Distal splenorenal shunt is known as not so easy to perform, because of the procedures to divide many pancreatic tributaries. Then, we modified this operative technique by using an autologous external iliac vein graft. The graft was retroperitoneally retrieved without any reconstruction and the internal iliac vein was preserved to maintain co-lateral venous flow. The graft was interpositioned between the splenic and the left renal vein instead of end-to-side anastomosis of the splenic and left renal vein as the conventional method.

The procedure was applied in 3 patients with esophagogastric varices. Each graft was 4～5 cm in length and there was no difference in diameter between the splenic vein and the graft. The splenic vein was exposed in only 2 cm in dividing 3 or 4 pancreatic branches. In comparison with the conventional method, there was no statistical difference concerning the intraoperative blood loss, operative time and hospital stay after surgery. Postoperative evaluations revealed the good patency of the grafts and the improvement of the varices in all three patients. The swelling of the legs in which the grafts were retrieved was hardly appeared.

In conclusion, the autologous iliac vein graft is useful for simplifying the operative procedure of distal splenorenal shunt.

The success of sclerotherapy for the treatment of leg varicose veins is believed to depend on uninterrupted compression of the veins at the sites of injection. In clinical practice, the duration and the amount of pressure are very important. However, there have been no randomized studies regarding the duration of compression or compression pressure. Proper randomized controlled trials are neccessary, in consideration of size, length and site of the varicose veins, extent of reflux, and sclerosing agents and techniques. The extent of the variation in pressure during posture changes and exercise is determined to a considerable extent by the bandaging materials. Short-stretch bandages produce a higher working pressure and a larger pressure difference between muscle contraction and relaxation during exercise compared with elastic materials. However, interface pressure under elastic materials during posture changes and exercise is similar to that under short-stretch bandages when compression pads are used, and pads effectively augment the muscle pump. In clinical practice, compression materials should be selected in consideration of their merits and demerits.

The technique using air-plethysmography presented by Christopoulos et al. has been used widely to assess the lower extremity venous function. Many subjects, however, could not stand with the weight on the opposite leg with ease. We tried therefore to put a box under opposite leg on standing position. The aim of this study was to compare our technique, using a box, with the technique of Christopoulos in the assessment of venous function using air-plethysmography.

Twenty normal limbs of 12 healthy volunteers were studied by our technique and by the technique of Christopoulos using air-plethysmography. Venous volume (VV), venous filling index, ejection fraction and residual volume fraction were 94.0±27.7ml, 0.92±0.43ml/sec., 53.2±14.3%, 28.8±14.9% by the technique of Christopoulos, respectively, and 84.2±22.6ml, 1.08±0.70ml/sec., 50.4±16.4%, 33.3±21.0% by our technique, respectively. VV measured by our technique was significantly lower than that by the technique of Christopoulos (p=0.014). There were, however, close correlations of the parameters between our technique and technique of Christopoulos.

The results suggest that, our technique is useful to assess the lower extremity venous function with ease.

We studied 42 patients (23 males and 19 females with mean age of 45.8 and 57.9 years) with intractable leg ulcers due to primary varicose veins treated over the past 20 years (between 1980 and 1999) at our department. The mean duration from appearance of varicose veins and leg ulcer to operation in males and females were 10.6 and 12.7 years and 14.4 and 8.8 months, respectively. Among males leg ulcer tended to occur in the youth rather than in the elderly at multiple lesions. Most patients with leg ulcers worked in restaurants and retail stores regardless of gender. Solitary leg ulcers were seen in 32 cases and multiple ulcers in 10 (7 males and 3 females).

Small ulcers less than 2 cm in diameter were completely cured by stripping of great saphenous vein and excision of varices. As for ulcers more than 2 cm in diameter, we performed complete stripping and ligation of veins around ulcers. In addition, we ligated extrafascial or subfascial perforating branches in cases with incompetent valve. Furthermore, middle layer skin grafting was performed in nine cases, including recurrent ulcers and ulcers larger than 10 cm². All grafts completely adhered and no recurrences have occurred. Eight cases with recurrent ulcer were not diagnosed leg ulcer resulting from incompetent valves. Therefore it is important to detect an incompetent valve and ligate it to prevent the recurrence of leg ulcer.

Thus intractable leg ulcer could be healed completely by various operative techniques within a short period.

We evaluated the efficacy of the intermittent brain compression for reducing the brain injury under the cerebral venous circulatory disturbances. Fifteen Wistar male rats were used. The brain surface was compressed at the frontal cortex near the dorsal vein by a compressed bar, and the changes of sequential local cerebral blood flow (1-CBF) were measured at the compressive area before and for 60 minutes after the compression. Rats were assigned to one of the following three experimental groups; (1) Sham-operated group (n=5), (2) continuous compression (CC) under vein occlusion (n=5), (3) intermittent constant exposure (ICE) under vein occlusion (n=5). After 24 hours, the rats were submitted to perfusion fixation and examined histologically. Just after the release from the compression, 1-CBF decreased significantly in the both CC and ICE groups (vs. Sham-operated group (p<0.001). After the release, however, the recovery was observed in the ICE group, but not in the CC groups (p<0.05). Moreover, damaged area in the ICE group was smaller than in the CC group (p=0.002).

