To evaluate the usefulness of endovascular surgery (ES) for venous diseases, we examined the effects and the results of patients treated with catheter-directed thrombolysis (CDT), inferior vena cava filter (IVC-F) or stents. Sixteen patients were treated by CDT; 4 subclavian veins, 10 ilio-femoral and 2 IVC thrombosis. The thrombolysis effect of CDT was higher than that of patients with general administration of urokinase. There were no cases of pulmonary embolism during CDT and no significant difference between the two groups. IVC-F was inserted into 26 patients, in which suprarenal filter placement was performed in 10. The follow-up period ranged from 3 months to 8 years and 1 month (average 3 years 3 months), in which 5 patients died from other disorders. There were no cases with caval occlusion or with hepatorenal dysfunction. Six patients were successfully treated by angioplasty and stent insertion. ES is useful in venous diseases and may lead to better results by combining it with other procedures. However further examination is needed to better understand indications and long-term results.

We report the efficacy of transesophageal echocardiography (TEE) in the diagnosis of severe, acute pulmonary embolism (APE). In ten cases, TEE was performed early after the occurrence of APE. In nine of the ten cases, transthoracic echocardiography (TTE) revealed distention of the right ventricle. In eight cases, TEE detected thrombus in the pulmonary artery. In cases with thrombus in the central pulmonary artery, the findings using TEE were almost same as those using chest computed tomography or pulmonary arteriography, or surgical findings. In six cases, thrombolytic and anti-coagulant therapy were given. Surgery was performed in four patients. One patient who received thrombolytic and anticoagulant therapy died. We conclude that TEE is a useful diagnostic tool for severe APE and, in cases with circulatory collapse, if TEE reveals thrombus in the pulmonary artery, surgery is indicated without the need for further diagnostic study.

Eight limbs of seven patients with deep venous thrombosis were treated by direct thrombolytic therapy using pulsed infusion catheters. The catheters were inserted via the common femoral, the popliteal, the short saphenous, the posterior tibial or the Cockett’s perforating veins. Urokinase was manually sprayed and then continuously injected using a infusion pump for 2～14 days. The total dose of urokinase was 1.08～3.12 million IU. Symptoms were immediately subsided in all limbs and completely disappeared in 5 limbs. Efficient thrombolysis was more observed than conventional systemic thrombolytic therapy on follow-up phlebography. In two limbs Palmaz stents were inserted in the left common iliac vein after PTA.

Catheter-directed thrombolysis could be the first choice of treatment for deep venous thrombosis. However, there are some problems in this therapeutic maneuver concerning the effect to old thrombus, insertion site of catheters, suitable duration of the treatment and prevention of pulmonary embolism.

The role of percutaneous treatment in the management of venous stenosis in hemodialysis patients with arteriovenous access graft in the lower extremity is unclear. The purpose of the study to evaluate the efficacy of percutaneous treatment of venous stenosis in patients with lower extremity bridge fistulas was retrospectively analysis. Twenty percutaneous treatment of venous stenosis were performed in 11 patients (2 men and 9 women, 47～75 years of age; mean, 60.3±8.2 years) with hemodialysis fistula in the lower extremity. The lesion was located on the saphenous vein in 2, the femoral vein in 4, the femoral and external iliac vein in 1, the external iliac vein in 4, and the common iliac vein in 3 cases. Palmaz stent implantation became necessary in 6 of 20 (30%), because the indication for stent placement restricted to insufficient restoration after simple balloon dilatation and early restenosis within the one year. Extremity swelling was improved and reduction of the pressure gradient was achieved in all cases. No acute complication, excluding one venous rupture during balloon inflation with 10 atmospheres occured during and after procedures. The venous rupture was treated with sustained balloon inflation and temporary graft clamp. The primary patency rates for percutaneous treatment including stent placement at 3, 6, 12, 15 months were 86.7%, 85.7%, 71.4% and 66.7%, respectively. None of angiographic restenoses in the stent placement sites were observed. Four patients died during the follow-up period, however these deaths were not directly related to these procedures. In 10 patients (90.9%) the shunt was still used for hemodialysis until the end of the observation period or the patient’s death. Although the number of patients may be too small and the follow-up period may be too short to make a valid conclusion regarding the efficacy of percutaneous treatment of venous stenosis in patients with lower extremity bridge fistulas, our results suggest that percutaneous treatment including stent placement is safe and effective in preserving functioning dialysis access fistula in the lower extremity.

Purpose: We reviewed the usefulness of platelet scintigraphy, in which autologous platelets labeled with indium-11-oxine reveal thrombotic activity, for evaluating pulmpnary embolism (PE).

