity, female sex, inactivity, and family history.96 Varicose veins can be classified as primary or secondary. Primary vari-cose veins result from intrinsic abnormalities of the venous wall, whereas secondary varicose veins are associated with deep and/or superficial venous insufficiency.Patients with varicose veins may complain of unsightly appearance, aching, heaviness, pruritus, and early fatigue of the affected leg. These symptoms worsen with prolonged standing and sitting and are relieved by elevation of the leg above the level of the heart. A mild amount of edema is often present. More severe signs include thrombophlebitis, hyperpigmentation, lipodermato-sclerosis, ulceration, and bleeding from attenuated vein clusters.An important component of treatment for


Surgery_Schwartz

Surgery_Schwartz. is often present. More severe signs include thrombophlebitis, hyperpigmentation, lipodermato-sclerosis, ulceration, and bleeding from attenuated vein clusters.An important component of treatment for patients with vari-cose veins is the use of elastic compression stockings. Patients may be prescribed elastic stockings with compression ranging from 20 to 30, 30 to 40, or even 40 to 50 mmHg. Stockings range in length from knee high to waist high, and they should cover the symptomatic varices. Elastic compression provides sufficient relief of symptoms in many symptomatic patients.Cosmetic concerns may lead to intervention. Addition-ally, interventions are warranted in patients whose symptoms worsen or are unrelieved despite compression therapy or who have lipodermatosclerosis or venous ulcer. Randomized trials of symptomatic patients with varicose veins have demonstrated improved quality of life with interventional treatment. Interven-tional management includes injection sclerotherapy,


Surgery_Schwartz

Surgery_Schwartz. Randomized trials of symptomatic patients with varicose veins have demonstrated improved quality of life with interventional treatment. Interven-tional management includes injection sclerotherapy, thermal ablation, surgical therapy, or a combination of these techniques. Injection sclerotherapy alone can be successful in varicose veins and in telangiectatic vessels. A recent multicenter, randomized trial compared foam sclerotherapy versus placebo for symp-tomatic varicose veins found significant symptom relief and improved cosmetic appearance with sclerotherapy.97 Sclero-therapy acts by destroying the venous endothelium. Scleros-ing agents include hypertonic saline, sodium tetradecyl sulfate, and polidocanol. Concentrations of 11.7% to 23.4% hypertonic saline, 0.125% to 0.250% sodium tetradecyl sulfate, and 0.5% polidocanol are used for telangiectasias. Larger varicose veins require higher concentrations: 23.4% hypertonic saline, 0.50% to 1% sodium tetradecyl sulfate, and 0.75% to 1.0%


Surgery_Schwartz

Surgery_Schwartz. sulfate, and 0.5% polidocanol are used for telangiectasias. Larger varicose veins require higher concentrations: 23.4% hypertonic saline, 0.50% to 1% sodium tetradecyl sulfate, and 0.75% to 1.0% polidocanol.92 Elastic bandages are wrapped around the leg after injection and worn continuously for 3 to 5 days to produce apposition of the inflamed vein walls and prevent thrombus formation. After the bandages are removed, elastic compression stockings should be worn for a minimum of 2 weeks. Complications from sclero-therapy include allergic reaction, local hyperpigmentation, thrombophlebitis, DVT, and possible skin necrosis.Newer devices combine sclerotherapy with catheter-based mechanical endoluminal injury to achieve nonthermal ablation.98 Additional nonthermal, nonsclerosant ablative techniques using proprietary adhesive formulations with cyanoacrylate are current being evaluated and have demonstrated promising early results.99Patients with symptomatic GSV or SSV reflux may be treated


Surgery_Schwartz

Surgery_Schwartz. using proprietary adhesive formulations with cyanoacrylate are current being evaluated and have demonstrated promising early results.99Patients with symptomatic GSV or SSV reflux may be treated with endovenous ablation techniques or surgical removal of the affected vein. Endovenous laser and radiofrequency abla-tion (RFA) techniques have gained in popularity in the past several years. Such techniques are generally associ-ated with equally effective but more rapid postprocedure recov-ery than traditional open surgical stripping of the GSV.With either endoluminal technique, the distal thigh or proximal calf GSV is punctured with a 21-gauge needle under ultrasound guidance. A sheath is placed over a guidewire, and the laser fiber or RFA catheter is advanced until it is near to, but not at, the saphenofemoral junction. Tumescent anesthetic is administered around the GSV, and the vein is treated as the catheter is withdrawn. Endovenous laser treatment and RFA result in durable ablation of


Surgery_Schwartz

Surgery_Schwartz. saphenofemoral junction. Tumescent anesthetic is administered around the GSV, and the vein is treated as the catheter is withdrawn. Endovenous laser treatment and RFA result in durable ablation of the GSV, with rates of varicose vein recurrence and clinical severity scores comparable to those seen with open surgery.100,101 Risks of endovenous ablation include DVT, ecchymosis, and saphenous nerve injury.Saphenous vein ligation and stripping may still be the pre-ferred therapy for patients with GSVs of very large diameter (>2 cm). Surgical removal of the GSV usually is performed via small incisions placed medially in the groin and just below the knee. The GSV is removed using a blunt tip catheter or an invagi-nation pin stripper. Complications associated with GSV stripping include ecchymosis, hematoma, lymphocele, DVT, infection, and saphenous nerve injury. GSV stripping is associated with a lower rate of recurrence of varicose veins and a better quality of life than saphenofemoral


Surgery_Schwartz

Surgery_Schwartz. hematoma, lymphocele, DVT, infection, and saphenous nerve injury. GSV stripping is associated with a lower rate of recurrence of varicose veins and a better quality of life than saphenofemoral junction ligation alone.4Brunicardi_Ch24_p0981-p1008.indd 99622/02/19 3:01 PM 997VENOUS AND LYMPHATIC DISEASECHAPTER 24Figure 24-14. Removal of varicose veins via stab avulsions.Larger varicose veins are best treated by surgical exci-sion using the “stab avulsion” technique. Stab avulsions are performed by making 2-mm incisions directly over branch varicosities, and the varicosity is dissected from the surrounding subcutaneous tissue as far proximally and distally as possible through the small incisions (Fig. 24-14). In most cases the vein is simply avulsed with no attempt at ligation. Bleeding is easily controlled with leg elevation, manual compression, and prepro-cedure tumescent anesthesia.CHRONIC VENOUS INSUFFICIENCYChronic venous insufficiency (CVI) affects an estimated 600,000 people


Surgery_Schwartz

Surgery_Schwartz. is easily controlled with leg elevation, manual compression, and prepro-cedure tumescent anesthesia.CHRONIC VENOUS INSUFFICIENCYChronic venous insufficiency (CVI) affects an estimated 600,000 people in the United States.102 Patients complain of leg fatigue, discomfort, and heaviness. Signs of CVI may include varicose veins, pigmentation, lipodermatosclerosis, and venous ulceration. Importantly, severe CVI is not necessarily associ-ated with varicose veins. Chronic venous ulcers carry significant negative physical, financial, and psychological implications. A quality-of-life study reported that 65% of patients with chronic leg ulcers had severe pain, 81% had decreased mobility, and 100% experienced a negative impact of their disease on their work capacity.103 The socioeconomic impact of chronic venous leg ulcers is staggering, with an estimated 2 million workdays lost per year.102 The annual healthcare cost in the United States to treat CVI is estimated at $1 billion.105CVI can be


Surgery_Schwartz

Surgery_Schwartz. chronic venous leg ulcers is staggering, with an estimated 2 million workdays lost per year.102 The annual healthcare cost in the United States to treat CVI is estimated at $1 billion.105CVI can be primary or secondary. Primary CVI results from intrinsic abnormalities of the vein wall, whereas second-ary CVI, so-called postthrombotic syndrome (PTS), occurs as a result of DVT. The signs and symptoms of CVI can therefore be attributed to venous reflux, venous obstruction, calf muscle pump dysfunction, or a combination of these factors, as well as loss of venous wall elasticity.106 In the majority of patients with CVI, the most important factor appears to be venous reflux, although most severe cases tend to have an obstructive etiology as well. Venous reflux results from abnormalities of the venous valve. Primary valvular reflux or incompetence is diagnosed when there is no known underlying cause of valvular dysfunction. Secondary valvular reflux is diagnosed when an identifiable cause


