Objective: We studied the clinical usefulness of catheter fragmentation and aspiration therapy in patients with acute pulmonary embolism (APE).

Subjects and Methods : The subjects were 12 patients who underwent thrombolytic therapy with urokinase or t—PA (group T) and 9 patients who underwent catheter aspiration therapy using a PTCA guide catheter (group C) from 25 patients. In group T, urokinase (240,000 to 960,000 units/day) or t—PA (12 million units/day) was administered intravenously. In group C, the pulmonary artery pressure was first measured using a Swan-Ganz catheter via the jugular vein or the femoral vein. Then a PTCA guide catheter was advanced into the pulmonary artery, and disruption of thrombus was performed repeatedly with a Radifocus wire (TERUMO) followed by manual aspiration. Subsequent treatment involved intravenous infusion of heparin (10,000 to 15,000 units/day) and urokinase (240,000 to 480,000 units/day).

Results: (1) Partial revascularization was achieved in most of all patients from both groups. (2) In group T, 6 patients died within one month of respiratory failure, re-embolization, and hemorrhagic complications. (3) In group C, 1 patient died of hemorrhagic shock. (4) In group C, the pulmonary artery systolic pressure (PAs) was significantly reduced from 47. 4 mmHg to 27.6 mmHg (p<0.01).

Discussion: Catheter treatment of APE associated with acute circulatory failure such as shock can rapidly improve the hemodynamics. Thrombolysis is an effective treatment, but bleeding problems are common and caution is required concerning its use.

Conclusion: Catheter thrombolytic aspiration therapy is effective for APE and minimally invasive, and should be the treatment of first choice.

The permanent inferior vena cava filter (IVCF) is effective for protection against pulmonary embolism (PE) associated with deep vein thrombosis (DVT). Nevertheless, permanent IVCF causes some complications. These issues have resulted in considerable interest in the development and use of new categories of device: temporary IVCF. Wer eport the procedure of temporary IVCF applied in 8 patients with DVT. Insertion and implantation of temporary IVCF was easy, and PE did not cause during the implantation in all of the patients, trapped thrombi within the temporary IVCF was seen in one patient, and one patient have subcutaneous bleeding at puncture site. In comparison with the permanent IVCF, temporary IVCF was equally effective in clot capturing. The concept of temporary IVCF is reasonable in special high-risk situations at systemic thrombolytic therapy, or during perioperative period. Definite indications, detailed study for maximum implantation time, and appropriate devices for each clinical situation are required for the development of temporary IVCF.

Hypercirculatory state in the splanchnic organs is associated with chronic portal hypertension as human liver cirrhosis. Vasoactive substances such as nitric oxide (NO), prostaglandins, endothelium-derived hyperpolarizing factor (EDHF) are the candidates which mediate the hypercirculatory state. In stomach, dilatation of the mucosal capillaries and submucosal vessels (human), and increase (rat) or increase/decrease (human) in the blood flow have been reported. Hypocirculatory state in the stomach is associated with acute portal hypertension. Decrease of the gastric blood flow with mucosal congestion and contriction of the submucosal arterioles and venules is seen. NO and endothelin (ET) produced locally are involved in the change of the arterioles and the predominant function of ET constricts the arterioles.

We performed pulmonary thromboendarterectomy (PTE) by median sternotomy under deep hypothermia and circulatory arrest in 36 cases of chronic pulmonary thromboembolism (CPTE) associated with pulmonary hypertension during the past 7 years. The patients were 14 males and 22 females aged 21～71 years (mean 50 years). The preoperative condition was NYHA class III in 24 and class IV in 12. Surgery was performed on emergent base in 4 patients. Hypoxemia, marked pulmonary hypertension (mean pulmonary artery pressure 46±9mmHg), and low cardiac output were observed in all patients. Deep vein thrombosis was established in 23 patients. Deep hypothermia (16℃) was induced using cardiopulmonary bypass. PTE was performed as much as possible in the bilateral lungs under intermittent circulatory arrest. 3 patients died due to cardiopulmonary failure and one patient had brain damage in emergent 4 patients. In elective 32 cases, PTE was insufficient in 1 patient with an obstructive lesion in the distal pulmonary artery, and the patient died due to postoperative cardiac failure and respiratory failure after 4 days. One patient died of tracheal bleeding. In the remaining 30 patients, no postoperative reperfusion injury was observed, the arterial blood oxygen concentration improved, and the mean pulmonary arterial pressure decreased to 18±6mmHg. The cardiac output also increased, and NYHA class was improved to I in 15 and II in 15. Concerning the long-term results, marked improvements in the respiratory-cardiac condition were observed and quality of life was improved remarkably in all 30 patients.

