From The Editor's Desk

Robert Perrillo

It is with great pleasure that we present this issue of The Ochsner Journal dedicated to deep vein thrombosis and pulmonary embolism. The guiding force for this issue was Dr. Frank Kazmier, who has recently made a career move to the Mayo Clinic in Scottsdale, Arizona. We thank Frank for his hard work in getting this excellent issue together and wish him success at this new location.

As with past topical issues of The Ochsner Journal, we begin with a concise overview of the entity in question. Dr. Michael Jaff, a well-recognized figure in the area of venous thromboembolism, is Director of Vascular Medicine at the renowned Heart and Vascular Institute at Morristown, New Jersey. Dr. Jaff lays particular emphasis on how diagnosis and management of this disorder have changed over the past 10 years. This serves as a background for a fascinating account of the history behind the surgical management of pulmonary embolic disease by Drs. Michael McFadden and John Ochsner. From reading their article, one can quickly understand Dr. Alton Ochsner's valuable contribution to this area. He was the first to point out that in the average instance the seemingly direct approach of pulmonary embolectomy was inherently dangerous and more appropriate attention needed to be given to the prophylaxis of pulmonary embolism by ligating the inferior vena cava on the cardiac side of the clot. The current practice of vena caval interruption has been modified in many ways since the initial surgical experiences, but it should be noted that it was first advocated by Drs. Alton Ochsner and his star pupil, Micheal DeBakey, during the early 1930s, and the general principle has withstood the test of time.

The diagnosis of deep vein thrombosis has been greatly facilitated by Doppler spectral analysis, and Drs. DiVittorio and colleagues of the Department of Radiology describe the Ochsner protocol as well as the accuracy of this technique. The authors point out that CT venography may even enhance the diagnostic yield in certain patients, such as the very obese, which I would parenthetically add is not an uncommon problem in the United States! Further expansion of the usefulness of CT imaging as a means of assessing pulmonary vasculature and determining the presence of thrombus in the lower extremities is aptly discussed by Dr. Olsan and colleagues in the Department of Radiology. The authors point out that multicenter trials will be necessary to answer some of the remaining questions, but at the very least CT certainly seems to be a promising alternative in situations where the V/Q scan is indeterminate for pulmonary embolism.

Dr. Stephen Deitelzweig has a longstanding interest in this important medical area, and he discusses the gradient of risk for pulmonary embolism in surgical patients. He logically points out that the intensity of the preventive measures should run parallel to the risk status. His article is a pragmatic review of current medical therapy regimens for prevention of venous thromboembolism. There will always be some failures of prophylaxis, however, and that is why the subsequent article by Drs. Subramaniam and White of the Department of Cardiology is extremely important. The authors allow the reader a glimpse of the medical and mechanical approaches that may be taken to dissolve clots once pulmonary embolism or deep venous thrombosis has been detected.

At Ochsner, the success of long-term medical prophylaxis of deep vein thrombosis is based upon a team effort and employs computer interventions for tracking the coagulation status of patients. The article by Annette Barrios and colleagues of the Ochsner Heart and Vascular Institute describes the system efficiencies that have been put in place. As the authors point out, the effective use of clinical pharmacists, the development of a locally designed computer software program, and direct telephone contact with patients are the underpinnings of a comprehensive and successful program.

Drs. Michael Conners and Samuel Money then describe the mechanisms of action of unfractionated and low molecular weight heparin. All current therapies have their limitations, and the authors describe several exciting new approaches (the synthetic heparins) in some detail and leave us with the hope that an oral formulation of heparin may be on the horizon.

Rounding out this issue is a vignette of Alton Ochsner by Dr. Hector Ventura. This includes several personal observations by Dr. Ochsner's contemporaries and pupils. The life and legacy of this outstanding physician continue to be an inspiration for us all.

We believe we have an outstanding issue for you and hope that you enjoy reading it.