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Chronic lymphedema is often staged using the classification developed by the International Society of Lymphology, which is based on clinical findings. However, the accurate diagnosis and classification of lymphatic function based on imaging findings is useful for aiding treatment selection. Ultrasonography can detect edema caused by venous disorders or other causes and is useful for checking the change in the fluid volume after treatment for lymphedema. Near infrared fluorescence lymphography with indocyanine green can be used to show the routes and flow rates of active lymph vessels near to the skin surface. The overall function of the lymphatic system can be evaluated with lymphoscintigraphy. Lymphatic vessels in superficial and deep areas can be visualized by single-photon emission computed tomography- lymphoscintigraphy（SPECT-LS）. We consider the indications, efficacy, and limitations of various treatments for lymphedema based on a combination of these examinations. It is important to select the optimal（most prognostically suitable）treatment for lymphedema based on a detailed evaluation of lymphatic function.

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The Japanese Certification Board for Lymphedema Therapists (JCLT) was established by 5 main societies including the Japanese College of Angiology, with the aims of evaluating a wide range of competencies, such as medical knowledge, skills, and proficiency required for therapists to provide complex lymphedema therapy in which various departments and healthcare workers are involved, as well as securing its healthcare standards. So far, more than 800 individuals have been certified as lymphedema therapists, of whom more than 70% are nurses, and they are providing therapy in every prefecture of Japan. Educational institutions are provided with teaching guidelines to promote academic standards. Although lymphedema is defined as a complication of cancer surgery in the present medical insurance system, it is necessary to evaluate lymphedema in terms of its therapy, including the treatment of primary lymphedema, as well as to ensure appropriate medical treatment fees reflecting the high-level skills of therapists. The healthcare environment of patients with lymphedema is expected to improve due to the growth in the number of lymphedema therapists.

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Complex physical therapy（CPT）is a classical conservative treatment for lymphedema that is widely used in Europe. The basic elements of CPT are used in various combinations according to each patient’s needs. They consist of techniques that move excessive accumulations of interstitial and lymph fluid（due to a transport disorder of the lymphatic system）to a healthy part of the body’s drainage system. CPT is recognized as the standard therapy for lymphedema by the International Society of Lymphology. In Japan, there is an increasingly high demand for CPT as a therapy for lymphedema after cancer surgery or radiotherapy. CPT has a wide range of indications and exhibits promising effects against edema due to chronic venous insufficiency, traumatic edema, and edema associated with extensive skin damage after traffic accidents or burn injuries. In Germany, one of the leading countries for CPT is employed for a wide range of purposes. It would be desirable if it could be used to treat venous diseases or in orthopedics in Japan in the future, too.

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The treatment of lower extremity lymphedema involves conservative therapy or surgery. Combined physical therapy is the gold standard of self-control therapy in lymphedema treatment.Lymphedema of the extremities is a chronic, debilitating disease. Lymphedema can be treated conservatively or surgically, including tissue resection and direct or indirect lymph drainage. Lymphaticovenular anastomosis（LVA）is an effective surgical treatment for obstructive lymphedema refractory to conservative decongestive therapy. The aim of LVA is to create as many lymphatic drainage pathways as possible while preserving the remaining lymph flow. Indocyanine green（ICG）lymphography has been reported to be an effective modality for evaluation of lymph circulation of the limbs and the diagnosis of lymphedema; it provides useful information for LVA. We report a safer and more secure LVA with guidance using ICG lymphography conducted in Saga University Hospital.

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Most venous pathologies affect the lower extremities because the leg veins are more susceptible to venous hypertension. A correct diagnosis should be made based on the patient’s history, physical findings, and a duplex scan of the legs based on the CEAP classification system. The main treatments are patient education and compression therapy. If superficial reflux is detected, vein stripping or endovenous thermal ablation is indicated to prevent recurrence（mainly in cases of primary varicose veins and sometimes in cases of post-thrombotic syndrome）. Skin grafting is usually unsuccessful in patients with untreated venous hypertension.

