Book Review

The Vein Book

N Engl J Med 2007; 357:1455-1456October 4, 2007

Article

The Vein Book
Edited by John J. Bergan. 617 pp., illustrated. San Diego, CA, Elsevier Academic Press, 2007. $179.95. ISBN: 978-0-12-369515-4

Experts from around the world have written the 65 chapters in The Vein Book, which covers all the important topics concerning chronic venous disease and venous thromboembolism. This work will be very useful to both the novice and the expert. It is one of the few books in the field that nicely bridges the gap between basic and clinical science. There are numerous color photographs, beautiful drawings, detailed diagrams, and other illustrations that make the cost of this high-quality volume altogether appropriate.

Recent findings concerning venous anatomy and the resulting new terminology are well explained in this book. Anatomy is described and is well related to the pathophysiology of venous disorders, and both are related to diagnostic testing. Epidemiology is covered adequately, with all the appropriate concepts and terms nicely summarized. There is a concise and detailed account of the newest systems for the classification of venous diseases that includes all the recent definitions and refinements of the CEAP (clinical severity, etiology, anatomy, pathophysiology) classification system. There is also a good description of how recurrent varicose veins are classified. All this information makes it easy for the reader to follow the concepts enumerated in the book, despite the complexity of the topic of venous disease.

Recently, much work has been done on the molecular basis of venous incompetence. Important molecular aspects of the problem, such as inappropriate leukocyte activation, tissue remodeling, genetic mechanisms, apoptosis, fibroblasts and collagen, cytokine regulation, tissue fibrosis, and alterations in smooth-muscle cells, are discussed in detail. The pathophysiology of skin damage and ulceration is also presented in detail, and all the different theories are laid out well.

There are many types of treatment for chronic venous disease, and they are applied alone or in combination. They are chosen mostly on the basis of clinical experience because there is not much evidence from clinical trials to provide guidance. Compression, for example, is an important part of most treatment protocols, and its mechanisms and effects are discussed in this book. Similarly, different types of sclerotherapy, possible volumes of sclerosing solutions, and various techniques — including ultrasound-guided sclerotherapy — are explained in detail along with their effects and complications. Traditional surgical techniques such as ligation, stripping, and phlebectomy, as well as more modern techniques such as powered phlebectomy, endovenous ablation with its use of various laser wavelengths, and venous closure are thoroughly described and analyzed.

One of the most difficult types of venous insufficiency to treat is deep venous insufficiency, whether it is primary or secondary to thrombosis. Very few centers in the world operate on patients with this condition, but those that do have had reasonable success. Various types of valve repair, axillary vein transfer, vein transposition techniques, and the potential use of prosthetic venous valves are discussed and analyzed adequately in this book.

Venous thromboembolic disease, although distinctly different from venous insufficiency, is the more important of the two conditions because of its potentially lethal component — pulmonary embolism. The epidemiology of venous thromboembolism, as well as its recurrence, risk factors, complications, and genetic alterations, are very well covered in a section dedicated to the subject. The mechanisms of thrombosis, with emphasis on the inflammatory pathway and hypercoagulable states, are also well covered in the same section.

Risk assessment for thrombosis, prophylaxis using mechanical and chemical methods, and newer drugs are described in depth. There is much information regarding the conventional treatment of thrombosis with unfractionated and low-molecular-weight heparins and with warfarin and related compounds. The use of newer therapies such as vitamin K antagonists that are administered by the patient is also discussed. The optimal duration of treatment and the management of complications are described in considerable depth. There are good accounts of surgical thrombectomy, thrombolytic therapy, mechanical thrombectomy, and the combination of these techniques, including discussion of their risks and benefits. Permanent and retrievable vena cava filters, the rationales behind their use, and the lack of randomized trials are detailed. A great description of complications associated with both types of filters is also provided.

All in all, this is a comprehensive — but not huge — work that covers quite thoroughly the many aspects of venous disorders and does so in an interesting and unpedantic fashion.

Nicos Labropoulos, M.D.
University of Medicine and Dentistry of New Jersey, Newark, NJ 07103
nlabrop@yahoo.com