Surgery_Schwartz

Surgery_Schwartz. venous valve. Primary valvular reflux or incompetence is diagnosed when there is no known underlying cause of valvular dysfunction. Secondary valvular reflux is diagnosed when an identifiable cause is present. The most frequent secondary cause is DVT.Evaluation of Venous InsufficiencyEarly diagnostic studies to evaluate CVI required invasive mea-surements of ambulatory venous pressure (AVP) and venous recovery time (VRT). To measure AVP and VRT, a needle is inserted into a dorsal foot vein and connected to a pressure transducer. The patient is asked to perform 10 tiptoe exercises. Initially there is often a slight upward deflection of pressure with the onset of exercise followed by a decline in pressure with each subsequent tiptoe maneuver. After approximately 10 tiptoes, the measured pressure stabilizes and reflects a bal-ance of venous inflow and outflow. The pressure at this point is the AVP, which is measured in millimeters of mercury. The patient is then asked to stop exercising


Surgery_Schwartz

Surgery_Schwartz. stabilizes and reflects a bal-ance of venous inflow and outflow. The pressure at this point is the AVP, which is measured in millimeters of mercury. The patient is then asked to stop exercising to allow the vein to fill with return of the venous pressure to baseline. The time required for the venous pressure to return from the AVP level to 90% of baseline pressure is referred to as the VRT. A normal VRT typically ranges from 20 to 60 seconds. Values less than 20 seconds indicate significant reflux with increasing severity. To distinguish between superficial and deep venous reflux, a thigh tourniquet can be placed inflated to 50 mmHg to eliminate influence of the superficial venous. A VRT that remains below 20 seconds after tourniquet inflation suggests both superficial and deep venous reflux. Elevations of AVP indicate venous hypertension. The magnitude of AVP reflects the severity of CVI. There is an 80% incidence of venous ulceration in patients with an AVP of >80


Surgery_Schwartz

Surgery_Schwartz. deep venous reflux. Elevations of AVP indicate venous hypertension. The magnitude of AVP reflects the severity of CVI. There is an 80% incidence of venous ulceration in patients with an AVP of >80 mmHg.107Plethysmography. Noninvasive plethysmography has been used to evaluate CVI. Venous photoplethysmography indirectly evaluates venous function through the use of infrared light. A light-emitting diode is placed just above the medial malleolus, and the patient then performs a series of tiptoe maneuvers. Pho-toplethysmography provides a measurement of VRT. In limbs with CVI, VRT is shortened compared with that in a normal limb. AVP and VRT are only measures of the overall venous function of a lower extremity venous system. They cannot local-ize the site of reflux or evaluate the function of the calf pump.Air plethysmography is a theoretically attractive but not widely used method to assess calf pump function, venous reflux, and overall lower extremity venous function.108 An air-filled


Surgery_Schwartz

Surgery_Schwartz. the calf pump.Air plethysmography is a theoretically attractive but not widely used method to assess calf pump function, venous reflux, and overall lower extremity venous function.108 An air-filled plastic pressure bladder is placed on the calf to detect volume changes in the leg during a standard set of maneuvers. The patient is first supine, and then the leg is elevated and the minimum volume of venous blood recorded. The patient is then asked to assume an upright position with the examined leg non-weight bearing. The venous volume of the examined leg is determined when the volume curve flattens. The venous fill-ing index (VFI), a measure of reflux, is calculated by dividing the maximum venous volume by the time required to achieve maximum venous volume. Next, the patient performs a single tiptoe maneuver, and the ejection fraction (EF) is determined. The EF is the volume change between the recorded volume before and after the tiptoe maneuver and is a measure of calf pump function.


Surgery_Schwartz

Surgery_Schwartz. tiptoe maneuver, and the ejection fraction (EF) is determined. The EF is the volume change between the recorded volume before and after the tiptoe maneuver and is a measure of calf pump function. At this point, the veins of the leg are allowed to refill. The patient then performs 10 tiptoe maneuvers, and the residual volume fraction is calculated by dividing the venous volume in the leg after 10 tiptoe exercises by the venous volume present before the exercises. The residual volume fraction is a reflection of overall venous function. Theoretically, patients with increased VFIs and normal EFs (indicating the presence of reflux with normal calf pump function) would benefit from anti-reflux surgery, whereas patients with normal VFIs and dimin-ished EFs would not.Venous Duplex Ultrasound. Venous DUS has become the gold standard for evaluation of venous function largely supplanting venographic and plethysmographic techniques. Brunicardi_Ch24_p0981-p1008.indd 99722/02/19 3:01 PM


Surgery_Schwartz

Surgery_Schwartz. DUS has become the gold standard for evaluation of venous function largely supplanting venographic and plethysmographic techniques. Brunicardi_Ch24_p0981-p1008.indd 99722/02/19 3:01 PM 998SPECIFIC CONSIDERATIONSPART IIFigure 24-15. Evaluation of a patient with chronic venous insuf-ficiency with duplex ultrasonography.Figure 24-16. Multilayered dressing for treatment of chronic venous insufficiency.The principle advantage of DUS is that it can be used to evalu-ate reflux in individual venous segments targeting abnormal areas for treatment. The examination has been validated when performed with the patient in the standing position and the examined leg non-weight bearing. Pneumatic pressure cuffs of appropriate size are placed around the thigh, calf, and fore-foot. The ultrasound transducer is positioned over the venous segment to be examined, just proximal to the pneumatic cuff (Fig. 24-15). The cuff is then inflated to a standard pressure for 3 seconds and then rapidly deflated.


Surgery_Schwartz

Surgery_Schwartz. is positioned over the venous segment to be examined, just proximal to the pneumatic cuff (Fig. 24-15). The cuff is then inflated to a standard pressure for 3 seconds and then rapidly deflated. Ninety-five percent of normal venous valves close within 0.5 second.109 The presence of reflux for >0.5 second is considered abnormal. Typically, the common femoral, femoral, popliteal, and posterior tibial veins, as well as the GSV and SSV, are evaluated in a complete examination.Nonoperative Treatment of Chronic Venous Insufficiency Compression Therapy. Compression therapy is the mainstay of CVI management. Compression can be achieved using a vari-ety of techniques, including elastic compression stockings, paste gauze boots (Unna’s boots), multilayer elastic wraps or dressings (Fig. 24-16), and pneumatic compression devices. Nonelastic compression bandages generally achieve higher and more prolonged degrees of compression than elastic compression bandages. The exact mechanism by which


Surgery_Schwartz

Surgery_Schwartz. and pneumatic compression devices. Nonelastic compression bandages generally achieve higher and more prolonged degrees of compression than elastic compression bandages. The exact mechanism by which compression therapy can improve CVI remains uncertain. An improvement in skin and 5subcutaneous tissue microcirculatory hemodynamics as well as a direct effect on subcutaneous pressure have been hypothesized as the mechanisms of efficacy of compression therapy.110 Addition-ally, compression therapy has demonstrated quantifiable differ-ences in ulcer healing with decreases in matrix metalloproteins and inflammatory cytokines.111,112 Clinically, routine use of elastic and nonelastic bandages reduces lower extremity edema in patients with CVI. In addition, supine perimalleolar subcutaneous pressure has been demonstrated to increase with elastic compression.111 With edema reduction, cutaneous metabolism may improve due to enhanced diffusion of oxygen and other nutrients to the cellular elements


Surgery_Schwartz

Surgery_Schwartz. has been demonstrated to increase with elastic compression.111 With edema reduction, cutaneous metabolism may improve due to enhanced diffusion of oxygen and other nutrients to the cellular elements of skin and subcutaneous tissues. Increases in subcutaneous tissue pressure with elastic compres-sion bandages may counteract transcapillary Starling forces, which favor leakage of fluid out of the capillary.Before the initiation of therapy for CVI, patients must be educated about their chronic disease and the need to comply with their treatment plan to heal ulcers and prevent recurrence. A definitive diagnosis of venous ulceration must be made before treatment is initiated. A detailed history should be obtained from a patient presenting with lower extremity ulcerations, includ-ing medications used and associated medical conditions that may promote lower extremity ulceration. Arterial insufficiency is assessed by physical examination or noninvasive studies. In addition, systemic conditions


