We have performed subfascial endoscopic perforator vein surgery(SEPS)for 36 patients, 49 limbs with primary varicose vein in the great saphenous vein since September 1997.

Incompetent perforators were examined by ascending phlebography and duplex scanning. In performing SEPS, we have developed our own system aiming at minimally invasive surgery. After exsanguinating with Esmarch tourniquet and blocking circulation with a pneumatic tourniquet 300mmHg, SEPS was performed using a 2mm endoscope and 1.5 mm electric cautery by 2-point puncture on the medial aspect of the lower leg in the first half of the cases, and using KTP Laser by a system whereby the procedure can be done coaxially with a 3 mm endoscope by 1-point puncture on the medial aspect of the lower leg in the second half of the cases. The visual field was secured by carbon dioxide gas insufflation.

The success rate of SEPS was 91.9% for the first half and 100%for the second half. No complication occurred in any cases. Symptoms disappeared or improved markedly. No recurrence of varix has been found up to the present. Our SEPS is minimally invasive and capable of treating incompetent perforators for sure and satisfying patients from the cosmetic viewpoint.

Particularly, division by one point puncture using KTP Laser enabled us to perform the surgery easily in a short time.

Thirty-nine patients with suspected deep venous thrombosis underwent 2D-TOF MR venography (MRV) using 1.5 T super-conducting MR systems with body coils. Scan parameters were as follows: SPGR (TR=35, TE=6.7ms, FA=45 deg) or FLASH (TR=30, TE=9ms, FA=45 deg). MIP post processing was performed to yield angiographic images. In 31 cases, stenoses or occlusions of the deep veins of the lower extremities were demonstrated on MRV. In addition, dilated collateral vessels or great saphenous veins were also noticed. In the other 8 cases, symptoms were soon improved and the diagnosis of DVT were not ensured. In the pelvis and thigh, MRV was superior to conventional venography in demonstrating deep veins and also stenoses or occlusions of deep veins. In 2 cases, follow-up MRV examinations after conservative therapy with a relief of symptoms showed marked improvement of stenosis. However, MRV sometimes failed to delineate small vessels in the lower legs. MRV with tourniquet or leg-warming might improve demonstraion of the lower leg veins. But, even with these techniques, demonstration of lower leg veins was not good enough. Therefore, contrast-enhanced MRV of the lower legs combined with 2D-TOF MRV from the pelvis through knee is recommended. One of great advantages of contrast-enhanced MRV is the possibility of direct imaging of thrombus in the lumen on non-enhanced original source images.

MRV is a non or less-invasive modality in demonstrating deep venous thrombosis. It should be performed before conventional venography and would be more widely used in the evaluation of the deep venous thrombosis.

In patients with lower limb varices complicated deep venous reflux, we evaluated the characteristics of deep venous reflux that disappeared after the treatment of varices alone.

When 335 limbs with the large saphenous vein type varices were examined by color duplex scanning, complication by deep venous reflux was observed in 61 segments (4.6%) of 37 limbs (11%). According to the CEAP classification, these cases of deep venous reflux were classified into Groups C2-4, and the frequency of complication by Group C4 deep venous reflux was higher than that by Group C2+3 deep venous reflux; 11/56 limbs (20%) vs. 26/279 limbs (9%), p=0.03. Moreover, the range of Group C4 deep venous reflux was larger than that of Group C2+3 deep venous reflux (2.7ア1.3 segments vs. 1.4ア0.5 segments, p=0.04). After sclerotherapy with high ligation, deep venous reflux in 23 segments (38%) of 14 limbs (38%) disappeared. Common femoral venous reflux and single segmental reflux tended to disappear, whereas superficial femoral venous reflux, popliteal venous reflux, and multi-segmental venous reflux tended to remain. The disappearance of deep venous reflux was not correlated to photoplethysmographic (PPG) findings obtained by preoperative below knee tourniquet method. However, deep venous reflux type PPG findings were persistently observed in patients with multi-segmental deep venous reflux. Therefore, preoperative examinations of deep venous reflux is important in patients with lower limb varices complicated by deep venous reflux type PPG findings.

Aim. Varicose veins have been treated with duplex scan oriented venous ligation in our outpatient varicose vein clinic. We here report this method and evaluate the result of this treatment for primary varicose veins accompanied by stasis leg ulcer. Subjects. Between January 1995 and December 1999, 2,514 limbs of 1982 patients with varicose veins were treated by duplex scan oriented venous ligation. Thirty-six of these patients (21 males (58%), mean age: 53ア13 years) had primary varicose veins with leg ulcer and had long duration of illness ranged from 1 to 25 years (11ア9 years). Method. Duplex scan was performed to examine regurgitation and varicose changes in the greater saphenous vein, lesser saphenous vein, and incompetent perforators. The saphenous vein and incompetent perforators were ligated in accordance with the results of the duplex scan examination. Results. Great saphenous type varicose veins were seen in 34 extremities (89%) and incompetent perforators (mean 2.7ア2.6) were detected in all the extremities but four. Stasis ulcers in all the extremities healed postopratively. In the 34 legs followed up after operation, healing was maintained over a mean period of 20 months in all but two. Conclusion. Venous ulcers can be cured and mid-term healing can be achieved in 91% of legs with duplex scan oriented venous ligation. We conclude that duplex scan oriented venous ligation is a minimally invasive and effective treatment for primary varicose vein with stasis leg ulcer.

