Before confirming the clinical diagnosis of deep vein thrombosis (DVT), patients complaining limb swelling sometimes require rather special, complexed, and invasive clinical tests, such as contrast and RI venography and doppler ultrasound scanning, to exclude lymphedema. The aim of this study was to evaluate the efficacy of CT in differentiating DVT from lymphedema. Ten patients with limb swelling were evaluated by CT since April 1998 to September 1999. Eight patients were confirmed as proximal type DVT by duplex scanning and two other patients were diagnosed as lymphedema. The ratio of femoral muscle swelling (affected/unaffected) was estimated by measuring the area of femoral muscles on CT (FMR ; femoral muscle ratio). All DVT patients showed FMR above 1.2, while two lymphedema patients showed FMR less than 1.1. Additionally enhanced CT only demonstrated the existence of venous thrombi in 3 of 8 DVT patients. Hereby, we conclude that plain CT with few slices is quick, safe, and easy access tool for evaluating patients with limb swelling and is a suitable test especially for primary care physicians.

Aggressive surgery combined with portal vein resection has been performed with safety and ease in pancreatobiliary cancer since the development of the catheter-bypass procedure in 1981. From 1981 to May 2000, portal vein resection was performed in 170 cases in our hospital. Operative death was observed in 10 (5.9%) of 170 cases. The main causes of the operative death were arterial thrombosis after arterial resection or intraabdominal bleeding due to anastomotic insufficiency of pancreatojejunostomy. In pancreatic cancer surgery, the resectability rate has remarkably increased by aggressive surgery combined with portal vein resection, but the postoperative prognosis is still poor. The most important factor affecting the postoperative prognosis has been the cancer-free surgical margins in the resected specimen. The indication of portal vein resection in pancreatic cancer surgery is to obtain cancer free surgical margins. The postoperative quality of life was not affected by the portal vein resection, but it becomes poor by the complete resection of nerve plexus around the superior mesenteric artery.

The significance of combined resection of inferior vena cava (IVC) in surgery for liver cancer and renal cell carcinoma (RCC) was studied. Eleven patients with liver cancer involving IVC (tumor thrombus, one patient ; difect invasion, 10), 7 patients with RCC (tumor thrombus), and one patient with adrenal cortical carcinoma (tumor thrombus) participated in this study. Macroscopic curative resection was obtained in 18 of 19 patients. The type of IVC reconstruction was simple closure in 13 cases, patch-graft repair in 1, and prosthetic graft replacement in 5. No postoperative complications associated with the IVC reconstruction occurred. However, the carcinoma recurred in all patients of liver cancer 9.2 months after operation in mean (in 90% of the patients the recurrence was in the remnant liver), and recurred in 5 of 8 patients of RCC or adrenal cortical carcinoma 12.3 months after operation (in 80% of them the recurrence was in the lung). The 1-, 3- and 5-year survival rate of the patients of RCC was 100%, 43%, and 43% respectively, while the 1- and 3-year survival rate of the patients of liver cancer was 64% and 13%. Mean hospital-free ratio was 76% in the patients of RCC and 48% in the patients of liver cancer. These results indicated the poor long-term outcome after surgery in the patients of liver cancer. The aggressive resection taken here for the malignancies involving vena cava could improve quality of life (QOL) in short-term after surgery, however could not obtain the sufficient long-term survival and QOL in the patients of liver cancer. Therefore, the indication of surgical resection for patients with liver cancer should be considered cautiously.

As of June 2000, forty-eight patients underwent insertion of vena cava filter for deep vein thrombosis. Filter placement was indicated because of wide spreaded deep vein thrombosis (DVT), acute pulmonary embolism (PE), and recurrent PE despite adequate anticoagulation. After insertion of a permanent filter, anticoagulation therapy was completed to control the underlying thrombotic process unless there was a contraindication. During placement of a temporary filter, anticoagulation therapy and/ or thrombolysis was instituted as soon as possible. In cases of pulmonary embolectomy, filters were inserted after hemodynamics became stable with embolectomy. In cases of deep vein thrombectomy and urological or gynecological operations, filters were inserted before these operations for fear of thrombus migration during these procedures. There were no complications regarding filter insertion such as hematomas, wound infections, or perioperative PE. Temporary filters were removed after the purpose was accomplished without any complications within 5 to 9 days after filter insertion. A long term follow-up study for all patients with a mean follow-up period of 26±22 months (range, 1 to 121 months) was carried out. Four patients (8.3%) had recurrent nonfetal PE after insertion of permanent filters because of insufficient anticoagulation therapy. The operative mortality rate was 8.3% (44/48), although none of the four deaths were related to filter insertion or recurrent PE. Four patients died of sepsis, lung cancer, uterus cancer, and dilated cardiomyopathy. Vena cava filter insertion is safe, and effective for prevention against fatal pulmonary thromboembolism. Temporary filter insertion would become popular in the near future.

During the past six years, 17 limbs of 13 patients with deep venous insufficiency reaching below knee underwent deep vein reconstruction in our hospital. Among them, 7 limbs in 4 patients underwent Kistner’s external repair (group-A) and the other 10 limbs in 9 patients purse-string suture for primary valve insufficiency (group-B). To evaluate the effectiveness for two external valvuloplastys in deep vein insufficiency, the late clinical condition after surgical treatment was retrospectively compared with two groups.

Late results of these groups were obtained by examination or telephone.

In clinical improvement, group B was superior to group A. However, compression therapy after discharge was required about 70% in both groups. On the other hand, compared with follow-up results for number of the reconstructed valve, cases reconstructed in two valves was superior to cases in single valve.

In conclusion, the technique of purse-string suture with plural vein reconstruction was very effective in improvement of clinical manifestation and venous hemodynamics.

