Current topics about the epidemiology, diagnosis, therapy, and prevention of pulmonary thromboembolism are provided in this chapter. The recent clinical characteristics of pulmonary thromboembolism has been clarified by the report from JaSPER. Magnetic resonance angiography and magnetic resonance perfusion imaging have been in advance as reliable noninvasive diagnostic techniques. The efficacy of catheter-directed pharmacomechanical thrombolysis for proximal deep vein thrombosis and the results of multicenter registry of temporary inferior vena cava filter are also described here. Finally, prevention of venous thromboembolism is crucially important. We recommend here the tentative prevention strategy for Japanese, in which mechanical methods such as elastic stockings, intermittent pneumatic compression and foot pump are emphasized.

Interruption of incompetent perforating vein (PVs) is important for varicose vein surgery. Duplex ultrasonography (US) is today widely used for the preoperative evaluation of varicose veins. In this study, we mentioned the pre and intraoperative diameter-reflux relationship of PVs in patients with varicose veins.

A total 324 calf PVs was detected in 304 legs in 175 patients with varicose veins. Diameters of competent and incompetent PVs (mm) defined by US averaged 2.45±0.17 and 3.40±0.13 at the upper calf, 2.84±0.12 and 3.68 ±0.08 at the lower calf and 2.64±0.21 and 3.40±0.15 at the posterior calf, respectively. During the operation, the incompetence of each PVs were judged by manual milking of the distal portion of the PV, and reflux was defined as spurt of blood from the stump of the disconnected PVs. Diameters of competent and incompetent PVs (mm) diagnosed by the intraoperative finding averaged 2.67±0.21 and 3.23±0.13 at upper calf, 2.85±0.12 and 3.68±0.08 at the lower calf and 2.67±0.27 and 3.27±0.14 at the posterior calf, respectively. Based on the operative findings, overall sensitivity of detecting the incompetence by US was 87.7%, and the specificity was 75.3%. Diameters of true incompetent PVs and false incompetent PVs were 3.59±0.07 mm and 3.31±0.17 mm. Diameters of true competent PVs and false competent PVs (mm) were 2.61±0.11 and 2.89±0.16, respectively.

Although the diameter of incompetent PVs is larger than that of competent PVs in both US and intraoperative finding, diameter measurement can not solely distinguish competent PVs from incompetent PVs by US. To achieve more accurate diagnosis of incompetent PVs, additional methods may be needed.

Plasma levels of hemostatic molecular markers were significantly high in patients with deep vein thrombosis (DVT), pulmonary embolism (PE), disseminated intravascular coagulation (DIC) and acute myocardial infarction. Especially, activated protein C (APC)-PC inhibitor complex had highest sensitivity and specificity for diagnosis of PE or DVT but APC-α1 antitrypsin complex had high sensitivity for only DIC. PE or DVT was caused by lupus anticoagulant (LA) in 29% of the cases, by PC deficiency in 4%, by malignant tumor in 3%, by antithrombin deficiency in 2%, by DIC in 2%, and by protein S deficiency in 1%. The measurement of hemostatic molecular markers and coagulation tests for LA is necessary for the diagnosis of PE or DVT.

Compression following sclerotherapy of varicose veins was essential to optimize the effect of the treatment. In this study, we evaluated two types of compression pads(beveled foam rubber and polyurethane foam pads)by measuring compression pressure, absorption of sweat and friction to the skin.

The compression pressure of cutaneous side of pads higher than that of elastic stocking side when the pads were applied reverse-trapezoidly. The compression pressure was remarkably increased at walking phase, as foam rubber pads were applied over the muscle. Transvers connection of reverse-trapezoid polyurethane foam pads could prevent insufficient compression, following sclerotherapy for complicated shape of varices.

The absorption of sweat of polyurethane foam pads was superior to that of foam rubber pads. The friction between rubber pads and skin was larger than that of polyurethane pads and skin.

In conclusion, polyurethane foam pads had promising feature for compression therapy, because of moderate compression pressure, absorption of sweat and small friction to the skin.