Surgery_Schwartz

Surgery_Schwartz. used and associated medical conditions that may promote lower extremity ulceration. Arterial insufficiency is assessed by physical examination or noninvasive studies. In addition, systemic conditions that affect wound healing and leg edema, such as diabetes mellitus, immunosuppression, mal-nutrition, and congestive heart failure, should be improved as much as possible.Compression therapy is most commonly achieved with graduated elastic compression stockings. Elastic compression stockings are available in various compositions, strengths, and lengths, and can be customized for a particular patient. The ben-efits of elastic compression stocking therapy for the treatment of CVI and healing of ulcerations have been well documented.114-117 In a retrospective study involving 113 venous ulcer patients,115 the use of below-knee, 30to 40-mmHg elastic compression stockings, after edema and cellulitis were first resolved if pres-ent, resulted in 93% healing. Complete ulcer healing occurred in 99


Surgery_Schwartz

Surgery_Schwartz. the use of below-knee, 30to 40-mmHg elastic compression stockings, after edema and cellulitis were first resolved if pres-ent, resulted in 93% healing. Complete ulcer healing occurred in 99 of 102 patients (97%) who were compliant with stocking use vs. 6 of 11 patients (55%) who were noncompliant (P <.0001). The mean time to ulcer healing was 5 months. The rate of ulcer recurrence was lower in patients who were compliant with their compression therapy. By life table analysis, ulcer recurrence was 29% at 5 years for compliant patients and 100% at 3 years for noncompliant patients.In addition to promoting ulcer healing, elastic compres-sion therapy can also improve quality of life in patients with CVI. In one prospective study,118 112 patients with CVI docu-mented by DUS were administered a questionnaire to quantify the symptoms of swelling, pain, skin discoloration, cosmesis, activity tolerance, depression, and sleep alterations. Patients were treated with 30to 40-mmHg elastic


Surgery_Schwartz

Surgery_Schwartz. a questionnaire to quantify the symptoms of swelling, pain, skin discoloration, cosmesis, activity tolerance, depression, and sleep alterations. Patients were treated with 30to 40-mmHg elastic compression stock-ings. There were overall improvements in symptom severity scores at 1 month after initiation of treatment. Further improve-ments were noted at 16 months after treatment.Patient compliance with compression therapy is crucial in treating CVI and especially venous leg ulcers. Many patients are initially intolerant of compression in areas of hypersensitiv-ity adjacent to an active ulcer or at sites of previously healed ulcers. They may also have difficulty applying elastic stockings. To improve compliance, patients should be instructed to wear their stockings initially only as long as it is easily tolerated and Brunicardi_Ch24_p0981-p1008.indd 99822/02/19 3:01 PM 999VENOUS AND LYMPHATIC DISEASECHAPTER 24Figure 24-17. Elastic compression device with Velcro to facilitate


Surgery_Schwartz

Surgery_Schwartz. long as it is easily tolerated and Brunicardi_Ch24_p0981-p1008.indd 99822/02/19 3:01 PM 999VENOUS AND LYMPHATIC DISEASECHAPTER 24Figure 24-17. Elastic compression device with Velcro to facilitate treatment of chronic venous insufficiency.then gradually to increase the amount of time the stockings are worn. Alternatively, patients can be fitted with lower-strength stockings initially followed by introduction of higher-strength stockings over a period of several weeks. Many commercially available devices, such as silk inner toe liners, adjustable elas-tic compression with Velcro, stockings with zippered sides (Fig. 24-17), and metal fitting aids (Fig. 24-18), are available to assist patients in applying elastic stockings. However, despite all these available adjuncts, many patients remain noncompliant with elastic compression therapy.Another method of compression was developed by the German dermatologist Paul Gerson Unna. Unna’s boot has been used for many years to treat venous


Surgery_Schwartz

Surgery_Schwartz. remain noncompliant with elastic compression therapy.Another method of compression was developed by the German dermatologist Paul Gerson Unna. Unna’s boot has been used for many years to treat venous ulcers and is available in many versions. A typical Unna’s boot consists of a three-layer dressing and requires application by trained personnel. A rolled gauze bandage impregnated with calamine, zinc oxide, glyc-erin, sorbitol, gelatin, and magnesium aluminum silicate is first applied with graded compression from the forefoot to just below the knee. The next layer consists of a 10-cm-wide continuous gauze dressing followed by an outer layer of elastic wrap, also applied with graded compression. The bandage becomes stiff after drying, and the rigidity may aid in preventing edema for-mation. Unna’s boot is changed weekly or sooner if the patient experiences significant drainage and soiling of the dressing.Once applied, Unna’s boot requires minimal patient involvement and provides


Surgery_Schwartz

Surgery_Schwartz. Unna’s boot is changed weekly or sooner if the patient experiences significant drainage and soiling of the dressing.Once applied, Unna’s boot requires minimal patient involvement and provides continuous compression and topical therapy. However, Unna’s boot has several disadvantages. It Figure 24-18. Metal fitting aid to assist in placement of elastic compression stockings.is bulky and can be uncomfortable, which may affect patient compliance. In addition, the ulcer cannot be monitored after the boot is applied, the technique is labor intensive, and the degree of compression provided is operator dependent. Occasionally, patients may also develop contact dermatitis to the components of Unna’s boot.The efficacy of Unna’s dressing has been studied. A ret-rospective 15-year survey encompassing 998 patients with one or more venous ulcers treated weekly with Unna’s dressing119 reported that 73% of ulcers healed in patients who returned for more than one treatment. The median time to healing


Surgery_Schwartz

Surgery_Schwartz. 998 patients with one or more venous ulcers treated weekly with Unna’s dressing119 reported that 73% of ulcers healed in patients who returned for more than one treatment. The median time to healing for individual ulcers was 9 weeks. Unna’s dressing has been com-pared to other forms of treatment. A randomized, prospective study comparing Unna’s boot to polyurethane foam dressing in 36 patients with venous ulcers demonstrated superior healing over 12 months in patients treated with Unna’s boot (94.7% vs. 41.2%).120 A recent Cochrane Review of 39 randomized controlled trials demonstrated that compression increases ulcer healing rates compared with no compression, multicomponent systems are more effective than single-component systems, and multicomponent systems that include an elastic bandage are more effective than those composed mainly of inelastic constituents.121Other forms of compression dressing available to treat CVI include multilayered dressings and legging orthoses. The


Surgery_Schwartz

Surgery_Schwartz. bandage are more effective than those composed mainly of inelastic constituents.121Other forms of compression dressing available to treat CVI include multilayered dressings and legging orthoses. The purported advantages of multilayered dressings include main-tenance of compression for a longer period of time, more even distribution of compression, and better absorption of wound Brunicardi_Ch24_p0981-p1008.indd 99922/02/19 3:01 PM 1000SPECIFIC CONSIDERATIONSPART IIFigure 24-19. Apligraf skin graft material supplied as a disk on an agarose gel nutrient medium.Figure 24-20. Trocar placement for subfascial endoscopic perfo-rator vein surgery. (Used with permission from Dr. Pankaj Patel.)exudates. However, the efficacy of multilayered dressings depends on the wrapping technique of healthcare personnel. A commercially available legging orthosis consisting of multiple adjustable loop-and-hook closure compression bands provides compression similar to that of Unna’s boot and can be applied


Surgery_Schwartz

Surgery_Schwartz. personnel. A commercially available legging orthosis consisting of multiple adjustable loop-and-hook closure compression bands provides compression similar to that of Unna’s boot and can be applied daily by the patient.122Skin Substitutes. Several types of skin substitutes are com-mercially available or under clinical study in the United States.105 Bioengineered skin ranges in composition from acellular skin substitutes to partial living skin substitutes. Their mechanism of action in healing venous ulcers is uncertain; however, they may serve as delivery vehicles for various growth factors and cytokines important in wound healing.Apligraf is a commercially available bilayered living skin construct that closely approximates human skin for use in the treatment of venous ulcers. It contains a protective stratum corneum and a keratinocyte-containing epidermis overlying a dermis consisting of dermal fibroblasts in a collagen matrix.122 Apligraf is between 0.5 mm and 1.0 mm thick and is