We have performed subfascial endoscopic perforator surgery (SEPS) using the soft trocar in six patients with lower leg varicose veins which CEAP clinical classes are 4 to 6. The soft trocar is a Y-shaped polyvinyl chloride bag equipped with two ports at one end and a flexible ring at the opposite end. The ring is inserted beneath the skin, and this prevents gas leakage during carbon dioxide insufflation. SEPS is performed through a 2cm incision below the knee. The subcutaneous fascia is exposed and incised. The subfascial plane is then dissected using the VasoView™ balloon dissection cannula (Origin Medsystems, Inc., Menlo Park, CA) with an endoscope and expanded by the balloon. The soft trocar is attached to the incision, and the subfascial cavity is inflated with carbon dioxide gas to 12mmHg pressure. The perforators are clearly identified and divided using UltraShears™ (Autosuture, USSC, Norwalk, CT), which are inserted with an endoscope passed through the second port of the soft trocar. After dividing all the identified perforators, the great saphenous vein is stripped from the incision below the knee in the usual manner. Results: A mean of 4.6 perforators were divided, the mean operating time was 161 min. There were no wound complications. Conclusions: The soft trocar enabled both an endoscope and a surgical instrument to access the tissue space simultaneously through a single incision. It is concluded that both viewing and manipulation during endoscopic subcutaneous surgery are greatly improved using this soft trocar.

The obstructive venous lesions in patients in arterio-venous access were studied retrospectively. From April 1996 to March 2000, 10 reconstructions for the obstructive venous lesions were performed in 5 patients with functioning arterio-venous hemodialysis shunt. Four were men and one was woman, age ranging from 62 to 78 (average 68.2) years old. The complaints were low flow of the shunt access in 2 patients and arm edema with pulsatile pain in 3 patients. The diseased veins were 3 cephalic veins of forearm, 3 cephalic veins of upperarm, 3 subclavian veins and 1 innominate vein. Three veno-venous anastomoses, 1 interposing, 1 patch-angioplasty, 3 balloon angioplasty and 2 bypasses were performed. They improved after the procedures. The evaluation of the outflow vein tract is important before arterio-venous accessing, especially for the patients who had the history of cannulation of the blood access catheter. The extraanatomical bypass with prosthesis can be of successful procedure for the obstruction of subclavian or innominate vein.

We evaluated changes of regional cerebral venous flow (rCBF) and cerebfal blood volume (rCBV) in chronic venous hypertension model in rat. Venous hypertension was induced by an end-to-end anastomosis between the right carotid artery and the right external jugular vein. Local CBF (1CBF) and 1CBV at 25 locations were assessed by a modern laser Doppler “scanning” technique at 4 times; before and after the anastomosis, 2 weeks after, and after the clip of the fistula. The animals were classified two groups; A group (n=6) (the carotid artery occlusion only) and B group (n=10). In the A group and the left hemisphere of the B group, both of rCBF and rCBV didn’t change. However, in the right hemisphere rCBV significantly increased 2 weeks after the bypass but recovered after clipping of the fistula (p<0.05), and rCBF significantly decreased 2 weeks after the bypass but recovered after clipping of the fistula (p<0.05).

In conclusion, the rat model of carotid-jugular arteriovenous fistula is clinically relevant and useful for studing the pathophysiology of chronic venous hypertension. Venus ischemia is a reversible condition which can be improved by appropriate early-stage treatment.

In this study, interface pressure under two different kinds of compression bandages was compared between different sites of the leg. In 20 healthy volunteers, the pressure beneath short-stretch bandages with a maximal tension of 70% and elastic bandages with a maximal tension of 170% was determined by using an Air Pack Type Analyser at the ankle, calf and thigh during lying and standing. With the elastic bandages, a graduated pressure drop in a proximal direction was observed in both supine position and standing. With the short-stretch bandages, while the same pressure gradient was observed during standing, pressure at the ankle was significantly lower than that at the calf in the supine position. When the bandages were applied on a wooden leg, the same results were observed. These results indicate that it is more difficult to gauge the tension in the short-stretch bandages than the elastic bandages when they are applied at the ankle region The interface pressure was significantly lower at the posterior region of the medial malleolus than at the 2cm above site of the medial malleolus. Furthermore, the pressure at the medial site was significantly lower than that at the pretibial zone. These findings indicate that the irregular shape of the ankle influences the interface pressure. The use of compression pads might be of value when sufficient pressure is needed at these regions.

The new surgical technique of groin-to-knee invagination stripping was introduced in this article. The stripper is specially designed to simplify the surgical technique and provide minimally invasive procedure. The stripper is equipped in the middle of the wire with two metalic fittings that enclose the “vein ligation zone”. The proximal end of the saphenous vein is tied to the ligation zone followed by being invaginated within itself and the vein is removed through the distal incision. When the vein is torn during the stripping, the distal end of the vein is tied to the ligation zone and the remained vein is removed from the proximal incision. The conventional Babcock’s method can be used as a final choice to remove the residual vein even if the invagination stripping fails to remove the entire vein because of tearing. A modified NLA anesthesia of midazolam and pethidine hydrochloride is suitable for the short stay surgery of invagination stripping. It is supplemented with tumescent local anesthesia (TLA) of 0.3% lidocaine solution along the saphenous trunk and local infiltration of 1% mepivacaine at the site of the skin incision. The TLA also offers long hours of pain relief after the operation. The TLA (with epinephine) infiltration before the stripping and 4̊C normal saline (with epinephrine) injection into the subcutatnous tunnel after stripping are effective in controlling postoperative bleeding. The invagination stripping with the newly designed stripper and the anesthesia descibed above are recommended to surgeons as a new simplified and reliable procedure.