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In Japan, there have recently been two important announcements regarding the treatment of varicose veins. The first one was when it was agreed that laser- or radio wave-based endovenous treatment for varicose veins would be covered by the Japanese national health insurance system. The second one was when a similar decision was made regarding subfascial endoscopic perforator surgery（SEPS）in April 2014. SEPS is a surgical method that is useful for treating severe refractory leg ulcers with stasis dermatitis. Compression therapy remains the first-choice treatment for stasis dermatitis（as is appropriate）, but SEPS has the following advantages: 1）it can rapidly ameliorate inflammation caused by stasis dermatitis and 2）it enhances the effectiveness of compression therapy. Therefore, we will first explain about chronic venous hypertension, which is the primary cause of stasis dermatitis. Then, we will outline the mechanism by which SEPS improves chronic venous hypertension. Furthermore, we discuss adequate compression therapy based on this pathological mechanism.

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Objectives: Management of critical limb ischemia（CLI）requires a multidisciplinary approach.Patients and methods: Sixty-eight patients with leg ulcers and ischemia were treated at our foot care clinic. We examined the association among diabetes, revascularization, avoidance of major amputation, and wound healing.Results: Diabetes was observed in 57 patients. Revascularization was performed in 31 patients（revascularization group）, and contraindicated in 14 patients（non-revascularization group）. The remaining 23 patients received only medical treatment. Major amputation was avoided in 27/31 patients（87%）in the revascularization group, significantly more than the 6/14 patients（42%）of the non-revascularization group. Wound healing was achieved in 26/31 patients（84%）in the revascularization group, significantly more than the 3/14 patients（21%）of the non-revascularization group. Conclusion: Correct blood flow assessment, effective revascularization, and plastic surgery procedures are necessary for successful treatment of CLI, and major amputation can be avoided by a multidisciplinary team approach.

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Although the ankle-brachial index（ABI）and skin perfusion pressure（SPP）have been widely used for the diagnosis of peripheral artery disease（PAD）, it is generally difficult to immediately evaluate peripheral circulation during endovascular therapy. We assessed the use of the Perfusion Index（PI）, defined as the ratio of pulsatile arterial flow to non-pulsatile blood flow or the static component in peripheral tissue. We observed a good correlation between ABI and PI, suggesting that PI may also be potentially useful for PAD screening. Furthermore, PI provides instant and continuous feedback pertaining to the perfusion status of the monitoring site, allowing noninvasive evaluation of the peripheral circulation during endovascular therapy. In PAD treatment, PI is beneficial for determining the endpoint of the procedure. Thus, PI may be a novel indicator of peripheral circulatory status, including during PAD treatment.

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Prophylactic surgery in diabetic feet reduces the risk of ulcer recurrence and morbidity in patients with diabetic neuropathy. Prophylactic foot surgery allows alleviation of high pressure areas in the foot by re-aligning bony structures. Patients with neuropathy often suffer from non-healing foot ulcers due to lack of sensation or foot deformities, often leading to the need for major amputation. We report three cases of non-healing neuropathic foot ulcers treated with prophylactic foot surgery. All patients had neuropathic non-healing foot ulcers for more than 2 years. After treatment, the patients were ulcer-free for up to 1 year, and were able to perform usual ADL. Although it is difficult to treat neuropathy, it is possible to improve foot deformities. Furthermore, it is important to achieve load relief for maintenance of patient QOL. Thus, prophylactic surgery may be an effective treatment for non-healing neuropathic foot ulcerations.

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Although it is necessary to perform both medical treatment of the wound and revascularization for treatment of CLI, the timings of these treatments are difficult. This paper reports a patient who was referred to our department from the Department of Cardiology because of right toe gangrene that developed after a low-temperature burn. Debridement, minor toe amputation, and local negative-pressure wound therapy were performed. The wound was finally closed seven months after the first EVT, requiring a total of three EVTs. We report the treatment content and course of this case, and discuss the associated challenges and important points of such treatment.

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