Among 24431 forensic autopsy cases in the Tokyo medical examiner’s office in the past 10 years, from 1992 to 2001, 215 cases died of pulmonary thromboembolism (PTE). The annual number of cases increased gradually. The percentage of PTE cases in the total number of autopsies also increased by up to 1% from 1999.

The ratio of males to females was 1: 1.25.

We investigated 40 autopsy cases of PTE and found that every case had deep vein thrombosis (DVT). Fresh thrombi were found in 38 cases; in 95% of such cases they were located in crural veins. In 92% of all cases a chronic repeated history of DVT was revealed by histopatological investigations.

These results suggest that most cases of sudden death by PTE might have had subclinical PTE and DVT in their lives. Early diagnosis and treatment of DVT in its early stages are required for the prevention of fatal PTE.

The numbers of currently suspicious DVT patients, who are introduced to our department, has been increased gradually. In our opinion this is because DVT has been widely recognized in Japan as economy class syndrome has come to be famous. In this paper we describe the features of DVT, which we have experienced since 1985, especially focusing on inpatient clinic.

We have had 114 DVT cases from April, 1985 through December, 2001. Two cases affect DVT in upper limbs and other 112 cases in lower limbs. Of 45 inpatient DVT cases, only 11 cases occurred in the former 10 years, however, 34 cases did in later 6 years. The number of inpatient DVT introduced by orthopedics is the largest, and that by gynecology is the second largest.

The most frequent pathogenesis of DVT is postoperative status, and the second ones are long term bed rest as many as anticoagulant disorder, malignancy and central venous catheter.

Concerning the prognosis of affected limb, efficacy of our treatment is 94%(72 cases) except for the unkown cases.

Although we have taken care of dislodging a clot that can cause a fatal pulmonary embolus(PE), 21 PE caes(18%) has been recognized. However, only 6 cases were symptomatic and 4 of them underwents vena cava filter placement.

DVT has been widely recognized and recently other departments have tried to perform some prophylaxis, such as pneumatic compression therapy, early mobilization and using heparin. In order to avoid DVT not only therapeutic management but propaganda and prophylaxis is very important.

We have experienced 22 cases of vena caval reconstruction over past 19 years. The causes were spread of renal cell carcinoma in 5, invasive thymoma in 4, thrombosis in 4, trauma in 3, and others in 6. The operations were tumor resection with vena cava reconstruction in 10, bypass with PTFE graft in 5, patch grafting in 3, and others in 4. In these, 5 of 10 grafts have been patent for one month to 5 years. Four of the 14 patients with malignancy have survived for 4 years or more. Malignant tumor with extension to vena cava should be treated surgically if there is no distant or lymphnode metastasis.

Contrast venography (VG) has remained the gold standard for the diagnosis of lower extremity deep venous thrombosis (DVT). Recently duplex ultrasound scanning (US) is more attractive, because it is noninvasive, quick, real time and free of radiation. The aim of this report is to evaluate the diagnostic accuracy of duplex US compared with VG in detecting DVT. A total of 271 lower extremities on 251 patients who visited our vascular surgery were studied. B-mode, pulse doppler and color doppler methods were used to examine for thrombosis, respiratory fluctuation of blood flow, and venous flow on squeezing, respectively. Ascending VG was performed later to determine the accuracy of duplex US. In 33 extremities, in which DVT (+) was diagnosed using US, DVT was detected using VG, but in 5 of 238 extremities, in which DVT (–) was diagnosed, DVT wsa detexted. Therefore, the sensitivity, specificity and accuracy of duplex US in detecting DVT was 86.8%, 100%, and 98.%. It should be recommended that the duplex US, a useful, nonivasive mthod and repeatable in real time for out patients, will become widely available.

One thousand three hundred and fifty four subjects from the general population retuned questionnaires giving details about muscle cramps. The overall prevalence of muscle cramps in the survey population was 59.7%. The prevalence of cramps occurring within 1 year prior to examination was 49.4%. Persons aged 50 or more years showed a significantly higher incidence of muscle cramps than persons aged 30-49 years or persons aged 10-29 years (p<0.001). Furthermore, the incidence of muscle cramps in persons aged 10-29 years was significantly higher than that in persons aged 30-49 years (p<0.05). Persons aged 10-29 years old showed a significantly higher incidence of muscle cramps during the day (p<0.05), and their muscle cramps were more often induced by daytime exercise than that in other age groups. Persons with leg varicose veins showed a significantly higher incidence of muscle cramps than those without varicose veins (p<0.001). However, there was no significant difference in the incidence of muscle cramps between persons with and without risk factors for arteriosclerosis. From these results it might be concluded that one reason muscle cramps were quite common in older people was the increased incidence of leg varicose veins. However, risk factors for arteriosclerosis were not a cause of developing muscle cramps.

DVT patients are often accompanied with PTE. Since PTE is one of life-threatening disease, we retrospectively analised DVT patients to evaluate the risk of concurrent PTE. We investigated 86 consecutive patients in our hospital, who were treated for DVT of lower limbs from 1998 to 2002.

