Both unfractionated heparin and warfarin were used as parentheral and oral anticoagulant agents only available for clinical use for a long period of time. They both are potent, but require close monitoring to prevent bleeding complications, because the dose necessary to achieve appropriate antithrombotic effects may vary from person to person, or even vary from day to day in the same patient. To avoid matabolic instability, low molecular weight component of the unfractionated heparin was extracted to make low-molecular-weight heparin. Stable anticoagulant effects can be achieved by fix-dose subcutaneous injection of low-molecular-weight heparin. Recently, orally available specific antth`]mbin has been developed to overcome the safety problem of warfarin. Indeed, the time-course of anticoagulant effects achieve by the oral ingestion of ximelagatran was similar to that of subcutaneous injection low-molecular- weight heparin. Anticoagulant agents, which can prevent thrombotic disease effectively, without increasing bleeding complicatons, are awaited.

Histopathological features about leg deep vein thrombosis(DVT) resulting in fatal pulmonary thromboembolism(PTE) are reviewed. Three characters of leg deep vein thrombosis are categorized as iliac, femoral, and crural type. Crural type is frequently found type of DVT with massive PTE. Among crural veins, soleal vein is especially important as a first occurrence site of DVT resulting in massive PTE. However, embolic source of large thromboemboli is free-float thrombi made at ilio-femoral veins as secondary thrombi made from primary thrombi in crural vein.

Peroneal vein and posterior tibial vein is also important site of thrombosis, because soleal vein thrombi grow through these drainage routes.

Once thrombosis occurs,a diameter of deep veins is at first dilated. Then it becomes retracted to normal diameter by organizing processes.

As venous valves are often destroyed during organizing processes, it is important not to cure DVT at early stage, but to prevent suffering from DVT.

We have experienced 4 cases who were complicated with deep venous thrombosis within 2 months after 1697 strippings for primary varicose vein from April, 1994 till March, 2004. Emergency thrombectomy and conservative therapy were performed in 2 cases each. This major complication after stripping is extremely rare and its clinical course is almost same as deep venous thrombosis unaccompanied with surgery of varicose vein. A serious case showing phlegmasia caerulea dolens requires emergency thrombectomy.

Purpose: Pulmonary artery embolectomy was performed in 6 cases between 1994 and 2003 (4 men and 2 women, mean age 62 years, range 28-69 years). These cases were reviewed to evaluate the effectiveness and longterm results of pulmonary artery embolectomy for massive pulmonary embolism (MPE). Methods and Results: MPE occurred perioperatively in 3cases.One patient had a history of superior mesenteric vein thrombosis. All patients had dyspnea, and 2 patients had loss of consciousness. Echocardiography showed right ventricular overload in all cases and emboli in the right atrium in 3 cases. Enhanced chest CT scan showed a definite filling defect in the pulmonary arteries in all cases. Chronic thrombus was also seen in 2 cases. PCPS was used preoperatively in 2 cases. Indications for embolectomy was failure of thrombolytic therapy in one case, shock assisted by PCPS in 2 cases, and right atrial thrombi in 3 cases. Pulmonary artery embolectomy was performed with the aid of extracorporeal circulation. A large amout of embolus was extracted through a transverse arteriotomy in the main pulmonary artery. IVC filters were inserted in all cases. All patients came back from the surgery. One late death occurred one year after the operation. The long term results of the other five cases was excellent (NYHA 1). Conclusions: This operation offers an excellent chance of survival and good long-term results, and is not the last resort reserved for clinically desperate circumstances, but one of several therapeutic options.

Fifty-eight legs on which stripping surgery was performed were divided into two groups; a group in which stripping surgery was performed on the whole length of the leg (conventional stripping, 14 legs) and a group in which stripping surgery was performed on the femoral region (limited stripping, 37 legs). Venous function was evaluated between the two groups with air plethysmography.

The preoperative venous filling index (VFI) in the conventional stripping was significantly higher than that in the limited stripping (9.6±4.2 vs. 7.0±3.6 ml/second, p<0.05), There were no significant differences in venous volume (VV), ejection volume (EV), ejection fraction (EF), or residual volume fraction (RVF) between the two groups (n.s.). The postoperative VV in the conventional stripping decreased from 149±50 ml to 109±32 ml, whereas that in the limited stripping decreased from 151±45 ml to 111±31 ml. The postoperative VFI in the conventional stripping and the limited stripping significantly decreased from 9.6±4.2 ml/second to 2.7±1.9 ml/ second and from 7.0±3.6 ml/second to 1.9±1.1 ml/second, respectively (p<0.01). The postoperative EV in the conventional stripping and the limited stripping significantly decreased from 62 ± 26 ml to 40±20 ml and from 61±32 to 46±28 ml, respectively (p<0.01). There were no significant differences in the preoperative and postoperative EF of both the conventional stripping (39±11% vs. 35±14%, n.s.) and the limited stripping (40±15% vs. 40±14%, n.s.). The decrease in RVF of the conventional stripping was mild (51±12% vs. 46±14%, p=0.09). On the other hand, RVF significantly decreased in the limited stripping (48±13% vs. 41±14%, p<0.05).