Surgery_Schwartz

Surgery_Schwartz. a protective stratum corneum and a keratinocyte-containing epidermis overlying a dermis consisting of dermal fibroblasts in a collagen matrix.122 Apligraf is between 0.5 mm and 1.0 mm thick and is supplied as a disk of living tissue on an agarose gel nutrient medium. It must be used within 5 days of release from the manufacturer123 (Fig. 24-19). The disk is easily handled and applied and con-forms to irregularly contoured ulcer beds though it is very costly.A prospective randomized study comparing multilayer compression therapy alone to treatment with Apligraf in addi-tion to multilayered compression therapy has been performed to assess the efficacy of Apligraf in the treatment of venous ulcers.118 More patients treated with Apligraf had ulcer healing at 6 months (63% vs. 49%, P = .02). The median time to com-plete ulcer closure was significantly shorter in patients treated with Apligraf (61 days vs. 181 days, P = .003). The ulcers that showed the greatest benefit with the living skin


Surgery_Schwartz

Surgery_Schwartz. median time to com-plete ulcer closure was significantly shorter in patients treated with Apligraf (61 days vs. 181 days, P = .003). The ulcers that showed the greatest benefit with the living skin construct were ones that were large and deep (>1000 mm2) or were longstand-ing (>6 months). No evidence of rejection or sensitization has been reported in response to Apligraf application.Surgical/Interventional Treatment of Chronic Venous Insufficiency Perforator Vein Ligation. Incompetence of the perforating veins connecting the superficial and deep venous systems of the lower extremities has been implicated in the development of venous ulcers. The classic open tech-nique described by Linton in 1938 for perforator vein ligation has a high incidence of wound complications and has largely been abandoned.124 A minimally invasive technique termed subfascial endoscopic perforator vein surgery (SEPS) evolved with improvement of endoscopic equipment.DUS is performed preoperatively in patients


Surgery_Schwartz

Surgery_Schwartz. abandoned.124 A minimally invasive technique termed subfascial endoscopic perforator vein surgery (SEPS) evolved with improvement of endoscopic equipment.DUS is performed preoperatively in patients undergoing SEPS to document deep venous competence and to identify per-forating veins in the posterior compartment. The patient is posi-tioned on the operating table with the affected leg elevated at 45° to 60°. An Esmarch bandage and a thigh tourniquet are used to exsanguinate the limb. The knee is then flexed, and two small incisions are made in the proximal medial leg away from areas of maximal induration at the ankle. Laparoscopic trocars are then positioned, and the subfascial dissection is performed with a combination of blunt and sharp dissection. Carbon dioxide is then used to insufflate the subfascial space. The thigh tourni-quet is inflated to prevent air embolism. The perforators are then identified and doubly clipped and divided. After completion of the procedure, the leg is


Surgery_Schwartz

Surgery_Schwartz. the subfascial space. The thigh tourni-quet is inflated to prevent air embolism. The perforators are then identified and doubly clipped and divided. After completion of the procedure, the leg is wrapped in a compression bandage for 5 days postoperatively.The efficacy of SEPS as a stand-alone procedure in treatment of venous insufficiency is controversial and unproven. In a report from a large North American registry of 146 patients undergoing SEPS125 (Fig. 24-20), healing was achieved in 88% of ulcers (75 of 85) at 1 year. Adjunctive procedures, primarily superficial vein stripping, were performed in 72% of patients. Ulcer recurrence was predicted to be 16% at 1 year and 28% at 2 years by life table analysis. These results are similar to those achieved in some studies with compression therapy alone. A review of several studies from 2003 to 2011 demonstrated, when taken in aggregate, that 2059 limbs with 896 ulcers underwent SEPS and concomitant saphenous vein ablation (70%) with a 0%


Surgery_Schwartz

Surgery_Schwartz. alone. A review of several studies from 2003 to 2011 demonstrated, when taken in aggregate, that 2059 limbs with 896 ulcers underwent SEPS and concomitant saphenous vein ablation (70%) with a 0% to 16% complication rate and achieved ulcer healing in 90% of patients.126 There has been a multicenter, prospective, European trial performed in patients with venous ulcers to evaluate the efficacy of SEPS. Post hoc analysis suggested possible benefit for SEPS in certain categories of patients with venous ulcer. Overall, however, primary analysis of the study’s end points indicated no advantage to SEPS in addition to superficial venous surgery and compression in the healing of venous ulcers.127 The technique appears to have fallen out of favor in most institutions with injection sclerotherapy preferred due to ease of use.Superficial Venous Surgery. Currently it is accepted that superficial venous surgery in addition to compression therapy has a role in the treatment of patients with venous


Surgery_Schwartz

Surgery_Schwartz. due to ease of use.Superficial Venous Surgery. Currently it is accepted that superficial venous surgery in addition to compression therapy has a role in the treatment of patients with venous ulcer. The ESCHAR trial was a randomized prospective trial performed in the United Kingdom to evaluate the combination of superficial Brunicardi_Ch24_p0981-p1008.indd 100022/02/19 3:01 PM 1001VENOUS AND LYMPHATIC DISEASECHAPTER 24Figure 24-21. Patient with severe longstanding lymphedema.venous surgery and compression vs. compression alone in the treatment of venous ulcer. Superficial venous surgery had no additive effect to compression alone in the healing of a venous ulcer but significantly reduced venous ulcer recurrence at 4 years. Based on the results of this trial, it is reasonable to offer ablation or removal of the GSV in addition to compression therapy in patients with abnormal saphenous veins and signs and/or symptoms of severe CVI.128Deep Venous Valvular Reconstruction. In the


Surgery_Schwartz

Surgery_Schwartz. ablation or removal of the GSV in addition to compression therapy in patients with abnormal saphenous veins and signs and/or symptoms of severe CVI.128Deep Venous Valvular Reconstruction. In the absence of sig-nificant deep vein valvular incompetence, saphenous vein stripping and possibly perforator vein ligation can be effective in the treat-ment of CVI. However, in patients with a combination of superfi-cial and deep vein valvular incompetence, the addition of deep vein valvular reconstruction theoretically may improve ulcer healing.130 Numerous techniques of deep vein valve correction have been reported. These techniques consist of repair of existing valves, transplant of venous segments from the arm, transposition of an incompetent vein onto an adjacent competent vein, and implanta-tion of cryopreserved vein segments including competent valves.Successful long-term outcomes of 60% to 80% have been reported for venous valve reconstructions by internal suture repair.129,130 However,


Surgery_Schwartz

Surgery_Schwartz. of cryopreserved vein segments including competent valves.Successful long-term outcomes of 60% to 80% have been reported for venous valve reconstructions by internal suture repair.129,130 However, among patients who initially had ulcer-ation, 40% to 50% still had persistence or recurrence of ulcers in the long term.127,129Valve transplantation involves replacement of a segment of incompetent femoral vein or popliteal vein with a segment of axillary or brachial vein with competent valves. Early results are similar to those for venous valve reconstruction.129,130 How-ever, in the long term, the transplanted venous segments tend to develop incompetence, intimal hyperplasia, and cusp sinus thrombosis with long-term outcomes that are poorer than those for venous valve reconstructions. The outcomes for venous transposition are similar to those for valve transplantation.Currently, reconstruction techniques for deep venous insufficiency and associated CVI are rarely performed.Venous


Surgery_Schwartz

Surgery_Schwartz. The outcomes for venous transposition are similar to those for valve transplantation.Currently, reconstruction techniques for deep venous insufficiency and associated CVI are rarely performed.Venous Stenting. Currently there is great interest in the role of venous stents in the treatment of CVI. Stenotic lesions of the iliac veins, primarily documented with IVUS, are being reported in a very high percentage of patients with edema, lipo-dermatosclerosis, or ulceration secondary to venous disease. It appears possible to percutaneously place stents in the iliac veins with near 100% technical success and excellent patency of the stent out to 4 years. Retrospective case series suggest favorable effects on ulcer healing, symptoms of CVI, and quality of life in patients with CVI. The role of venous stenting as an indepen-dent procedure in the treatment of patients with CVI remains an area of active investigation.131LYMPHEDEMAPathophysiologyLymphedema is extremity swelling that results from a


Surgery_Schwartz

Surgery_Schwartz. stenting as an indepen-dent procedure in the treatment of patients with CVI remains an area of active investigation.131LYMPHEDEMAPathophysiologyLymphedema is extremity swelling that results from a reduction in lymphatic transport and accumulation of lymph within the interstitial space. It is caused by anatomic and or physiologic abnormalities such as lymphatic hypoplasia, functional insuf-ficiency, or absence of lymphatic valves.The original classification system, described by Allen, is based on the cause of the lymphedema. Primary lymphedema is further subdivided into congenital lymphedema, lymph-edema praecox, and lymphedema tarda. Congenital lymph-edema may involve a single lower extremity, multiple limbs, the genitalia, or the face. The edema typically develops before 2 years 6of age and may be associated with specific hereditary syndromes (Turner syndrome, Milroy syndrome, Klippel-Trénaunay-Weber syndrome). Lymphedema praecox is the most common form of primary lymphedema,


