In the first article of this special issue, Linnemann et al
[2] present a state-of-the-art overview of the diagnosis and treatment of lower extremity
deep vein thrombosis (LEDVT). Since the symptoms of LEDVT are nonspecific, a prompt
and standardized diagnostic workup is essential to ensure the earliest possible start
of treatment with the aim to minimize the risk of pulmonary embolism (PE) in the acute
phase and to prevent thrombosis progression, recurrence of VTE, and post-thrombotic
syndrome in the long term.
Acute PE is related to significant morbidity and mortality in the acute phase of VTE
and requires prompt diagnosis and management. In this issue, Opitz and Meyer give an overview about the pretest probability scores, diagnostic algorithms, and
risk stratification models when PE has been confirmed.[3] The authors also provide an overview of risk-adapted treatment strategies, such
as early revascularization procedures in hemodynamically unstable patients, monitoring
and anticoagulant therapy for patients at intermediate risk, and finally outpatient
treatment or early discharge of patients at low risk. The article by Janssens focuses on specific aspects of intensive care treatment for patients with severe
PE and circulatory or respiratory failure, such as ventilation, volume therapy, pharmacological
treatment with vasopressors and inotropics, mechanical circulatory support, and reperfusion
therapy.[4] Finally, Meyer and Opitz provide an excellent overview on the relevant aspects of the post-PE syndrome, which
manifests with pulmonary hypertension (chronic thromboembolic pulmonary hypertension
[CTEPH]) or with normal pulmonary artery pressure (chronic thromboembolic pulmonary
disease [CTEPD]).[5] Because the management of CTEPH is complex, patients with suspected or confirmed
CTEPH should be referred to specialized centers for comprehensive invasive diagnostic
assessment and interdisciplinary decision-making on treatment options.
Visceral vein thrombosis (VVT) is often related to liver cirrhosis, myeloproliferative
neoplasia, or severe thrombophilia such as the antiphospholipid syndrome. Although
the risk of bleeding complications is increased, anticoagulant therapy remains the
first-line therapy in patients with stable circulation and no evidence of organ complications.
Treatment recommendations, reviewed by Mühlberg in this issue, are mainly based on case series, observational studies, or studies
with small case numbers.[6] Treatment decisions therefore have to be made on an individual basis taking into
account the patient's risk of bleeding and recurrent thrombosis.
Tumor patients have an increased risk of VTE when compared with nontumor patients,
which has a negative impact on the quality of life, morbidity, and mortality. While
low-molecular-weight heparins (LMWHs) have long been the anticoagulants of choice
for patients with cancer-associated VTE (CT), recently published randomized trial
data show advantages of the direct factor Xa inhibitors (DXIs), but also some disadvantages
in terms of bleeding complications. Riess et al provide an overview of current study data and recommendations for the treatment of
CT.[7]
Despite the proven efficacy of anticoagulation, approximately 2% suffer a VTE recurrence
during anticoagulant therapy. Klamroth et al provide an overview of possible causes (e.g., nonadherence to medication, subtherapeutic
drug levels due to resorption disorders, drug–drug interactions, concomitant disease
with high thrombogenicity) and highlight management options (e.g., switching and/or
intensifying anticoagulant treatment), which are mainly based on expert consensus
in the absence of study data.[8]
It should be noted that the applicability of evidence- and consensus-based guideline
recommendations must always be assessed in the individual situation. In this respect,
guidelines are to be understood as “corridors for action and decision-making.” However,
in justified cases, deviations can or even must be made.
We highly appreciate the time and effort all our authors have spent in preparing their
manuscripts. We cordially thank them and the expert reviewers for actively supporting
this special issue, and we are confident that the articles provided will serve as
state-of-the-art references for our everyday clinical work.
