There is a potential risk of sacrificing the cortical vein during neurosurgical operations, especially in the interhemispheric or subtemporal approach. Impaired cortical vein might cause venous circulatory disturbances resulting in venous infarction. In this article, we reviewed the management and results of 9 cases with postoperative venous infarction.

We have encountered 8 cases with postoperative venous infarction (0.3%) during the past 5 years. The series is composed of 3 male and 5 female, ranged in age 43 to 76 year-old (a mean age of 58.1 year-old), and consisted of five brain tumors, one cavernoma, one dural AVF, one trigeminal neuralgia. Initial symptoms occurred intraoperatively in two, 0 day after the operation in three, 1 day in one, 3 days in one, and 4 days in one case. Symptoms were intraoperative brain edema in two cases, disorientation in one, cerebellar sign in one, hemiparesis in one, aphasia in two, headache in one. Two cases required surgical intervention. Results were good outcome in 6 and fair in two cases.

In conclusion, there are two types in postoperative venous infarction; severely and gradually progressed. The former needs immediate treatment including operation, and the prevention of the ongoing venous thrombosis is substantial in the latter .

Retroperitoneal leimyosarcoma is rare and surgical resection is the most effective treatment. However, the prognosis is poor due to local recurrence in spite of complete resection. The invasion to the large vessels, especially to the inferior vena cava (IVC), poses a technical challenge during operation. Special care should be taken to prevent unexpected exsanguinations and tumor emboli during manipulation of the IVC. We experienced three patients with retroperitoneal leiomyosarcoma invading to the IVC. One was primary and two were recurrent cases. The isolation was performed along the adventitia of the vessels, and the tumor could be removed safely and completely with part of IVC. The advanced tumor in the lumen could be pulled out from the inferior vena cava. In the two recurrent cases, the pain was relieved and the life prolonged. The retroperitoneal leiomyosarcoma, which invades the inferior vena cava, could be removed completely and safely by primary isolation of the large vessels in spite of the tumor capsule.

Nutcracker syndrome (left renal vein (LRV) entrapment syndrome) refers to compression of the LRV between the aorta and the superior mesenteric artery (SMA). This anatomical condition results in renal venous hypertension and macrohematuria. In this paper we report two cases of nutcracker syndrome treated with LRV transposition.

Patient #1: A 24-year-old male suffered from a 9-year history of severe left flank pain and macroscopic hematuria. Ultrasonography revealed a narrow segment of the LRV between the aorta and the SMA. Venous velocity in the narrow segment was 160 cm/sec. Computerized tomography (CT) revealed a compressed LRV between the aorta and the SMA and a highly dilated distal part of the LRV. The nutcracker distance between the aorta and the SMA was 4mm. Selective left renal phlebography revealed a compressed part at a junction between the LRV and the inferior vena cava (IVC). The pressure gradient between the LRV and the IVC was 6.8cmH₂O. Transposition of the LRV, 3cm caudal in relation to an original site, was carried out. Postoperatively the left flank pain and macroscopic hematuria disappeared. The pressure gradient between the LRV and the IVC lowered to 2.4cmH₂O.

Patient #2: A 16-year-old male suffered from a 5-year history of macroscopic hematuria. It worsened after exercise, which then had to be restricted. Ultrasonography and CT revealed a compressed LRV between the aorta and the SMA. The nutcracker distance between the two arteries was 4 mm by ultrasonography and 6 mm by CT. The pressure gradient between the LRV and the IVC was 5.4cmH₂O. Caudal transposition of the LRV was carried out. His hematuria did not change much after a short period of alleviation. Postoperative phlebography revealed occlusion of the anastomosis. After several months, his hematuria became progressively milder.

Because many subjects could not stand with their weight on the opposite leg with ease, we use a box under the opposite leg in the standing position to evaluate lower extremity venous function using air plethysmography. The purpose of this study was to evaluate the lower extremity venous function of limbs with primary varicose veins and deep venous thrombosis and to compare them with those of normal limbs using air plethysmography by our techinique.

Twenty normal limbs of 12 healthy volunteers, forty-two limbs of 29 patients with primary varicose veins (PVV) and nineteen limbs of 15 patients with deep venous thrombosis (DVT) were evaluated by our techinique using air plethysmography.

The values obtained by air plethysmography were outflow fraction (OF), venous volume (VV), venous filling index (VFI), ejection fraction (EF) and residual volume fraction (RVF).

The values of OF and VV of PVV were significantly higher than those of normal limbs and DVT. The values of VFI of PVV and DVT were significantly higher than those of normal limbs, and the values of VFI of PVV were higher than those of DVT. The values of EF of PVV and DVT were significantly lower than those of normal limbs, and the values of EF of DVT were significantly lower than those of PVV. The values of RVF of PVV were significantly lower than those of normal limbs and DVT.