Surgery_Schwartz

Surgery_Schwartz. age and may be associated with specific hereditary syndromes (Turner syndrome, Milroy syndrome, Klippel-Trénaunay-Weber syndrome). Lymphedema praecox is the most common form of primary lymphedema, accounting for 94% of cases. Lymphedema praecox is far more common in women, with the gender ratio favoring women 10:1. The onset is during childhood or the teen-age years, and the swelling involves the foot and calf. Lymph-edema tarda is uncommon, accounting for <10% of cases of primary lymphedema. The onset of edema is after 35 years of age.Secondary lymphedema is far more common than primary lymphedema. Secondary lymphedema develops as a result of lymphatic obstruction or disruption. Axillary node dissection leading to lymphedema of the arm is the most common cause of secondary lymphedema in the United States. Other causes of secondary lymphedema include radiation therapy, trauma, infection, and malignancy. Globally, filariasis (an infection caused by Wuchereria bancrofti, Brugia malayi,


Surgery_Schwartz

Surgery_Schwartz. the United States. Other causes of secondary lymphedema include radiation therapy, trauma, infection, and malignancy. Globally, filariasis (an infection caused by Wuchereria bancrofti, Brugia malayi, and Brugia timori) and environmental exposure to minerals in volcanic soil resulting in podoconiosis in barefoot populations are the most common causes of secondary lymphedema.Clinical DiagnosisIn most patients, the diagnosis of lymphedema can be made based on the history and physical examination alone. Patients commonly complain of heaviness and fatigue in the affected extremity. The limb size increases throughout the day and decreases to some extent, usually minimally, over the course of the night when the patient is recumbent. The limb, however, never completely nor-malizes. In the lower extremity, the swelling classically involves the dorsum of the foot, and the toes have a squared-off appear-ance. In advanced cases, hyperkeratosis of the skin develops, and fluid weeps from


Surgery_Schwartz

Surgery_Schwartz. lower extremity, the swelling classically involves the dorsum of the foot, and the toes have a squared-off appear-ance. In advanced cases, hyperkeratosis of the skin develops, and fluid weeps from lymph-filled vesicles (Fig. 24-21).Brunicardi_Ch24_p0981-p1008.indd 100122/02/19 3:01 PM 1002SPECIFIC CONSIDERATIONSPART IIFigure 24-22. Lymphoscintigraphy of the lower extremity.Figure 24-23. Normal lymphangiogram of the pelvis.Recurrent cellulitis is a common complication of lymph-edema. Repeated infection results in further lymphatic damage, worsening existing disease. The clinical presentation of cellu-litis ranges from subtle erythema and worsening of edema to a rapidly progressive soft tissue infection with systemic toxicity.Many medical conditions can cause edema. If the symp-toms are mild, distinguishing lymphedema from other causes of leg swelling can be difficult. Venous insufficiency is often confused with lymphedema. However, patients with advanced venous insufficiency


Surgery_Schwartz

Surgery_Schwartz. are mild, distinguishing lymphedema from other causes of leg swelling can be difficult. Venous insufficiency is often confused with lymphedema. However, patients with advanced venous insufficiency typically have lipodermatosclerosis in the gaiter region, skin ulceration, and/or varicose veins. Bilateral pitting edema is typically associated with congestive heart fail-ure, renal failure, or a hypoproteinemic state.Radiologic DiagnosisDuplex Ultrasound. When a patient is evaluated for edema, it is often difficult to distinguish the early stages of lymphedema from venous insufficiency. DUS of the venous system can determine if there is concomitant venous thrombosis or venous reflux, perhaps contributing to extremity edema. The diagnostic modalities discussed in the following sections have limited use in clinical practice. They are invasive and tedious and rarely change the management of a patient with lymphedema. Most physicians rely on the patient’s history and physical examina-tion


Surgery_Schwartz

Surgery_Schwartz. limited use in clinical practice. They are invasive and tedious and rarely change the management of a patient with lymphedema. Most physicians rely on the patient’s history and physical examina-tion alone to make the diagnosis of lymphedema.Lymphoscintigraphy. Lymphoscintigraphy has become the most commonly, but still overall uncommonly, used diagnostic test to identify lymphatic abnormalities. It has largely replaced lymphangiography. A radiolabeled sulfur colloid (technetium 99 m sulfur colloid) is injected into the subdermal, interdigital region of the affected limb. The lymphatic transport is moni-tored with a whole-body gamma camera, and major lymphatics and nodes can be visualized (Fig. 24-22). In normal individu-als, tracer activity may be detected in the inguinal region within 15 to 60 minutes. Within 3 hours, uptake should be present in the pelvic and abdominal lymph nodes. In patients with lymph-edema, various patterns may be seen on lymphoscintigraphy. There may be delayed


Surgery_Schwartz

Surgery_Schwartz. to 60 minutes. Within 3 hours, uptake should be present in the pelvic and abdominal lymph nodes. In patients with lymph-edema, various patterns may be seen on lymphoscintigraphy. There may be delayed or absent transport to the inguinal nodes. Increased cutaneous collaterals may be seen with obstruction of the primary axial channels. There may also be localized regions of reduced uptake in patients with prior node dissection or radia-tion therapy.Lymphangiography. Radiologic lymphangiography is per-formed by first visualizing the lymphatics by injecting colored dye into the hand or foot. The visualized lymphatic segment is exposed through a small incision and cannulated with a 27to 30-gauge needle. An oil-based dye is then injected slowly into the lymphatics over several hours. The lym-phatic channels and nodes are then visualized with traditional radiographs (Figs. 24-23 and 24-24). Lymphangiography is reserved for patients with lymphangiectasia or lymphatic fis-tulas, and patients


Surgery_Schwartz

Surgery_Schwartz. channels and nodes are then visualized with traditional radiographs (Figs. 24-23 and 24-24). Lymphangiography is reserved for patients with lymphangiectasia or lymphatic fis-tulas, and patients who are being considered for microvascular reconstruction.ManagementAn important aspect of the management of lymphedema is patient understanding that there is no cure for lymphedema. The primary goals of treatment are to minimize swelling and to prevent recurrent infections. Controlling the chronic limb swelling can improve discomfort, heaviness, and tightness, and potentially reduce the progression of disease.132Brunicardi_Ch24_p0981-p1008.indd 100222/02/19 3:01 PM 1003VENOUS AND LYMPHATIC DISEASECHAPTER 24Figure 24-24. Normal lymphangiogram of the thigh and lower leg.Compression Garments. Graded compression stockings are widely used in the treatment of lymphedema. The stockings reduce the amount of swelling in the involved extremity by decreasing edema accumulation while the extremity is


Surgery_Schwartz

Surgery_Schwartz. compression stockings are widely used in the treatment of lymphedema. The stockings reduce the amount of swelling in the involved extremity by decreasing edema accumulation while the extremity is dependent. When worn daily, compression stockings have been associated with long-term maintenance of reduced limb circumference.134 They may also protect the tissues against chronically elevated intrinsic pressures, which lead to thickening of the skin and sub-cutaneous tissue.135 Compression stockings also offer a degree of protection against external trauma that may lead to cellulitis.The amount of compression required for controlling lymphedema ranges from 20 to 60 mmHg and varies among patients. The stockings can be custom made or prefabricated and are available in aboveand below-knee lengths. The stock-ings should be worn during waking hours. The garments should be replaced approximately every 6 months when they lose elasticity.Bedrest and Leg Elevation. Elevation is an important aspect


Surgery_Schwartz

Surgery_Schwartz. The stock-ings should be worn during waking hours. The garments should be replaced approximately every 6 months when they lose elasticity.Bedrest and Leg Elevation. Elevation is an important aspect of controlling lower extremity swelling and is often the first recommended intervention. However, continuous elevation throughout the day can interfere with quality of life more than lymphedema itself. Elevation is an adjunct to lymphedema ther-apy but is not the mainstay of treatment.Intermittent Pneumatic Compression Therapy. The use of IPC with a single-chamber or multichamber pump temporar-ily reduces edema and provides another adjunct to the use of compression stockings. These devices have been shown to be effective in reducing limb volume; however, use of compres-sion stockings is necessary to maintain the volume reduction when the patient is no longer supine because fluid transport is not associated with the transport of macromolecules (proteins) from the tissue. Typically, IPC is