When phlebectomy and ligation of incompetent perforators were appropriately performed, limited stripping in the femoral region provided improved venous functions comparable to the conventional stripping.

Catheter-directed thrombolysis (CDT) is used as treatment of deep vein thrombosis, after retrievable TVC filter inserted, for prevention against pulmonary thromboembolism. A 28-year old woman, she was 9 weeks pregnant, was diagnosed of deep vein thrombosis by ultrasound. Retrievable inferior vena cava filter (IVC filter/Gunther tulip vena cava filter®) was inserted infrarenal vena cava before CDT preventing from pulmonary embolism due to isolated thrombus. CDT was performed administering urokinase that dose was 120,000 to 240,000 IU/day. Maintenance dosing of heparin and urokinase were 8,000 to 24,000 IU/day and 240,000IU/day. Seven days after inserted IVC filter, MRI revealed the complete occlusion of the IVC filter. We tried CDT administering urokinase dose 180,000 IU, but unsuccessful. The patient was underwent catheter thrombectomy using hydrodynamic thrombectomy catheter (Hydrolyzer®). We could eliminate thrombus and could retrieve IVC filter without complication of significant pulmonary thromboembolism.

The cause of acute inferior vena cava filter complete occlusion was unknown. But, hydrodynamic thrombectomy catheter therapy was effective and safe method for acute inferior vena cava filter thromboembolism.

Internal jugular vein thrombosis (IJVT) has generally been considered rare and of limited clinical importance. IJVT may become more commonly reported as a result of increased usage of central venous catheters (CVCs) and increased concern about deep venous thrombosis (DVT). Here, we report 3 cases of IJVT that were treated at our department. Case 1 involved a 22-year-old woman with a history of CVC insertion via the right jugular vein. Case 2 involved a 44-year-old man with swelling on the left side of his neck; computed tomography (CT) revealed left IJVT and thrombus formation in the superior vena cava. Case 3 involved a 76-year-old man who had undergone radiation therapy for hypopharyngeal cancer; follow-up CT revealed left IJVT. All 3 patients were treated on an outpatient basis. Patients 1 and 3 received antiplatelet therapy, and patient 2 received anticoagulation treatment. None of the patients exhibited symptoms suggesting pulmonary embolism during the observation period. In case 1, the thrombus in the internal jugular vein disappeared. In cases 2 and 3, no change was seen in the thrombus. The patients had any of risk factors; endothelial injury, blood flow abnormalities or hypercoagulability. Because of several previous reports indicating that IJVT can lead to pulmonary embolism, the present patients were carefully observed. Management of IJVT generally involves conservative medical therapy, as there are usually a few indications for surgical intervention.

We encountered 2 cases of compartment syndromes which occurred after surgery for varicose veins of the leg (great saphenous vein stripping and varicectomy). They were a 39-year-old man and a 46-year-old man. Around 6 hours after the operations, severe pain and muscle swelling developed in their left lower leg, especially in anterior tibial part. After diagnosis of compartment syndrome, fasciotomies were performed. The compartment syndromes were probably caused by Esmarch’s bandage during the operation or by compression bandages after the procedures, or a combination of both. Legs with well-grooved muscles potentially have high unforced compartment pressure. It is very important to place bandages carefully on the legs of such patients.

63-year-old woman had hypotension and hypoxemia with syncope and dyspnea. Chest enhanced computed tomography scan and transthoracic echocardiogram revealed massive pulmonary embolism with large floating right heart thrombi. Thrombolytic theraphy was performed, preparing percutaneous cardiopulmonary support(PCPS) for hemodynamic deterioration. Mobile right heart thrombi disappeared 30 minutes after thrombolytic agent administration. Her blood pressure and arterial blood gases improved dramatically 60 minutes after administration, without hemodynamic deterioration. We present a case report of massive pulmonary embolism with large floating right heart thrombus, which was successfully treated with thrombolytic therapy.

A 47-year-old female was admitted to our hospital for her swelled lower legs and rapid getting weight. She was obese, and her arterial blood gas analysis showed hypoxia. CT and venography revealed a double inferior vena cava (IVC), with occlusion of its right side. The two cavae were jointed by the internal iliac anastomosis and the left renal vein. Perfusion lung scintigraphy revealed marginal perfusion defects. After the fibrinolysis therapy and heparin, she got better and was discharged.