We reviewed 15 cases, which underwent pulmonary thromboembolectomy with the aid of cardiopulmonary bypass (CPB) for acute massive pulmonary thromboembolism between January 1988 and May 2000. According to the operative mortality (26.7 %), these patients were divided into two groups: group I (n=11, 4m ales, age: 61±13years), survived; group II (n=4, 1 male, age: 61±26years), died. The age, sex distribution, rate of preoperative shock, and duration of CPB were not significantly different between the two groups. In group II, significantly more patients underwent cardiac massage preoperatively than in group I (75% vs. 0%, p<0.01). Three patients died of low cardiac output syndrome and one patient died of multi—organ failure. The mean follow-up of the 11 survivors was 53 months (range: 5-130 months). One patient died of malignant lymphoma 130 months postoperatively. In the other 10 patients, nine were in NYHA functional class I and one was in class II. Asymptomatic pulmonary infarction occurred in one patient 11 months postoperatively. The operative mortality was low in cases without preoperative cardiac massage and the late results were satisfactory. These results suggest that pulmonary thromboembolectomy with the aid of CPB is a useful treatment for acute massive pulmonary thromboembolism.

In 24 patients with deep vein thrombosis treated fibrinolytic and anticoagulant therapy, we evaluated late changes of venous function and recanalization. Recanalization of deep vein thrombosis and venous function were assessed, respectively, by duplex scanning and by Ga-In straingauge plethysmography. In 12 limbs (41%) thrombus was disappeared in the late stage, and venous function became normalized in 5 of the 12 limbs. In the other 7 limbs, despite disappearance of the thrombus, stagnation of venous return remained. Recurrence of deep vein thrombosis was observed in 7 of all the 24 patients, and 5 of all the patients with reccurence had received oral anti-platelet agents. It was suggested that the efficacy of oral administration of anti-platelet agents could not be expected during the period when the possibility of recurrence was high, and that since recurrence occurred before thrombin-antithrombin III complex became normalized, anticoagulant therapy using warfarin was necessary before the complex became normalized.

We prospectively studied 103 patients with venous thrombosis of the extremities (61 patients with deep vein thrombosis (DVT), 42 patients with thrombophlebitis of varicose veins) to detect the causes or predisposing factors. Twenty—three patients with DVT had various diseases. Half of these patients had cancer. Coagulopathy or uterine myoma were found in five of the 15 patients who had a predisposing episode before they developed DVT. Sixteen of the 20 patients who had no known disease or predisposing episode were found to have malignant tumors, benign tumors, or coagulopathy. In conclusion, most patients (96.7%) with DVT had a causative disease or predisposing factor. Ten of the 42 patients with thrombophlebitis of their varicose veins also had coagulopathy or another predisposing disease. It is important to remember the possibility of a tumor (malignant or benign) or coagulopathy when treating venous thrombosis, especially idiopathic deep venous thrombosis.