Surgery_Schwartz

Surgery_Schwartz. to maintain the volume reduction when the patient is no longer supine because fluid transport is not associated with the transport of macromolecules (proteins) from the tissue. Typically, IPC is used for 4 to 6 hours per day at home when the patient is supine, with pressure ranges between 30 and 60 mmHg demonstrated to be most effective.135Lymphatic Massage. Manual lymphatic drainage is a form of massage developed by Vodder136 that is directed at reduc-ing edema. In combination with the use of compression stock-ings, manual lymphatic drainage is associated with a long-term reduction in edema and fewer infections per patient per year.137Antibiotic Therapy. Patients with lymphedema are at increased risk of developing cellulitis in the affected extremity due to microscopic breakdown in the skin barrier either second-ary to swelling or unrecognized and untreated tinea pedis. Recur-rent infection can damage the lymphatics, aggravating the edema and increasing the risk for subsequent


Surgery_Schwartz

Surgery_Schwartz. the skin barrier either second-ary to swelling or unrecognized and untreated tinea pedis. Recur-rent infection can damage the lymphatics, aggravating the edema and increasing the risk for subsequent infection. Staphylococcus and β-hemolytic Streptococcus are the most common organisms causing soft tissue infection. Aggressive antibiotic therapy and elevation with compression are recommended at the earliest signs or symptoms of cellulitis. The drug of choice is penicil-lin or a cephalosporin active against Streptococcus for 5 days. In patients with recurrent cellulitis despite methods to reduced edema, treatment with monthly intramuscular injections of ben-zathine penicillin 1.2 MU, twice-daily erythromycin 250 mg, or penicillin V 1 g daily has proven effective at suppression.138Surgery. A variety of surgical procedures have been devised for the treatment of lymphedema. Surgical treatment involves either excision of extra tissue139 or anastomosis of a lymphatic vessel to another


Surgery_Schwartz

Surgery_Schwartz. variety of surgical procedures have been devised for the treatment of lymphedema. Surgical treatment involves either excision of extra tissue139 or anastomosis of a lymphatic vessel to another lymphatic or vein.140 In excisional procedures, part or all of the edematous tissue is removed. This does not improve lymphatic drainage but debulks redundant tissue. The microsurgical procedures involve the creation of a lymphati-colymphatic or lymphaticovenous anastomosis, which theo-retically improves lymphatic drainage. No long-term follow-up data are available for these interventions, and therefore opera-tive therapy for lymphedema is not well accepted worldwide. Furthermore, operative intervention has the potential to further obliterate lymphatic channels, worsening the edema.141SUMMARYLymphedema is a chronic condition caused by ineffective lymphatic transport, which results in edema and skin damage. Lymphedema is not curable, but the symptoms and long-term effects can be controlled with a


Surgery_Schwartz

Surgery_Schwartz. is a chronic condition caused by ineffective lymphatic transport, which results in edema and skin damage. Lymphedema is not curable, but the symptoms and long-term effects can be controlled with a combination of elastic com-pression stockings, limb elevation, pneumatic compression, and massage. Controlling the edema protects the skin and potentially prevents cellulitis.REFERENCESEntries highlighted in bright blue are key references. 1. Moncada S, Radomski MW, Palmer RM. Endothelium-derived relaxing factor. Identification as nitric oxide and role in the control of vascular tone and platelet function. Biochem Pharmacol. 1988;37:2495-2501. 2. van Bemmelen PS, Beach K, Bedford G, et al. The mecha-nism of venous valve closure. Its relationship to the velocity of reverse flow. Arch Surg. 1990;125:617-619. 3. Moneta GL, Strandness DE, Jr. Basic data concerning nonin-vasive vascular testing. Ann Vasc Surg. 1989;3:190-193. 4. Neglen P, Berry MA, Raju S. Endovascular surgery in the treatment of


Surgery_Schwartz

Surgery_Schwartz. GL, Strandness DE, Jr. Basic data concerning nonin-vasive vascular testing. Ann Vasc Surg. 1989;3:190-193. 4. Neglen P, Berry MA, Raju S. Endovascular surgery in the treatment of chronic primary and post-thrombotic iliac vein obstruction. Eur J Vasc Endovasc Surg. 2000;20(6):560-571. 5. Bettman MA, Robbins A, Braun SD, et al. Contrast venogra-phy of the leg: diagnostic efficacy, tolerance, and complica-tion rates with ionic and nonionic contrast media. Radiology. 1987;165:113-116.Brunicardi_Ch24_p0981-p1008.indd 100322/02/19 3:01 PM 1004SPECIFIC CONSIDERATIONSPART II 6. White R. The epidemiology of venous thromboembolism. Circulation. 2003;107:I4-I8. 7. Spyropoulos AC, Hussein M, Lin J, et al. Rates of symptom-atic venous thromboembolism in US surgical patients: a ret-rospective administrative database. J Thromb Thrombolysis. 2009;28:458-464. 8. Heit JA, Cohen AT, Anderson FA. Estimated annual number of incident and recurrent, non-fatal and fatal venous thromboem-bolism (VTE)


Surgery_Schwartz

Surgery_Schwartz. database. J Thromb Thrombolysis. 2009;28:458-464. 8. Heit JA, Cohen AT, Anderson FA. Estimated annual number of incident and recurrent, non-fatal and fatal venous thromboem-bolism (VTE) events in the US. Blood. 2005;106:910. 9. Pengo V, Lensing AWA, Prins MH, et al. Incidence of chronic thromboembolic pulmonary hypertension after pulmonary embolism. N Engl J Med. 2004;350:2257-2264. 10. Kahn SR, Ginsberg JS. The post-thrombotic syndrome: current knowledge, controversies and directions for future research. Blood Rev. 2002;16:155-165. 11. Mohr DN, Silverstein MD, Heit JA, et al. The venous sta-sis syndrome after deep venous thrombosis or pulmonary embolism: a population-based study. Mayo Clin Proc. 2000;75:1249-1256. 12. Rosendaal FR. Risk factors for venous thrombotic disease. Thromb Haemost. 1999;82:610. 13. Ageno W, Becattini C, Brighton T, et al. Cardiovascular risk factors and venous thromboembolism: a meta-analysis. Circulation. 2008;117:93-102. 14. White R, Zhou H, Romano P.


Surgery_Schwartz

Surgery_Schwartz. 1999;82:610. 13. Ageno W, Becattini C, Brighton T, et al. Cardiovascular risk factors and venous thromboembolism: a meta-analysis. Circulation. 2008;117:93-102. 14. White R, Zhou H, Romano P. Incidence of idiopathic deep venous thrombosis and secondary thromboembo-lism among ethnic groups in California. Ann Intern Med. 1998;128:737-740. 15. Bezemer ID, Bare LA, Doggen CJM, et al. Gene variants asso-ciated with deep vein thrombosis. JAMA. 2008;299:1306-1314. 16. Rogers SO, Jr, Kilaru RK, Hosokawa P, et al. Multivariable predictors of postoperative venous thromboembolic events after general and vascular surgery: results from the Patient Safety in Surgery Study. J Am Coll Surg. 2007;204:1211-1221. 17. Bahl V, Hu HM, Henke PK, Wakefield TW, Campbell DA, Jr, Caprini JA. A validation study of retrospective venous thromboembolism risk scoring method. Ann Surg. 2010;251:344-350. 18. Markel A, Manzo RA, Bergelin RO, et al. Pattern and dis-tribution of thrombi in acute venous thrombosis. Arch


