RT Book, Section A1 Chopra, Atish A1 Liem, Timothy K. A1 Moneta, Gregory L. A2 Brunicardi, F. Charles A2 Andersen, Dana K. A2 Billiar, Timothy R. A2 Dunn, David L. A2 Kao, Lillian S. A2 Hunter, John G. A2 Matthews, Jeffrey B. A2 Pollock, Raphael E. SR Print(0) ID 1164312976 T1 Venous and Lymphatic Disease T2 Schwartz's Principles of Surgery, 11e YR 2019 FD 2019 PB McGraw-Hill Education PP New York, NY SN 9781259835353 LK accesssurgery.mhmedical.com/content.aspx?aid=1164312976 RD 2024/11/11 AB Key Points Thrombolytic therapy, surgical thrombectomy, and placement of inferior vena cava filters are adjunctive treatments that may be indicated in patients with extensive and complicated venous thromboembolism. Deep vein thrombosis (DVT) and pulmonary embolism are well-recognized complications after major abdominal and orthopedic procedures. The risk is further increased in patients with malignancy and a history of venous thromboembolism. Options for DVT prophylaxis include intermittent pneumatic compression, use of graduated compression stockings, and administration of low-dose unfractionated heparin, low molecular weight heparin, fondaparinux, and vitamin K antagonists. Direct thrombin inhibitors and factor Xa inhibitors are approved for prophylactic use only for orthopedic procedures and for recurrent VTE. However, prophylaxis should be stratified based on the patient’s level of risk. In patients with established DVT, unfractionated heparin, low molecular weight heparin, fondaparinux, and some factor Xa inhibitors are options for initial antithrombotic therapy. Vitamin-K antagonists, direct thrombin inhibitors, and factor Xa inhibitors are utilized for long-term anticoagulation. The duration and type of long-term anticoagulation should be stratified based on the provoked or unprovoked nature of the DVT, the location of the DVT, previous occurrence of DVT, and presence of concomitant malignancy. High ligation and stripping, endovenous laser, or radiofrequency ablation and sclerotherapy are effective therapies for patients with saphenous vein valvular insufficiency. Concomitant varicose veins may be managed with compression therapy, sclerotherapy, and phlebectomy. New nonthermal ablative techniques, including the combination of sclerotherapy with endoluminal mechanical injury as well as injection of cyanoacrylate, show early promising results. The mainstay of treatment for chronic venous insufficiency is compression therapy. Sclerotherapy, perforator vein ligation, and venous reconstruction or ablative techniques may be indicated in patients in whom conservative management fails or as a means to decrease ulcer recurrence. Lymphedema is categorized as congenital, primary (with early or delayed onset), or secondary. The goals of treatment are to minimize edema and prevent infection. Lymphatic massage, sequential pneumatic compression, use of compression garments, and limb elevation are effective forms of therapy.