We evaluated retrospectively the clinical records of 21 cases with acute pulmonary embolism (PE) between 1985 and 2000. Eight cases were in shock status and 13 cases were not before any therapy. Nine cases of 13 had no clinical signs and symptoms at all. Sixteen cases had confirmed deep venous thrombosis (DVT) either with upper or lower limbs prior to pulmonary embolism. Three cases underwent catheter directed thrombolysis (CDT) and 2 cases had been treated with operative embolectomy under cardiopulmonary bypass, whereas 16 cases resulted in satisfactory only with the use of intravenous administration of heparin and urokinase. After PE event all patients have received oral anticoagulant therapy and particular 13 cases were treated with the insertion of inferior vena cava filter to avoid fatal recurrent PE.

Our findings can indicate that surgical therapy, including CDT and operative embolectomy is mandatory to the patients with poor cardiopulmonary status and intravenous heparin and urokinase administration is efficacious and feasible management to the patients with well preserved cardiopulmonary status.

We investigated the clinical characteristics and treatment of documented in-hospital acute pulmonary embolism (APE). Twenty-two of 71 consecutive APE patients treated in our hospital experienced in-hospital onset of APE (Group 1); onset in the remaining 49 occurred prior to admission (Group 2). Patients were treated with anticoagulation and thrombolytic therapy and temporary inferior vena cava filter implantation for secondary embolus prevention until they resumed daily activity. The mortality rate was 27.3% (6/22)in Group 1 and 16.3% (8/49) in Group 2. The 6 Group 1 patients died within 4 hours of APE onset, with 5 of the 6 dying within 1 hour of onset. Severe symptoms, such as cardiopulmonary arrest, shock, and syncope, occurred significantly more frequently in Group 1 patients (15/22, 68.2%) than in Group 2 patients (12/49, 24.5%). The 12 Group 1 patients experienced no prodromal episodes before the onset of severe symptoms. Thus, the physical condition of Group 1 patients deteriorated suddenly with the onset of APE, and most deaths in this group occurred just after APE onset. In conclusion, we strongly recommend that anticoagulation and thrombolytic therapy commence as soon as possible for patients suffering in hospital APE.

The present author reported previously that the diagnostic efficacy of computed tomography (CT) for deep vein thrombosis. This study was carried out in order to find out whether diagnostic efficacy of the combined use of CTwith plasma thrombin-antithrombin III complex (TAT) and D-Dimer (D-D). Thirty-two patients with limb swelling were selected for this study. The ratio of femoral muscle swelling (affected/unaffected) was estimated by measuring the area of femoral muscles on CT (FMR: femoral muscle area ratio). All patients who showed FMR above 1.2 were diagnosed as having DVT. There were no DVT patients who showed FMR less than 1.1 and normal plasma level of TAT and D-D. Hereby, we conclude that combined use of plain CT with plasma TAT and D-D is quick and easy access tool for evaluating patients with limb swelling.

It is well known that the skin temperature of the lower limbs in patients with varicose veins is higher than that of normal limbs. This higher temperature is considered to be due to incompetent perforating veins and/or precapillary arterio-venous shunts. However, little is known about the role of the saphenous vein in this temperature increase. The purpose of this study was to assess the influence of saphenous vein incompetence on the skin temperature of the lower leg.

The subjects were 18 patients with unilateral or bilateral varicose veins associated with long saphenous vein incompetence detected by Doppler imaging. They consisted of 5 men and 13 women whose ages ranged from 26 to 74 years, with a mean age of 58.2 years. Altogether, 28 affected limbs (2 right, 6 left and 10 bilateral) were investigated. Patients were asked to stay in the standing position in a quiet room at a temperature of 23-25℃ for approximately 5 minutes; and then, their skin temperature was measured by thermography (TH3106ME, NEC San-ei, Tokyo, Japan). After these procedures the patients were asked to lie on a bed, the leg was raised, and a light rubber band was then placed around the upper thigh, at about 5 cm below the inguinal ligament. The patients were then asked to stand up quickly, and thermography was performed again. The maximum skin temperature of the lower limb (MST) was then recorded.