These results indicate that the intermittent brain compression can reduce the brain retraction injury even under cerebral venous circulatory disturbances.

Muscle cramps in patients with varicose veins occur more frequently in comparison with those from the general population. In this study, 421 patients with primary variocse veins were analyzed by using a questionnaire and muscle pump plethysmography in order to investigate the risk factors for the occurrence of muscle cramps in patients with varicose veins. In this analysis, 421 patients whose muscle cramps occured within 1 year prior to examination and 114 patients without muscle cramps were compared. The incidence of muscle cramps was significantly higher in patients with saphenous vein incompetence than in patients with non-saphenous varicosities. Furthermore, the patients with skin changes such as lipodermatosclerosis, pigmentation, eczema or ulcer showed a significantly higher incidence of muscle cramps than the patients without skin changes. The half-refilling time after five active dorsiflexions of the feet in photoplethysmography was significantly shorter in patients with muscle cramps than patients without muscle cramps. These findings indicate that muscle cramps occur more frequently in patients with severer venous insufficiency. In patients aged 50 or more, the prolonged standing occupation was also a risk factor for the occurrence of muscle cramps. After treatments for varicose veins, 84 of 158 patients, 53%, reported complete relief or marked decrease in the frequency of muscle cramps. However, the relief of muscle cramps was not related to age, sex, obesity, type of varicose veins, occupation, characteristics of muscle cramps or the degree of venous reflux before treatments.

By left gastric venous caval shunt (LGCS) using a ringed expanded polytetrafluoroethylene (ePTFE) prosthetic graft, we have successfully treated a patients who had been suffering from esophageal varices due to idiopathic portal hypertension. Follow-up endoscopic examination of the esophagus and CT scan were performed postoperatively, which showed marked reduction in the size of the varices. Although LGCS has been recognized as to be technically difficult up to the present, this procedure may be safely performed by the use of ringed vascular graft, with a satisfactory result.

Leiomyosarcoma of inferior vena cava is rare tumor reported only 40 oases in Japanese literature.

A 44-year-old woman was admitted to the hospital because of the edema of bilateral lower extremities and proteinuria. CT and magnetic resonance imaging revealed a tumor in the inferior vena cava extending into the left renal vein. Laparotomy revealed a dilated inferior vena cava containing elastic hard mass, surface of which was smooth and not adherent to the surrounding structures. Tumor occupied the inferior vena cava from just below the level of hepatic vein to just below the renal veins and the left renal vein. Inferior vena cava was completely obstructed. The tumor in the inferior vena cava and left renal vein were completely resected by phlebotomy and concomitant left nephrectomy. Histologic diagnosis was leiomyosarcoma, however its origin could not be clarified. CT scan performed 17 days after surgery revealed no residual mass in the inferior vena cava. She is asymptomatic and doing well.

The temporary inferior vena cava (IVC) filter is effective for protection against pulmonary embolism (PE) associated with acute proximal deep vein thrombosis in patients contraindicated for anticoagulant therapy or who have undergone thrombolytic therapy or thrombectomy. We report a rare filter complication in man who suffered from IVC thrombosis due to renal transitional cell carcinoma. A 47-year-old man was admitted to our hospital with an abdominal mass and edema of both lower extremities. CT and MRI imaging revealed a tumor in the left kidney with extension into the renal vein and IVC, resulting in secondary thrombi in the infrarenal IVC. A radical nephrectomy was planned. Two days before surgery, a temporary IVC filter was implanted via the right internal jugular vein into the suprarenal IVC for protection against massive PE during surgery. That night, the patient felt a dull pain in the upper abdomen and coughed vigorously for about 30 minutes. Abdominal X-ray revealed no migration of the filter: however, a deformity of one of the six limbs was observed, which due to accidental insertion of the limb into the right hepatic vein. When the filter was retrieved carefully under fluoroscopic observation after surgery, one of the limbs was found to be detached from the filter and migrated into the left pulmonary artery. It was recovered immediately by successful catheter manipulation and without complication. It appeared that the deformed limb had been continuously stressed by the upward and downward movement of the filter upon respiration and finally separated form its attachments. Breakage of the temporary IVC filter is a rare complication, but we should be aware of such possibility when implanting into the suprarenal IVC.

Although the method of treatment for acute deep vein thrombosis (DVT) are surgical thrombectomy and pharmacological thrombolysis, and also the actural effectiveness of venous thrombectomy has still now been controversial, technically and radiologically controlled thrombectomy has been practised for approximately as long as thrombolysis. However, the main clinical objectives for DVT treatment are prevention of fatal pulmonary embolism, reduction of the severity of the post-thrombotic syndrome reduction of the severity of the presenting symptoms and release of limb amputation. Therefore this paper demonstrated the detail of venous thrombectomy; indication and contraindication, preoperative managements, anesthesia, medical instruments, actural technological method, adjuvant arteriovenous fistulae, nticoagulation and protection against complications.