Surgery_Schwartz

Surgery_Schwartz. retrospective venous thromboembolism risk scoring method. Ann Surg. 2010;251:344-350. 18. Markel A, Manzo RA, Bergelin RO, et al. Pattern and dis-tribution of thrombi in acute venous thrombosis. Arch Surg. 1992;127:305-309. 19. Nicolaides AN, Kakkar VV, Field ES, et al. The origin of deep vein thrombosis: a venographic study. Br J Radiol. 1971;44:653-663. 20. Brockman SK, Vasko JS. The pathologic physiology of phleg-masia cerulea dolens. Surgery. 1966;59:997-1007. 21. Lensing AW, Prandoni P, Brandjes D, et al. Detection of deep-vein thrombosis by real-time B-mode ultrasonography. N Engl J Med. 1989;320:342-345. 22. O’Leary DH, Kane RA, Chase BM. A prospective study of the efficacy of B-scan sonography in the detection of deep venous thrombosis in the lower extremities. J Clin Ultrasound. 1988;16:1-8. 23. Mussurakis S, Papaioannou S, Voros D, et al. Compression ultrasonography as a reliable imaging monitor in deep venous thrombosis. Surg Gynecol Obstet. 1990;171:233-239. 24. Habscheid


Surgery_Schwartz

Surgery_Schwartz. 1988;16:1-8. 23. Mussurakis S, Papaioannou S, Voros D, et al. Compression ultrasonography as a reliable imaging monitor in deep venous thrombosis. Surg Gynecol Obstet. 1990;171:233-239. 24. Habscheid W, Hohmann M, Wilhelm T, et al. Real-time ultra-sound in the diagnosis of acute deep venous thrombosis of the lower extremity. Angiology. 1990;41:599-608. 25. Comerota AJ, Katz ML, Grossi RJ, et al. The comparative value of noninvasive testing for diagnosis and surveillance of deep vein thrombosis. J Vasc Surg. 1988;7:40-49. 26. Gomes AS, Webber MM, Buffkin D. Contrast venography vs. radionuclide venography: a study of discrepancies and their possible significance. Radiology. 1982;142:719-728. 27. Hull R, Hirsh J, Sackett DL, et al. Clinical validity of a nega-tive venogram in patients with clinically suspected venous thrombosis. Circulation. 1981;64:622-625. 28. Kearon C, Akl E, Comerota A, et al. Antithrombotic ther-apy for venous thromboembolic disease: antithrombotic therapy and


Surgery_Schwartz

Surgery_Schwartz. clinically suspected venous thrombosis. Circulation. 1981;64:622-625. 28. Kearon C, Akl E, Comerota A, et al. Antithrombotic ther-apy for venous thromboembolic disease: antithrombotic therapy and prevention of thrombosis. American College of Chest Physicians evidence-based clinical practice guidelines (9th edition). Chest. 2012;141(2 suppl):e419S-e496S. The most recent American College of Chest Physicians clinical practice guidelines on antithrombotic therapy for venous thromboembolic disease. These recommendations cover multimodality therapies and are based upon an exhaustive review of the literature, including randomized clinical trials. 29. Raschke RA, Reilly BM, Guidry JR, et al. The weight-based heparin dosing nomogram compared with a standard care nomogram. A randomized controlled trial. Ann Intern Med. 1993;119:874-881. 30. Hylek EM, Regan S, Henault LE, et al. Challenges to the effective use of unfractionated heparin in the hospital-ized management of acute thrombosis. Arch


Surgery_Schwartz

Surgery_Schwartz. trial. Ann Intern Med. 1993;119:874-881. 30. Hylek EM, Regan S, Henault LE, et al. Challenges to the effective use of unfractionated heparin in the hospital-ized management of acute thrombosis. Arch Intern Med. 2003;163:621-627. 31. Amiral J, Bridey F, Dreyfus M, et al. Platelet factor 4 com-plexed to heparin is the target for antibodies generated in heparin-induced thrombocytopenia. Thromb Haemost. 1992;68:95-96. 32. Warkentin TE, Levine MN, Hirsh J, et al. Heparin-induced thrombocytopenia in patients treated with low-molecular-weight heparin or unfractionated heparin. N Engl J Med. 1995;332:1330-1335. 33. Warkentin TE, Kelton JG. Heparin and platelets. Hematol Oncol Clin North Am. 1990;4:243-264. 34. Calaitges JG, Liem TK, Spadone D, et al. The role of heparin-associated antiplatelet antibodies in the outcome of arterial reconstruction. J Vasc Surg. 1999;29:779-786. 35. Warkentin TE, Kelton JG. A 14-year study of heparin-induced thrombocytopenia. Am J Med.


Surgery_Schwartz

Surgery_Schwartz. antiplatelet antibodies in the outcome of arterial reconstruction. J Vasc Surg. 1999;29:779-786. 35. Warkentin TE, Kelton JG. A 14-year study of heparin-induced thrombocytopenia. Am J Med. 1996;101:502-507. 36. Gould MK, Dembitzer AD, Doyle RL, et al. Low-molecular-weight heparins compared with unfractionated heparin for treatment of acute deep venous thrombosis: a meta-anal-ysis of randomized, controlled trials. Ann Intern Med. 1999;130:800-809. 37. Dolovich LR, Ginsberg JS, Douketis JD, et al. A meta-analysis comparing low-molecular-weight heparins with unfraction-ated heparin in the treatment of venous thromboembolism: examining some unanswered questions regarding location of treatment, product type, and dosing frequency. Arch Intern Med. 2000;160:181-188. 38. Van Dongen CJJ, van der Belt AGM, Prins MH, et al. Fixed dose subcutaneous low molecular weight heparins versus adjusted dose unfractionated heparin for venous thromboem-bolism. Cochrane Database Syst Rev.


Surgery_Schwartz

Surgery_Schwartz. CJJ, van der Belt AGM, Prins MH, et al. Fixed dose subcutaneous low molecular weight heparins versus adjusted dose unfractionated heparin for venous thromboem-bolism. Cochrane Database Syst Rev. 2004;4:CD001100. 39. Kikta MJ, Keller MP, Humphrey PW, et al. Can low molecular weight heparins and heparinoids be safely given to patients with heparin-induced thrombocytopenia syndrome? Surgery. 1993;114:705-710. 40. Koopman MM, Prandoni P, Piovella F, et al. Treatment of venous thrombosis with intravenous unfractionated heparin administered in the hospital as compared with subcutaneous low-molecular-weight heparin administered at home. The Tas-man Study Group. N Engl J Med. 1996;334:682-687. 41. Levine M, Gent M, Hirsh J, et al. A comparison of low-molecularweight heparin administered primarily at home with unfraction-ated heparin administered in the hospital for proximal deep-vein thrombosis. N Engl J Med. 1996;334:677-681. 42. Büller HR, Davidson BL, Decousus H, et al. Fondaparinux or


Surgery_Schwartz

Surgery_Schwartz. at home with unfraction-ated heparin administered in the hospital for proximal deep-vein thrombosis. N Engl J Med. 1996;334:677-681. 42. Büller HR, Davidson BL, Decousus H, et al. Fondaparinux or enoxaparin for the initial treatment of symptomatic deep venous thrombosis: a randomized trial. Ann Intern Med. 2004;140:867-873. 43. The Matisse Investigators. Subcutaneous fondaparinux versus intravenous unfractionated heparin in the initial treatment of pulmonary embolism. N Engl J Med. 2003;349:1695-1702.Brunicardi_Ch24_p0981-p1008.indd 100422/02/19 3:01 PM 1005VENOUS AND LYMPHATIC DISEASECHAPTER 24 44. Warkentin TE, Maurer BT, Aster RH. Heparin-induced throm-bocytopenia associated with fondaparinux. N Engl J Med. 2007;356:2653-2655. 45. Kelton JG. The pathophysiology of heparin-induced thrombocytopenia: biological basis for treatment. Chest. 2005;127:9S-20S. 46. Martin K, Beyer-Westendorf J, Davidson BL, Huisman MV, Sandset PM, Moll S. Use of the direct oral anticoagulants in obese


Surgery_Schwartz

Surgery_Schwartz. thrombocytopenia: biological basis for treatment. Chest. 2005;127:9S-20S. 46. Martin K, Beyer-Westendorf J, Davidson BL, Huisman MV, Sandset PM, Moll S. Use of the direct oral anticoagulants in obese patients: guidance from the SSC of the ISTH. J Thromb Haemost. 2016;14(6):1308-1313. 47. Schulman S, Shortt B, Robinson M, Eikelboom JW. Adher-ence to anticoagulant treatment with dabigatran in a real-world setting. J Thromb Haemost. 2013;11(7):1295-1299. 48. Pollack CV, Jr, Reilly PA, Eikelboom J, et al. Idarucizumab for Dabigatran Reversal. N Engl J Med. 2015;373(6):511-520. 49. Eerenberg ES, Kamphuisen PW, Sijpkens MK, Meijers JC, Buller HR, Levi M. Reversal of rivaroxaban and dabigatran by prothrombin complex concentrate: a randomized, placebo-controlled, crossover study in healthy subjects. Circulation. 2011;124(14):1573-1579. 50. Holbrook A, Schulman S, Witt DM, et al. Evidence based management of anticoagulant therapy. American College of Chest Physicians Evidence-Based Clinical