Materials: 12 cases who were diagnosed as having PE using Tc-99m MAA scintigraphy were entered in this study.

Results: Among them, 3 cases showed abnormal accumulation in the lungs (25%). None of these cases has shown deterioration or recurrence during anticoagulant and thrombolytic therapy. Six cases showed abnormal accumulation at sites outside the lungs (the inguinal region in 3 cases, the neck in 2 and the subclavian region in one). In the veins at these sites, the thrombus was detected by means of venography and duplex scanning and was considered to be the source of pulmonary embolism.

Conclusion: Platelet scintigraphy can facilitate the assessment of thrombotic activity and might be useful for deciding the treatment strategy for acute vascular thrombosis. It can provide the whole body images that allow for detection of the source of pulmonary embolism.

Chronic thromboembolic pulmonary hypertension (CTEPH) is one of the major causes of pulmonary arterial (PA) hypertension presenting with severe disability and often fatal outcome. Although this condition is often misdiagnosed as a disease showing similar pathophysiological characteristics such as primary pulmonary hypertension (PPH), it is potentially curable by thromboendarterectomy (PTE) if bilateral thrombotic legions in the proximal (main or lobar) PA are accurately assessed and definable for the surgical accessibility. Recent studies have shown that intravascular imaging provides direct evidence of lesions in PA as well as coronary and peripheral arteries. The purpose of this study is to clarify whether intravascular imaging is valuable in making the differential diagnosis and determining the surgical indication in patients with CTEPH. An angioscopy (XPF-30AL, Olympus, Tokyo, Japan) with an inflatable balloon on the distal tip and a mechanically rotated intravascular ultrasound imaging system (IVUS; SSD550, Aloka, Tokyo, Japan) were utilized. Direct visualization with these devices was performed in consecutive 25 patients initially diagnosed as CTEPH with angiographically equivocal surgical indication. Angioscopy was particularly useful in determining the location and extent of organized thrombi and thickened intima, recognized by the deformity of the intima and lumen in CTEPH. On the other hand, IVUS could quantify the magnitude of the thickness of intima and luminal thrombi, and therefore made iteasy to determine the surgical accessibility and procedure. A three layered structure with an intermediate echo-lucent zone and at hickening of the intima-media complex more than 1.0mm in the proximal PA determined by IVUS were reliable predictors for complete PTE in CTEPH, because ten patients whose images met to the criteria described above were successfully operated on. These images were also helpful in making final diagnosis in 7 of 25 patients Five with PPH and each one with neoplasm and vasculitis in PA, respectively. In conclusion, intravascular imaging in PA might contribute significantly to the final diagnosis and surgical decision making in patients with CTEPH.

From 1985 to 1999, 24 cases of malignant tumors (renal carcinoma (17), adrenal carcinoma (2), hepatocellular carcinoma, leiomyosarcoma, paraganglioma and Wilms tumor respectively (1 each) with inferior vena caval invasion were treated surgically. Of these, 17 cases (14 men and 3 women), 47～78 years old (mean age 61.6) of advanced renal cell carcinomas involving the inferior vena cava, underwent radical nephrectomy and removal of the tumor thrombi. Vena caval tumor thrombus associated with renal cell carcinoma occurs in 4 to 10% of all renal tumors. Radical nephrectomy with vena caval thrombectomy represents the only realistic chance for cure for patients with renal cell carcinoma that has extended into the inferior vena cava.

We operated on these cases using two main methods. One was the simple vena caval incision method (SVCI), the other was the cardiopulmonary bypass and hypothermic (25℃) circulatory arrest method (CPBA). In all cases, the primary tumor and thrombi were completely removed. Ten out of the 17 patients who underwent operative removal of the tumor and tumor thrombi by various methods were survived (58.8%). The maximal long term survival was 163 months. The operation time and transfusion requirement were slightly higher for CPBA than for SVCI, but there was no statistically significant difference between the two methods. The results of both methods for surgical resection of renal carcioma extending into the inferior vena cava were satisfactory. We conclude that CPBA facilitates the excision of renal carcinoma with a higher level of tumor thrombi in the inferior vena cava (Novick’s classification levels 3 and 4).

Aggressive resection can be performed with acceptable morbidity and mortality rates in these patients.

