Although recognition of HIT is becoming wide spread, it is still considered a rare disease in Japan. There is no evidence of the incidence of HIT despite of an annual consumption of heparin amounting to about eleven billion yen in Japan. Data collected from the Japanese HIT clearinghouse were analyzed from April to December 2002. Thirtyone clinical cases of HIT diagnosed by decreased platelet counts under 10×10⁴/μl or a decrease >50% from the baseline were reviewed to confirm the diagnosis by detection of anti-heparin/PF4 antibodies(HIT antibodies). Twentyone of these 31 cases (67.7%) were positive for HIT antibodies and thus confirmed as HIT. All of sixteen HIT patients on hemodialysis were detected in the initial stage. The initial sign of HIT in hemodialysis was recognized as clotting in the extracorporeal circulation that could not resolve until the cessation of heparin. Three of seven patents with cardiovascular diseases were also positive at HIT- antibody detection. The low figure indicates the difficulty of excluding other causes of thrombocytopenia in case of cardiac intervention and surgery. Currently, HIT is thought to be uncommon, but supposedly not rare in Japan, with an incidence equal to that in western countries. As an alternative to heparin, the first choice among direct thrombin inhibitors is argatroban, which can be used as offlabel, because there is no official approval for other direct thrombin inhibitors in Japan. Dosage for argatroban for HIT in Japanese patients should be lower than the approved dosage in the United States. Argatroban dosage for HIT is empirically considered about one-third of that approved by the FDA. One reason might be supposed treatment with a combination of some anti-platelet agents, and the need to avoid unexpected bleeding under an adequate level of APTT prolongation. Therefore, alternative anticoagulation should be started as soon as HIT is suspected to avoid a poor outcome.

In the present study, the clinical application of physical techniques for preventing deep vein thrombosis was described in accordance with our results and the available scientific evidence in the literatures. Of simple physical techniques including limb exercise, calf squeezing, limb elevation and deep respiration, ankle exercise or calf squeezing, which are performed maximally, might be the first recommendation for promoting venous return and reducing venous stasis at the calf. Of ankle exercises, dorsi-plantar flexion of the ankle is considered to be the most effective in. prophylaxis of deep vein thrombosis. In intermittent pneumatic compression (calf pump), the optimal compression pressure is approximately 45 mmHg at the ankle level. The simultaneous use of elastic stockings and intermittent pneumatic compression is not contraindicated.

Chronic venous insufficiency of lower extremity causes varicose vein. The most important strategy for treatment of varicose vein is to eliminate the venous reflux at the saphenofemoral junction. For this purpose, new endovasculsr treatments using laser wave (endovascular laser treatment: EVLT) or radiofrequency wave (RF) were introduced recently. These minimally invasive treatments were done under local anesthesia using tumescent local anesthesia. In EVLT, a 810nm diode laser was widely used with a 600μm laser fiber introduced into the saphenous vein. Venous obliteration rates after initial EVLT reported in the literature were 97-100 %. There have been no skin burns, paresthesias, or deep vein thrombosis after EVLT.

During follow-up, venous obliteration was maintained in most of the cases. Because of the less expensive equipment, EVLT was cost-effective compared to RF.

EVLT is simple and effective. It should be recommended in minimally invasive treatment of varicose vein of lower extremities.

This report summarizes our clinical experience with 24 percutaneous IVC filters and aims to establish the well-organized indication for the choice of temporary or permanent filters. A total of 24 patients (6 males, 18 females) who ranged in age from 30 to 87 years old (mean age 62±15 years) underwent implantations of 15 temporary IVC filters (TF group), 9 permanent IVC filters (PF group). We evaluated the results of two groups. No acute pulmonary thromboembolism occurred during implantation or at removing of the filter between each group. In the TF group, there were seven cases (46.7%) of filter thrombosis but all cases were successfully treated with the use of thrombolysis and anticoagulant. As the result, all temporary IVC filters were able to be removed. The only difference between TF group and PF group was patients’ average age. The mean age of TF group was 55 years old and that of PF group was 74 years old. Each filter was also effective for the prevention of pulmonary thromboembolism. The case of effective anticoagulation and young patients should be selected temporary IVC filters. However, the cases of aged patients and contraindication of anticoagulant are recommended to be selected for permanent IVC filters.

