The etiology of chronic pulmonary thromboembolism remains unknown. In this report, we tried to clarify sex difference. Methods: we compared 8 men with 19 women, underwent thromboendarterectomy (TEA) under cardiopulmonary bypass with deep hypothermia and intermittent circulatory arrest. Results: 1) The coagulation abnormalities were present in female patients more than male, but the incidence of deep vein thrombosis (DVT) between female and male was not significant. 2) According to the typing on CT scan, 4 patients were classified as peripheral type. All of these 4 patients were female. Conclusion: Surgical treatment has improved the prognosis of selected patients with pulmonary thromboembolism. In female patients, other etiology except for DVT seems to be present.

We reviewed our experience of surgical treatment of renal cell carcinoma (RCC) involving inferior vena cava (IVC), focusing on deep hypothermic circulatory arrest (DHCA) as an adjunctive measure. Between 1985 and 2001, 19 patients with RCC with IVC tumor underwent radical nephrectomy with excision of the caval tumor. The mean patient age was 61.6 years old (47-78 years old), and 16 patients were male and 3 female. The caval thrombus was either intraatrial (n=3), suprahepatic (n=4), intrahepatic (n=5) or subhepatic (n=7). The thrombus was removed without any circulatory assistance in 8 patients (Group 1). Venous shunt with centrifugal pump was used in 5 patients (Group 2), while DHCA was used in 6 patients (Group 3). The mean time of circulatory arrest was 21.7 min. The operative time and the volume of blood transfusion were not significantly different among these three groups, while the length of ICU stay was significantly longer in Group 3 than Group 2. One operative death occurred because of an intraoperative pulmonary embolism in Group 2. In Group 1, one patient died of multiple pulmonary embolism originating from residual tumor in the lumbar veins on the 35th day after surgery. In-hospital mortality was 10.5% in this series. There were no postsurgical complications and in-hospital deaths in patients undergoing DHCA. Overall 5-year survival rate was 40%. We conclude that DHCA facilitates excision of large IVC thrombi and provides the potentials for cure with low morbidity and mortality rates in the treatment of advanced renal cancer.

We evaluated 1,704 legs of 1,197 patients after treatment using an outpatient-based procedure for stripping lower extremity varicose veins in our hospital during the last 5 years (large saphenous vein stripping in 1,307 legs and small saphenous vein stripping in 397 legs). We used two local anesthetic agents concomitantly with intravenous Propofol. The principle treatment was a selective stripping using complete high-position ligation, removal of the reflux portions of the saphenous vein, and adjunctive varicose phlebectomy. We allowed patients to return home after one hour of bed rest postoperatively. While there were no manifestations of anesthetic toxicity, propofol induced premature ventricular contracture in two cases, forcing us to switch over to general anesthesia. Operative complications included hemostatic difficulty in 3 patients and postoperative bleeding in 1 patient who had been receiving an antiplatelet agent. The patient with postoperative bleeding required immediate retreatment, and remittance was achieved after hematoma removal. Wound infection was observed in 6 legs (0.35%), all of which were completely resolved by outpatient treatment. Saphenous nerve disorder was observed in only 59 legs (4.5%). Even in the patients who had undergone full-length stripping, the prevalence of saphenous nerve disorder was only 8.8%. This low prevalence may have been largely due to the efficacy of the local anesthesia in facilitating intra-adventitial dissection. No severe complications such as deep vein thrombosis or pulmonary infarction were observed.

One hundred seventeen patients with 139 involved limbs underwent saphenous vein ligation at the groin, above the knee and below the knee.

We measured the length of the skin incison, the extent of the resected great saphenous vein (GSV) and the number of dissected tributaries. The average number of skin incisions was 3.4±0.8 per limb. The total dissected length of the GSV including groin , above knee and below knee was 20.3±7.3cm.

In patients whose GSV (above knee, below knee) was ligated by the stab avulsion technique, the skin incison length was smaller than that in patients whose GSV was ligated by the traditional method (p<0.01) even though the resected length of the GSV and the number of dissected tributaries showed no significant difference between the two techniques. Stab avulsion truncal saphenectomy produced excellent cosmetic results.

The treatment of lymphedema is a difficult and challenging problem. We performed lymphatic-venous shunt (L-V shunt) for the lower limb lymphedema. The subjects included 12 cases, 13 limbs for which lymph vessel-great saphenous vein shunt was performed between 1993 and 2002.