For the purpose of a short hospital stay, a new stripping procedure was designed and performed on 51 limbs in 34 patients. It is expected to avoid postoperative hematoma and neuralgia in the thigh which sometimes occured in the standard procedure. Our procedure includes high ligation, selective stripping from Dodd’s to Boyd’s perforator at the knee level and crural varicose avulsion. Many selective stripping procedures in the thigh have already reported. However, our method is less invasive because it could reduce the rate of complications described above. The average follow-up period of these 34 patients is 2.7 months (range 1～4 months) and no recurrence or disadvantageous effect were found during these periods. These early results suggest that our new stripping method is useful for the treatment of a short hospital stay patient with varicose vein. However, we consider a long term follow-up also needs to make a final decision on its value.

Venous aneurysms (VAs) are rare and known to cause pulmonary embolism, leading to sudden death. Seven patients with VAs were surgically treated in our institution between 1991 and 1998.

Patients included 5 female and 2 male, with mean age of 53.3 years (range 11 to 77 years).

There were two patients with external jugular VAs, two patients with dorsal pedic VAs, two patients with lesser saphenous VAs, and one patient with cephalic VA.

Each patient initially noticed a painless mass of the lesion, and was diagnosed as VAs by angiography, ultrasonography, and/or CT scan. Four VAs were saccular type aneurysms and three were fusiform type aneurysms.

In all cases, surgical treatment was performed. Although in our two cases the VAs were located in the peripheral vein (lesser saphenous vein, cephalic vein), we successfully performed an aneurysmal excision with venous reconstruction using by end-to-end anastomosis. In four patients, the operations were performed by day surgery using local anesthesia.

In all cases, histologic examination of the venous wall of the aneurysms revealed a flattended layer of endothelial cells, and the other side of the vein wall was composed primarily of fibrous connective tissues, fragmented elastic fibers, and few smooth muscle cells, however, no infiltrations of inflammatory cells were seen. Partial intimal hyperplasia was observed in 3 cases, and intraaneurysmal thrombus was observed in 3 cases. All patients were doing well after a longest 7-year follow-up.

Early surgical treatment is required for VAs of the popliteal vein, the iliac vein, the superior vena cava and the portal vein, because of the risks such as pulmonary emboli and rupture. However, the natural history of the peripheral VA may run the gamut from stable, painless subcutaneous masses to painful lesions producing distal embolization, no serious complications have resulted from them. Nevertheless, early surgical treatment for the peripheral VA may be done, because of the progressive symptoms such as pain and/or discomfort and of the tendency to form the intraaneurysmal thrombus.

Tenascin is an extracellular matrix glycoprotein having elasticity associated with embryonic morphogenesis and tissue remodeling. The expression of tenascin was investigated immunohisto-chemically in normal human veins (internal jugular, pulmonary, portal, great saphenous vein, and inferior vena cava) and veins under pathologic conditions (varicose saphenous vein and portal vein with liver cirrhosis). Tenascin expression was detected from newborn or young age except for portal veins, and was increased until middle age. In old age groups, tenascin expression in the portal vein was decreased, but such alterations in other veins were not prominent.

Tenascin expression was mainly present around smooth muscle cells in all examined venous walls. Among then, strong staining was detected in the walls of great saphenous and varicose vein. These results indicate that tenascin is associated with maintenance and remodeling of the venous wall and also may function as a lubricator for the characteristic distensibility of the veins, as well as a defense against invaded blood substances through the venous wall.

Perineal varicose veins are contiguous to vulval varicose veins which are very rare accounting for about 1～7% of peripheral varices. Most of them are not indicated for surgery, because they appear during pregnancy and reduce after delivery. A thirty-nine year-old woman was admitted to our hospital because of perineal varix. The perineal varix and varices of the bilateral lower limbs appeared during the second pregnancy. Although the bilateral varices of the lower limbs disappeared rapidly after caesarian section, the perineal varix remained with the symptoms of pain and discomfort. The perineal varix was 2cm in diameter. Venography revealed dilatation of the vaginal venous plexus and the uterine venous plexus. Contrast medium was drained to the internal pudendal vein, obturator vein and external pudendal vein. Ligation of the drainage veins and resection of the perineal varix were performed. The symptoms disappeared postoperatively.

We mentioned the indication and percutaneous technique for placement of the inferior vena cava filter, and analyzed the early and late results of this method. A placement of the inferior vena cava filter is very effective and safe procedure to prevent recurrent and massive pulmonary thromboembolism due to deep vein thrombosis. As inferior vena cava filter, Titanium Greenfieid filter, Stainless steel Greenfieid filter, Simon nitinol filter, Vena Tech filter and Bird’s nest filter are available in Japan. Antheor temporary vena cava filter is also used nowadays.