Thirty-eight limbs (21 patients) with varicose veins were examined by three-dimensional CT scanning (3DCT) between April 2002 and March 2003. Five vascular surgeons independently reviewed 3D-CT images of the varicose veins, in terms of running course and dilatation of the veins, and sites of incompetent perforators. These results were compared with those obtained by duplex scanning (DS). Although 3D-CT was performed in a supine position, the running course and dilatation of the veins was clear in all patients except for one with lipodermatosclerosis. Incompetent perforators were categorized into six regions, producing low true-positive rates of 3D-CT and DS of 10.0-31.6%. However, the rate of false positives in 3D-CT that were negative in DS was also low, at 3.1-20.8%. These results suggest that 3D-CT is useful for anatomical evaluation of a superficial vein in cases without lipodermatosclerosis, and might be a substitute for a phlebogram. However, 3D-CT was unable to provide information on venous reflux and the deep-vein system, nor exact information about incompetent perforators; therefore, accurate diagnosis requires combination with DS.

Between 1982 and 2002, a total 112 patients with deep vein thrombosis have been treated at our hospital. The present study retrospectively analyzed these patients with regard to treatment, according to site of thrombosis and duration after onset. The 112 patients with ilio-femoro-popliteal thrombosis were divided into 3 groups: the surgical group (n=24), treated surgically; the catheter group (n=12), treated using catheter-directed thrombolysis; and the thrombolysis group (n=76), treated using medication. Limb condition and onset of pulmonary embolism was compared between the 3 groups.

The catheter group displayed improved degree of thrombolysis and reduced onset of pulmonary embolism during the course of treatment, compared to the other groups.

To clarify the best suited concentrations of Polidocanol (POL) for sclerotherapy in the treatment of varicose veins, a prospective multicenter study was conducted. Between February 1995 and May 1997, 259 patients were divided into three groups; less than 1mm in the diameter of varicosity (group 1), from 1mm to 3mm (group 2), and over than 3mm (group 3). The POL concentration was decided by lot and compression sclerotherapy was performed. POL concentrations were selected among 0.25%, 0.5 % and 1.0% in group 1, 0.5%, 1.0 %, 2.0% in group 2, 2.0%and 3.0 % in group 3. There was no difference in the disappearance rate of varicose veins between 0.5% and 1.0% in group 1, and between 1.0% and 2.0% in group 2. The disappearance rate of 0.5% was higher than 0.25% in group 1 (p<0.05). The rate of 1.0% was higher than 0.5 % in group 2, and the one of 3.0% was higher than 2.0% in group 3 (p<0.05). There were no complications. The localized side effects were intravariceal thrombosis of 30.9% and pigmentation of 27.0%. Clinical examinations revealed that RBC, Hb and Ht were slightly decreased after treatment. In conclusion, the best suited concentration of POL is 0.5% for less than 1mm varicose vein, 1.0% for over than 1mm and less than 3mm, and 3.0% for over than 3mm in the treatment of varicose veins.

To clarify the effects to lower extremity venous hemodynamics of simultaneous use of elastic stocking (ES) and intermittent pneumatic compression system (IPC), blood flow velocity was evaluated by duplex scanning. Twelve limbs in 6 volunteers without evidence of venous disease were studied. IPC device (Ven Assist model VA-1000 (ACI Medical, USA)) with a foot and calf cuff and ES (Comprinet pro, Terumo•BNS, Hamburg) were used.Measurements were obtained in supine position from the common femoral vein and the great saphenous vein. Peak venous velocity was significantly increased by IPC (p<0.01) and was not significantly changed by ES alone in the common femoral vein and in the great saphenous vein. By simultaneous use of IPC and ES, peak venous velocity was not increased and acceleration time was found to be significantly lower than by ICP alone (p<0.05). In conclusion, the simultaneous use of IPC and ES does not increase peak velocity of compressed wave in the common femoral vein and the great saphenous vein. However, further studies are necessary to evaluate the prophylactic effects for preventing deep vein thrombosis.

[Purpose] Relations between clinical symptoms, signs, age, sex and the types of varicose veins were examined, to define a characteristics of outpatients with varicose veins.