The causes of the lower limb lymphedema broke down to 2 primary cases and after treatment of uterine cancer (surgery and radiotherapy) 10 cases. L-V shunt was performed under a surgical microscope in accordance with the Degni’s pull through method. Administration of anti-platelet agents, Hadomer and lymph induction massage were given to all cases after surgery. Evaluation was made by clinical symptoms and measurement of the perimeter of the lower limb at two weeks after operation.

The result were rated as markedly effective where the perimeter of the lower limb decreased more than 5cm, as effective where the perimeter decreased less than 5cm, as slightly effective where the perimeter remained unchanged but tissue became soft and as ineffective where there was no change. There were markedly effective 5 limbs, effective 3 limbs, slightly effective 3 limbs and ineffective 2 limbs. No postoperative complication was seen. The more shunts, the better results were obtained. The results were satisfactorily, the effective rate of surgery begin 84.6%. Oral administration of anti-platelet agents and lymph induction massage are considered necessary to keep edema improved.

The frequencies and distributions of bands and webs (b&w), which was one of specific forms of organized thrombi, were investigated. Histopathological examination of pulmonary arteries and deep veins was performed in nine autopsy cases with massive pulmonary thromboembolism. (3 male 6 female, mean age 59.8±16.5year-old).

b&w in pulmonary arteries was found in eight patients and in deep vein in seven patients, which strongly suggested their subclinical history of recurrent thromboemboli.

The frequencies in pulmonary arteries were differing in each patient though; the distributions were seemed to extend according to the high frequency.

We classified the nine cases into two groups by the distributions of b&w in lower extremities; the number of the patients in group S, which b&w were locally in soleal veins or none, were three. Those of in group B, which b&w were extended to lower extremities, were six.

The mean frequencies of b&w in pulmonary arteries in two groups were 6.2% in group S and 40.0% in group B.

These results suggest that when the recurrent history of thrombosis increases and the distributions of b&w extend in lower extremities, the frequency of b&w in pulmonary artery also increases and that might lead to the disturbance of their pulmonary circulation.

Then early treatment of deep vein thrombosis is required for proper prognosis of pulmonary thromboembolism.

We herein report a patient who repeatedly presented with hemorrhagic episodes from venous aneurysms of the jejunum loop after pancreaticoduodenectomy (PD).

The patient was a 49-year-old male. He had been followed for about 1 year on an outpatient clinic basis since he underwent PD with the preoperative diagnosis of pancreatic head cancer, which was revealed postoperatively to be chronic pancreatitis. During the follow up, he began to pass tarry stool repeatedly. Because the origin of bleeding was not known, he was hospitalized and underwent thorough examinations for the tarry stool.

Abdominal angiography demonstrated that the splenic vein was occluded and hepatopetal collateral veins along the jejunum loop arising in the pancreas remnant flowed into the supramesenteric vein. Following unsuccessful attempts of reopening the occluded portion at percutaneous transhepatic portal venography, transcatheter partial splenic artery embolization was performed. However, bleeding episodes were repeatedly observed thereafter. Finally, the enlarged collateral veins (venous aneurysms) were embolized with coils after a transcatheter maneuver under percutaneous transsplenic splenoportography failed to reopen the occlusion portion. The hepatopetal blood flow was maintained even after the embolization via collateral veins along the jejunum loop. He has been quiet well for 6 years after the embolization treatment without a bleeding episode or anemia.

In the present patient, the origin of gastrointestinal bleeding was considered to be heterotopic venous aneurysms of the jejunum loop, which had developed secondary to the splenic vein obstruction after PD.

A 68-year-old man was admitted to our hospital because of repeated hemoptysis. Fiberoptic bronchoscopy and chest CT showed no bronchiectatic findings. Bronchial arteriography revealed hypervascular lesion and dilated tortous bronchial artery in the right upper lobe. Bronchial artery embolization could not be performed because of very strong meandering. Wedge resection of the upper lobe and clipping of the upper bronchial artery were performed under VATS. Histopathological findings revealed hemoptysis caused by a rupture of the enlarged and meandering bronchial artery in the old pulmonary infarction lesion. Left leg venography revealed the deep vein (left common iliac vein) thrombosis which was considered as a cause of the pulmonary infarction. A permanent filter was placed into the inferior vena cava below the bilateral renal veins. Asymptomatic pulmonary infarction should be considered as a cause of unknown intrabronchial bleeding.

Prophylaxis against venous thromboembolism consists of pharmacological and physical agents. Although these are of proven efficacy in preventing deep vein thrombosis, complications occasionally occur when these are used uncorrectly. In the present paper, the proper use of elastic stockings and intermittent pneumatic compression, which were active procedures for preventing deep vein thrombosis, was described in accordance with the available scientific evidence.