Surgery_Schwartz

Surgery_Schwartz. Circulation. 2011;124(14):1573-1579. 50. Holbrook A, Schulman S, Witt DM, et al. Evidence based management of anticoagulant therapy. American College of Chest Physicians Evidence-Based Clinical Practice Guide-lines, 9th ed. Chest. 2012;114:e152S-e184S. 51. Schulman S, Rhedin A-S, Lindmarker P, et al. A comparison of six weeks with six months of oral anticoagulant therapy after a first episode of venous thromboembolism. N Engl J Med. 1995;332:1661-1665. 52. Research Committee of the British Thoracic Society. Optimal duration of anticoagulation for deep vein thrombosis and pul-monary embolism. Lancet. 1992;340:873-876. 53. Levine MN, Hirsh J, Gent M, et al. Optimal duration of oral anticoagulant therapy: a randomized trial comparing four weeks with three months of warfarin in patients with proximal deep vein thrombosis. Thromb Haemost. 1995;74:606-611. 54. Kearon C, Gent M, Hirsh J, et al. A comparison of three months of anticoagulation with extended anticoagulation for a first episode


Surgery_Schwartz

Surgery_Schwartz. proximal deep vein thrombosis. Thromb Haemost. 1995;74:606-611. 54. Kearon C, Gent M, Hirsh J, et al. A comparison of three months of anticoagulation with extended anticoagulation for a first episode of idiopathic venous thromboembolism. N Engl J Med. 1999;340:901-907. 55. Agnelli G, Prandoni P, Santamaria MG, et al. Three months versus one year of oral anticoagulant therapy for idiopathic deep venous thrombosis. N Engl J Med. 2001;345:165-169. 56. Ridker PM, Goldhaber SZ, Danielson E, et al. Long-term, low-intensity warfarin therapy for the prevention of recurrent venous thromboembolism. N Engl J Med. 2003;348:1425. 57. Kearon C, Ginsber JS, Kovacs MJ, et al. Comparison of low-intensity warfarin therapy with conventional-intensity warfarin therapy for long-term prevention of recurrent venous thrombo-embolism. N Engl J Med. 2003;349:631-639. 58. Lee AYY, Levine MN, Baker RI, et al. Low-molecular-weight heparin versus a coumarin for the prevention of recurrent venous thromboembolism in


Surgery_Schwartz

Surgery_Schwartz. thrombo-embolism. N Engl J Med. 2003;349:631-639. 58. Lee AYY, Levine MN, Baker RI, et al. Low-molecular-weight heparin versus a coumarin for the prevention of recurrent venous thromboembolism in patients with cancer. N Engl J Med. 2003;349:146-153. 59. Akl EA, Barba M, Rohilla S, et al. Anticoagulation for the long term treatment of venous thromboembolism in patients with cancer. Cochrane Database Syst Rev. 2008;2:CD006650. 60. Watson LI, Armon MP. Thrombolysis for treatment of acute deep vein thrombosis. Cochrane Database Syst Rev. 2004;4:CD002783. 61. Vedantham S, Goldhaber S, Julian J, et al. Pharmacomechanical Catheter-Directed Thrombolysis for Deep-Vein Thrombosis. N Engl J Med. 2017;377:2240-2252. 62. Vedantham S, Goldhaber S, Julian, J, et al. Interventional ther-apy for prevention of the post-thrombotic syndrome: results of the NHLBI-sponsored ATTRACT trial. 2017. Unpublished manuscript. 63. Decousus H, Leizorovicz A, Parent F, et al. A clinical trial of vena caval filters in


Surgery_Schwartz

Surgery_Schwartz. of the post-thrombotic syndrome: results of the NHLBI-sponsored ATTRACT trial. 2017. Unpublished manuscript. 63. Decousus H, Leizorovicz A, Parent F, et al. A clinical trial of vena caval filters in the prevention of pulmonary embolism in patients with proximal deep-vein thrombosis. Prévention du Risque d’Embolie Pulmonaire par Interruption Cave Study Group. N Engl J Med. 1998;338:409-415. 64. Becker DM, Philbrick JT, Selby JB. Inferior vena cava filters. Indications, safety, effectiveness. Arch Intern Med. 1992;152:1985-1994. 65. Morales JP, Li X, Irony TZ, Ibrahim NG, Moynahan M, Cavanaugh KJ Jr. Decision analysis of retrievable inferior vena cava filters in patients without pulmonary embolism. J Vasc Surg Venous Lymphat Disord. 2013;1(4):376-384. 66. Morales JP, Li X, Irony TZ, Ibrahim NG, Moynahan M, Cava-naugh KJ, Jr. Decision analysis of retrievable inferior vena cava filters in patients without pulmonary embolism. J Vasc Surg Venous Lymphat Disord. 2013;1(4):376-384. 67. Plate


Surgery_Schwartz

Surgery_Schwartz. NG, Moynahan M, Cava-naugh KJ, Jr. Decision analysis of retrievable inferior vena cava filters in patients without pulmonary embolism. J Vasc Surg Venous Lymphat Disord. 2013;1(4):376-384. 67. Plate G, Ohlin P, Eklof B. Pulmonary embolism in acute ilio-femoral venous thrombosis. Br J Surg. 1985;72:912-915. 68. Eklof B, Kistner RL, Masuda EM. Surgical treatment of acute iliofemoral deep venous thrombosis. In: Gloviczki P, Yao JST, eds. Handbook of Venous Disorders. New York: Arnold; 2001:202. This chapter reviews outcomes following surgical treatment for acute iliofemoral deep venous thrombo-sis in addition to an illustrative review of surgical technique. 69. Juhan CM, Alimi YS, Barthelemy PJ, et al. Late results of ilio-femoral venous thrombectomy. J Vasc Surg. 1997;25:417-422. 70. Schmid C, Zietlow S, Wagner TO, et al. Fulminant pulmonary embolism: symptoms, diagnostics, operative technique, and results. Ann Thorac Surg. 1991;52:1102-1105. 71. Kieny R, Charpentier A, Kieny MT. What


Surgery_Schwartz

Surgery_Schwartz. C, Zietlow S, Wagner TO, et al. Fulminant pulmonary embolism: symptoms, diagnostics, operative technique, and results. Ann Thorac Surg. 1991;52:1102-1105. 71. Kieny R, Charpentier A, Kieny MT. What is the place of pulmonary embolectomy today? J Cardiovasc Surg. 1991;32:549-554. 72. Gulba DC, Schmid C, Borst HG, et al. Medical compared with surgical treatment for massive pulmonary embolism. Lancet. 1994;343:576-577. 73. Schmitz-Rode T, Janssens U, Schild HH, et al. Fragmentation of massive pulmonary embolism using a pigtail rotation cath-eter. Chest. 1998;114:1427-1436. 74. Greenfield LJ, Proctor MC, Williams DM, et al. Long-term experience with transvenous catheter pulmonary embolec-tomy. J Vasc Surg. 1993;18:450-457. 75. Gould MK, Garcia DA, Wren SM, et al. Prevention of VTE in nonorthopedic surgical patients: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012;141(2 suppl):


Surgery_Schwartz

Surgery_Schwartz. surgical patients: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012;141(2 suppl): e227S-e277S. The most recent American College of Chest Physicians clinical practice guidelines on prevention of venous thromboembolism in nonorthopedic surgical patients. These recommendations review evidence-based literature regarding perioperative venous thromboembolism prophylaxis. 76. Mismetti P, Laporte S, Darmon JY, et al. Meta-analysis of low molecular weight heparin in the prevention of venous throm-boembolism in general surgery. Br J Surg. 2001;88:913-930. 77. Agnelli G, Bergqvist D, Cohen AT, et al. Randomized clinical trial of postoperative fondaparinux versus perioperative dalte-parin for prevention of venous thromboembolism in high-risk abdominal surgery. Br J Surg. 2005;92:1212-1220. 78. Turpie AG, Bauer KA, Caprini JA, et al. Fondaparinux combined with intermittent pneumatic