The air plethysmography is a useful noninvasive method to evaluate lower extremity venous function. However, it is necessary to consider the phase of the desease and location of obstruction to evaluate DVT.

Patients who diminish or eliminate the pedal pulses with passive dorsal flexion (PDF) of the ankle (positive PDF test) without any symptoms caused by popliteal vascular entrapment is called functional popliteal entrapment syndrome. We report three cases of functional popliteal vein entrapment syndrome which might cause deep vein thrombosis (DVT). In the first case, a 73-year-old man had bilateral leg swelling with positive PDF test. Ascending venography demonstrated postthrombotic recanalization of left popliteal vein and compression of right popliteal vein with dorsal flexion of the ankle. Since right popliteal vein was involved by venographic finding, left popliteal vein entrapment was also suspected. The second patient, a 81-year-old man had right lower leg varicose veins and swelling with right positive PDF test. Ascending venography demonstrated a thrombus in right popliteal vein. Compression of right popliteal vein with dorsal flexion of the ankle has been shown after recanalization of deep vein. The third patient, a 52-year-old male had left leg swelling with left positive PDF test. Ascending venography demonstrated a thrombus in left popliteal vein and compression of left popliteal vein with dorsal flexion of the ankle. The first and second cases were diagnosed as pulmonary embolization by pulmonary perfusion scintigraphy. All three cases were treated with compression stockings and anticoagulation therapy and have done well. It is indicated that functional popliteal vein entrapment syndrome, frequently found in the healthy people, may be likely to develop spontaneous calf DVT.

Clinical course was evaluated in 6 patients with acute pulmonary thromboembolism; APTE. Their ages ranged from 64 to 94 years. Three of them were over 80-year-old, two were schizophrenic who were put on the psychotropics. Following the patient’s methodical history taking and physical examination, all patients underwent transthoracic two-dimensional echocardiography; TTE and venous ultrasonography. In all 6 patients TTE showed diastolic bowing of the interventricular septum into the left ventricle. Three patients detected deep venous thrombus by ultrasonography. Spiral computed tomography of the chest with contrast medium demonstrated the presence of thrombi in the proximal pulmonary artery. After treatment, CT image showed these thrombi decreased in size or disappeared in all. All patients studied received anticoagulation with unfractionated heparin and 2 patients received additional thrombolytic therapy. Two were no bleeding complications and no deaths. An allergic adverse reaction to psychotropics is suspected in 2 patients. Further study should be necessary.

Between 2000 and 2001, 296 patients with varicose veins were seen in our clinic. We analyzed the factors which affect the chosen form of management in primary varicose veins. The patients who were offered stripping had a significantly longer duration from the onset of the disease than those offered sclerotherapy with ligation (p<0.05). In sclerotherapy group, no patients showed skin changes, and the half refilling time in plethysmography was significantly longer compared with stripping (p<0.01) and sclerotherapy with ligation groups (p<0.01). These results indicate that the degree of venous insufficiency was mild in sclerotherapy group. In patients who were introduced by other clinics, treatments for varicose veins were carried out more frequently compared with patients without introduction or patients who were introduced by other patients treated previously in our clinic (p<0.05). However, the symptoms were not associated with varicose veins even in 37.5% of patients introduced by other clinics. Careful differential diagnosis is important.

We report four patients with intravenous foreign bodies. There are one man and three women at the age of 38 to 90. The foreign bodies were fragments of central venous catheters which had been accidentally pulled out by the patients in two cases, a guidewire which was used in placement of a double-lumen catheter, and a fragment of introducer sheath broken during intracardiac electrophysiology study. They were located in the right jugular vein to the femoral region (1 case), the superior vena cava to right atrium(2 cases), and the right external iliac vein (1 case), and were removed by open surgery (2 cases), endovascular procedure (1 case), and combination of the both methods (1 case). There was no complication including pulmonary embolism during removal procedure, while duration between occurrence and removal ranged from one hour and a half to four months.

Most of intravenous foreign bodies have an iatrogenic etiology, so that they should be removed by secure, unfailing and case-by-case means.

Bleeding is a rare complication of varicose veins, but some fatalities have been reported. A 57-year-old man was admitted to our hospital with bleeding from varicose veins. Past history included pulmonary embolism. For the past 10 years he had had varicose veins with pigmentation and lipodermatosclerosis in both legs. Bleeding from blue blebs on his right ankle began after a towel was passed over the veins. He was treated with a pressure bandage at a local hospital. On the following day, he consulted our hospital to prevent rebleeding. The treatment plan was to treat the bleeding problem first by preventing rebleeding because the patient strongly refused the treatment of the primaryvaricose veins. After bilateral high ligations were performed to decrease venous hypertension and to prevent recurrence of idiopathic pulmonary embolism, injection to blue blebs and adjacent feeding veins was made. He has had no

bleeding for ten months follow-up.