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

Thirty-four primary varicose limbs of 21 patients were studied by our technique and by Christopoulosユ technique using air plethysmography. Venous volume (VV), venous filling index, ejection fraction and residual volume fraction were 147.4ア39.1 ml, 5.67ア4.05 ml/sec, 42.2ア15.4% and 36.1ア16.0% by Christopoulosユtechnique, and 126.0ア37.8 ml, 5.71ア4.18 ml/sec, 37.8ア12.7% and 40.0ア21.4% by our technique, respectively. VV measured by our technique was significantly lower than Christopoulosユtechnique measurement (p<0.001). A close correlation of the parameters between our technique and that of Christopoulos existed except EF (r=0.383).

The results suggest that our technique is easier for patients than the conventional method.

Varicose vein in 416 limbs of 270 patients underwent surgical treatment or sclerotherapy from July 1998 to March 2000. Regardless of varicose types, incompetent perforators were ligated. For saphenous type (SA), a high ligation of the saphenous vein followed by sclerotherapy was performed except for cases with varicoid saphenous vein or saphenous vein with varices of over 1 cm in the diameter and significant reflux of saphenofemoral junction, which underwent stripping. One hundred ninty-six of 210 limbs in which one year had passed since first treatment, including 6 web type (WE), 34 reticular type (RE), 35 segmental type (SE), 121 saphenous type (SA) could be examined. Recurrences were detected in 7 limbs (4%), 1 (17%) in WE, 4 (12%) in RE including 3 of sclerotherapy only and 1 of sclerotherapy with ligation of the perforator, 1 (3%) of sclerotherapy with ligation of perforator in SE, 1 (1%) of sclerotherapy with high and perforator ligations in SA, which forms 3% of SA of sclerotherapy with high and perforator ligations. These good short-term results suggest that treatment method could be fairly selected depending on the types of varicose veins.

This paper describes the experiments of cerebral venous circulation disorders (CVCDs) using rat photochemical cortical vein occlusion and information. Male Wistar rats were used. Cortical veins occlusion was induced by photochemical activation under general anesthesia. We examined changes of the cerebral venous flow pattern by fluorescence angiography, regional cerebral blood flow (rCBF) measured at 25 locations assessed by laser Doppler メscanningモ technique and histology 24 hours after surgery. We performed the following experiments; experiment-1: the effect of brain compression under cortical vein occlusion, experiment-2: the effect of age on cortical vein occlusion, experiment-3: CBF autoregulation in asymptomatic cortical vein occlusion. As results, (experiment-1): We demonstrated that, compared with vein occlusion or brain compression alone, the accumulated episode caused severe ischemia and increased the vulnerability of the tissue damage in the rat brain.(experiment-2): The results demonstrated an age-related increase in rate and size of venous infarction following vein occlusion, suggesting that the greater vulnerability to CVCDs in the aged brain might be attributed to early and extensive hypoperfusion of circumscribed brain areas drained by the occluded vein. (experiment-3): Autoregulatory capacity of CBF is influenced subsequent to vein occlusion, leaving surviving brain tissue partly susceptible to blood pressure change.

In conclusions, CVCDs manifest itself via additional pathways, i.e. brain compression, blood pressure decrease, and in old patients, even under conditions where the vein occlusion itself does not cause brain damage.

We conducted a present study to clarify the influence of endothelium derived relaxing factor (EDRF) on human venous vasculature. Forearm volume and transmural venous pressure are continuously monitored using water plethysmogram method. With stepwise increase in forearm transmural venous pressure, pressure-volume curve was compared between before and after l-NMMA infusion into forearm. Forearm venous distensibility was significantly decreased. On the other hand, the rate of continuous increase in forearm volume during constant transmural venous, which represents the rate of extravasation from the forearm vasculature, was not significantly influenced by 1-NMMA infusion. Thus, the continuous effect of EDRF on the relaxation is suggested, while there was no evidence for the effect of EDRF on transmural exudation in human forearm.

The Simon nitinol inferior vena cava filter was placed successfully and rapidly through left femoral vein in sixty-six -old man with right lower free floating deep vein thrombosis. The indication for filter insertion was mainly in the setting of prophylaxis for pulmonary embolism. The Simon nitinol inferior vena cava filter employs a thermal memory alloy allowing it to be introduced in a straight form via a 9Fr sheath when cool but transforming instantly into its predetermined filter shape at body temperature. It is notable that SNF can be placed via the antecubital vein and subclavian vein including femoral and internal jugular vein. The SNF is the only filter currently usable by an antecubital approach. Tilting of the dome of the SNF does not alter its filter capacity unlike the Greenfield filter is also notable. Recurrent pulmonary embolism was documented in very low rate and radiologic follow-up showed no filter migration. We should pay attention to the fact that penetration of IVC wall by hook-like struts of the SNF on literature, but no clinical symptoms was reported. Asymptomatic cases and rare IVC occlusion was reported. Anticoagulation after filter insertion does not seem to be routinely indicated.

The SNF is one of a new range IVC filter and it is encouraging to use preferentially. In the future, more careful attention needed to be studied for a better evaluation of late complications.