Retroperitoneal fibrosis with ilio-caval tract obstruction is rare. During a 13-year period (1987 ～1999), we encountered four cases diagnosed as retroperitoneal fibrosis with stenosis and obstruction of the iliac vein and inferior vena cava. All the patients were male and their ages ranged from 51 to 79 years and they were all referred to our hospital with the chief complaint of swelling of the lower limbs. We treated one case by surgery and the oral administration of steroids and the other three cases were treated using the oral administration of steroids with satisfactory results. The venous lesions were stenosis of the inferior vena cava in Case 1, obstruction of the left common iliac vein in Case 2, obstruction of the inferior vena cava in Case 3 and stenosis of the right common iliac vein and inferior vena cava in Case 4. The period from the onset of the disease to inception of the steroid oral administration was 10 months, 2 months, 4 months and 12 days respectively. Fibrinolytic therapy using urokinase was administered to Case 2 and 4 prior to the diagnosis of retroperitoneal fibrosis. Diagnosis was made by CT and phlebography in all the cases. Periaortic mass lesion were revealed in all of the cases on CT scan. Phlebography showed the obstruction of the common iliac veins and inferior vena cava. All patients improved after steroid administration. Our findings suggest the importance of early diagnosis by CT and phlebography and early oral administration of steroids in cases of retroperitonoal fibrosis with ilio-caval tract obstruction.

In the recent sixty-four months from July 1994 to November 1999, we treated 428 limbs of 385 patients with primary varicose vein of the lower limb. One hundred and fourty four limbs of 112 patients were treated with standard stripping (ST group), and 284 limbs of 273 patients were treated with selective stripping (SST group). The therapeutic results of the two groups were compared. Concerning about the complications, a nerve injury was seen in sixteen of 144 patients (11.1 %) treated only with standard stripping. There was a significant difference (p<0.0001). Any other complications were not seen in both groups. The initial curative rates and the last curative rates of both groups were 100% respectively. As for the interval to the goal of treatment, a ST group needed 67.5±58.3days and a SST group needed 66.6±55.7 days, which showed no significant difference statistically. The recurrent rates were 3.5% in a ST group and 0% in a SST group, which showed a significant difference statistically. In conclusion, low-invasive selective stripping should be recommended rather than standard stripping as a surgical procedure for primary varicose vein of the lower limb.

For progressive pancreatic cancer with portal infiltration, it is thought that, if combined resection of the portal vein resulted in curability A or B, it is expected to be no significant difference in prognosis between the case used this method and the case of curability A or B without portal infiltration.

We carried out extended pancreatectomy combined with resection of the portal vein in 46 cases from October 1986 to December 1998. When evaluating these prognosis, average survival time for curability A and B was 12.3 months as compared with 5.0 months for curability C, the former one was significantly better in prognosis and one case of them had 6 years or more survival time. On the other hand, the later one had little significance of operation as compared with the national average of survival time being without operation.

If overestimation before operation was avoided and complete cure could be expected, aggressive resection alone can be used to improve prognosis of the pancreatic cancer with portal infiltration. However, it will result in little significance without complete cure. The collateral vessel may sometimes be found after cutting it during combined resection of the portal vein in particular, and it is an issue to ensure the portal blood stream after operation if changing the technique. We experienced a case that could avoid this problem by using stent in the portal vein. It is considered that curative operation is required to be performed safely and exactly using these techniques concurrently.

The frequency of asymptomatic pulmonary embolism (PE) was assessed in patients with deep vein thrombosis (DVT). A total of 19 limbs of 17 patients (1 upper limb, 18 lower limb) during this 3-year period referred to our hospitals with clinically suspected DVT. The patients underwent the following procedure: DVT was diagnosed by Ultrasound or MRI, assessment of risk factors, coagulation factor and immunological blood test, pulmonary perfusion scanning (Tc^99m-MAA). If the perfusion scan showed pulmonary perfusion deficits, the same test would be performed after 6 month. The patients whose onset was within one week received thrombolysis therapy and oral anti-coagulation therapy. Those whose onset was after one week only received oral anticoagulation or anti-platelet therapy. Seven of thirteen patients who had initially pulmonary perfusion scan were positive but asymptomatic (53.2%). However, all the patients except one who had previous venous thrombectomy 6 years ago showed no trace of pulmonary perfusion deficit after 6 months. The ratio of asymptomatic pulmonary artery embolism was high. However, the deficits of pulmonary perfusion scan improved by conservative therapy. Therefore, the indication of

temporarily IVC filter would be limited.