[Subject] 1,497 patients with 1,914 limbs (right/left: 965/949) that were treated between January 1999 and February 2003 at our outpatient clinic were examined about clinical symptoms and signs. There were 411 men and 1,086 women aged between 19 and 92 years (58±11 years old).

[Results] 86% of female patients and 78% of male had symptoms such as heaviness, feel of swelling and cramp, and 41% of male and 21% of female patients had signs such as pigmentation, dermatitis, skin ulcers. Women were significantly more likely than men to report symptoms such as heaviness, feel of swelling and cramp (p<0.001). Men were significantly more likely than women to have signs such as stasis dermatitis, pigmentation, skin ulcers (p<0.001). Prevalence of symptoms tends to increase with age (p<0.001). Signs were more prevalent in S type and S+SSV type than other types (p<0.01).

[Conclusions] Varicose veins are not a cosmetic problem, because about 80% of patients with varicose veins have symptoms and signs. It is important to think that varicose veins are a disease with symptoms and signs, and to treat varicose veins not only for cosmetic problem, but also for symptoms and signs. Patient education about varicose veins is also important.

Although the inferior vena cava (IVC) filter is effective for protection against pulmonary embolism associated with deep venous thrombosis, several kinds of complications have been reported. We herein report a case of complete IVC occlusion shortly after IVC filter insertion. A 44-year-old male was admitted to our department with a diagnosis of deep venous thrombosis and pulmonary embolism. After conservative therapy with heparin and urokinase, Nitinol Trapease filter was inserted in infrarenal IVC. Six days after the insertion, the patient presented with acute lower abdominal pain, swelling and pain in both lower limbs. CT scan revealed the complete occlusion of the IVC through bilateral iliac and femoral vein. After five days of medical therapy without success, the patient underwent thrombectomy through right femoral vein. The swelling and pain in both legs resolved soon, and the patient was discharged home at 29 days after operation. Although this is a rare complication, we must carefully observe patients shortly after insertion of IVC filter.

Objective: To study the risk factors, diagnostic method, distribution, and treatment method of acute deep vein thrombosis (DVT) in 614 Japanese adults.

Methods: This was a cross-sectional, multicenter study with 62 institutions.

Results: Operation was the most important risk factor for DVT (24%), followed by immobilization (18%) and known malignancy (16%). Subsequent pulmonary embolism was detected in 23% of the patients which show the similar prevalence to that observed in the 1st Japanese Vein Study. Protein S deficiency was the most common thrombophilia which accounted for 6% of the patients. In 70% of the patients, DVT was diagnosed by ultrasound, whereas contrast venography was used in 38%. DVT was detected in 61% in left leg, 30% in right leg, and 9% in bilateral legs. In the proximal veins, 51% of the patients had DVT in the superficial femoral, 51% had DVT in the popliteal, and 46% had DVT in the common femoral vein. DVT in the profunda femoris vein was found in only 8% of the patients. In the distal veins, posterior tibial vein thrombosis was most frequent accounting for 20% of the patients, followed by peroneal (16%) and soleal (14%) vein thrombosis. The unfractionated heparin was used in 61% of the patients with the mean initial dose from 2000 to 43200 U (mean: 12417 U). The warfarin was used in 77% with the mean INR of 1.9. The low molecular weight heparin was used in only 5% of the patients. Urokinase was used for thrombolysis in 49% of the patients with the mean initial dose of 264100 IU. The thrombectomy was performed in only 3%. The permanent inferior vena cava filter was placed in 13% of the patients for secondary prevention, and the temporary filter in 11%. The catheter-directed thrombolysis was performed in 9%, and the endovenous stenting was done in 1% of the patients.

Conclusions: The ultrasonography has been widely used, and the contrast venography is becoming less important for the diagnosis of DVT when compared to the 1st Japanese Vein Study which was carried out in 1997. Similar prevalence was observed concerning the subsequent pulmonary embolism or thrombophilia compared to that of 1st Study. The anticoagulation is commonly used for the treatment of DVT, however, mean INR for the use of warfarin was <2. The endovenous procedures are becoming common in Japan. These data show recent trends in the diagnosis

and the treatment of DVT.