In 29 cases, DVT occurred in right lower limb. Among them, 10 cases (34%) were complicated PTE. In 53 cases, DVT occurred in left lower limb. Among them, 13 cases (25%) were complicated PTE. In 3 cases, DVT occurred in bilateral limbs, in which no PTE occurred. In 5 cases, DVT was associated with malignant tumors. Among them, 3 cases were accompanied with PTE.

Some reports indicated that hyperlipidemia is one of the causes of venous thrombosis. We also investigated the relationship between DVT and hyperlipidenmia. Among 74 DVT patients, 30 patients (41%) showed hyperlipidemia.

In summary, right-sided DVT and/or concurrent malignant tumor seemed to be a risk factor of PTE.

The incidence of postoperative pulmonary thromboembolism (PPTE) during the past seven years in National Kyushu Medical Center was 0.14%. The incidence of PPTE was not so high, but the mortality rate for the patients was critical. Therefore, the perioperative prevention is very important step. Among the risk factors, the frequency of ages over 40 years, malignancy, hypertension, and obesity were high in cases with PPTE. As for the types of operation, the frequency of laparotomy was highest, and that of orthopedic surgery, which is only 3 cases was lowest. PPTE occurred within 2 days after operation in most of the cases, and many of them took place after changing position. The mortality rate was 29%. To avoid this serious complication, thorough preoperative evaluation and prevention steps are necessary.

Between April 2000 and May 2002, 15 patients were performed endovascular intervention (EVI) for deep vein thrombosis (DVT). There were 9 men and 6 women, with average age of 54.3±17.9 years old and ranging from 28 to 76 years old. Twelve patients had left side and 3 patients had right side DVT.

Temporary IVC filter was placed in infra-renal vena cava inserted from right jugular vein or right subclavian vein before EVI preventing from pulmonary embolism due to isolated thrombus.

Patients were placed prone position and delivery seath was inserted from popliteal vein using ultrasound guiding.

Endovascular intervention was performed catherter-directed thrombolysis administering urokinase that doses were 120,000 to 480,000 IU and catheter thrombectomy using hydrodinamic thrombectomy catheter (Hydrolyzer^® or OASIS^®). Percutaneous transluminal angioplasty (PTA) and stent implantation were performed for iliac compression syndrome in the left side DVT.

After 1 week, all patients were performed follow up venography for evaluated patency and removed temporary IVC filter.

Direct thrombolysis was performed all of patients and only one patient was carried out complete revascularization. Another 14 patients were performed catheter thrombectomy. Eight patients in left side DVT were combined with iliac compression syndrome, therefore PTA and Stent implantation were performed. Eight in the all of 15 patients were carried out revascularization in follow up venography and early patency was 53.3%.

Endovascular intervention is expected of new and less invasive treatment for the deep vein thrombosis.

We examined histopathologically whole areas of deep veins of lower extremities of seven autopsy cases with massive pulmonary thromboembolism.

Bilateral deep vein thrombosis (DVT) was detected in all cases. Fresh thrombi are found in all cases (bilateral 3 cases, unilateral 4 cases). The fresh thrombi located locally at crural veins in 80% of the cases. The bands and webs like appearance, which is an older form of organized thrombi, were found in 6 cases (bilateral 4 cases, unilateral 2 cases). In whole deep veins, soleal vein is the most frequent site of DVT, found in 7 cases bilaterally.

The locations of thrombi in each case were examined. Fresh thrombi were tend to accompany with bands and webs and always located at proximal side of the bands and webs. It suggested repeated history of thrombosis and proximal propagation. From their distributions of DVT, thrombi were rose from soleal vein and propagated to peroneal vein and posterior tibial vein and same way as blood flow. Then the thrombus pours into the popliteal trunk and become free float thrombi that would easily become emboli.

Compression of the left renal vein between the superior mesenteric artery and the aorta has been termed the left renal vein entrapment syndrome. We recently treated this rare condition in two young patients. A 23-year-old man presented with a history of gross hematuria and left flank pain. A 20-year-old woman also presented with a history of gross hematuria and she was found to have anemia. In both of them, computed tomography revealed compression of the left renal vein between the superior mesenteric artery and the aorta. The pressure gradients between the left renal vein and the inferior vena cava were 5 mm Hg and 4 mm Hg, respectively. Despite treatment with hemostatic agents and injection of silver nitrate into the renal pelvis, their hematuria had continued. The patients underwent surgery with a diagnosis of the left renal vein entrapment syndrome. At operation, compression of the left renal vein was corrected with an external stent of ring-reinforced polytetrafluoroethylene prosthesis. They had an uneventful recovery. Although his microscopic hematuria continued, their gross hematuria, his left flank pain and her anemia resolved postoperatively. The external stenting procedure is a simple and physiologic procedure and may be an efficient surgical approach for the treatment of the left renal vein entrapment syndrome.