The MSTs with and without a tourniquet were 34.83±0.76℃ and 35.22±0.69℃, respectively. The former was statistically lower than the latter (p=0.0001). In 22 limbs (78.6%), the MST decreased by 0.54℃ on average with the tourniquet versus without the tourniquet. In these limbs the high ligation of the saphenous vein could have been effective to improve the congestive conditions of the lower limbs. However, in 5 limbs ( 17.9%) the MST increased by 0.18℃ on average, with the tourniquet. In these limbs incompetent perforators and/or precapillary AV shunts may have played a role in the increase of the skin temperature. In only one limb (3.5%) no difference in MST was observed between with and without the tourniquet.

These findings suggest the possibility that not only incompetent perforating veins and/or precapillary AV shunts, but also saphenous vein incompetence, play a role in the increase of skin temperature of the legs of patients with varicose veins.

【Purpose】The importance of descending phlebography (DP)was assessed in the lower limbs with chronic venous insufficiency (CVI).

【Patients and Methods】The venous reflux was evaluated in 35 lower limbs of 22 patients with CVI by using both air plethysmography (APG) and DP. APG was performed in 97 normal limbs for control. In the CVI limbs, venous filling index (VFI) with and without a 10-cm air tournique (t inflated at the pressure of 60 mmHg) was used as a parameter quantitatively to assess the degree of venous reflux. The morphological information of the venous reflux was assessed by DP.

【Results】In the normal limbs, the VFI was less than 1.8ml/sec. In the CVI limbs, the VFI with and without an air tourniquet were 4.5±3.6 ml/sec and 6.7±4.1 ml/sec, respectively. The VFI was normalized in the 11 of 35 limbs with an air tourniquet. No reflux to the deep venous system was observed in these limbs by DP. Twenty-four of 35 limbs were not normalized after inflating the air tourniquet. Nine of 24 limbs had a venous reflux to the deep calf vein.

【Conclusion】DP was able to evaluate the morphological changes in CVI. Accordingly, DP was useful for CVI evaluation.

A 70-year-old male was transferred to our department with a diagnosis of abdominal aortic aneurysm with impending repture. Because his respiratory function was poor; we concluded that endovascular stent grafting was indicated. While awaiting surgery, the patient suddenly exhibited abdominal pain and hypotension, and urgent surgery was performed after diagnosis of a ruptured abdominal aortic aneurysm. There was an extensive hematoma near the inferior vena cava (IVC). Abdominal CT performed on the 8th day after the operation revealed inferior vena caval thrombotic obstruction. A Greenfield IVC filter was immediately inserted into the infrarenal segment of the IVC, and thrombolytic treatment was started. The patient was discharged 55 days after the operation, with no symptoms. Although various complications may occur after surgery for a ruptured abdominal aortic aneurysm, inferior vena caval thrombosis is a rare complication. However, because IVC thrombosis may cause pulmonary embolism and may become fatal, early diagnosis and medical treatment are important. We conclude that it is important to consider not only arterial complications but also venous complications after surgery for a reptured abdominal aortic aneurysm.

A 73-year-old man with completely thrombosed popliteal venous aneurysm is reported. The patient was first seen with acute pulmonary embolism. Then he returned to our hospital with localized swelling and pain in the left popliteal fossa.

Preoperative investigation including duplex scanning and magnetic resonance imaging, this was diagnosed as a benign soft tissue cyst. Surgical resection was performed and operation revealed a saccular aneurysm of the left popliteal vein, which was completely thrombosed. Postoperative course was uneventful.

Although popliteal venous aneurysms are rare, care should be taken whenever diagnosing a soft tissue popliteal fossa mass or looking for the cause of recurrent pulmonary embolism.

We report the case of a 72-year-old man who was admitted in the hemorrhagic shock by the perforation of the inferior vena cava by a Greenfield filter that had been inserted 6 months before because of deep vein thrombosis associated with pulmonary embolism. Computed tomography demonstrated the retroperitoneal hematoma by the perforation of the inferior vena cava. The anti-shock therapy was performed immediately, and the hospital course was stable without surgical therapy, after that the patient was discharged home at 39 days after admission. The follow-up was uneventful, and the patient was doing well 6 years later. We must carefully follow-up after the insertion of the Greenfield filter because of the specific complication such as this will be encountered.