We have already studied and reported that the optimal concentrations of Polidocanol (POL) were 0.5% for less than 1mm varicose vein (Group 1), 1.0% for greater than 1mm and less than 3mm (Group 2), and 3.0% for more than 3mm (Group 3) in the treatment of varicose veins. To clarify the usefulness of these concentrations of POL, a double-blind and placebo-controlled study was conducted in multicenters. Between January 1998 and May 1999, 86 patients were divided into the three groups. The POL or placebo was selected by controlled double-blind method and a standard compression sclerotherapy was performed. The disappearance efficacy rates were as follows; 0.5% POL was 69.2%, 1.0% POL was 86.7% and 3.0% POL was 100%, which were significantly higher than those of placebo groups; 7.1%, 0% and 9.1% (p<0.05). There was no case with general complications and the localized side effects were intravariceal thrombosis of 35.6% and pigmentation of 22.2% with slight grade. In conclusion, compression sclerotherapy using the best suited concentration of POL is very effective and useful.

In the leg with varicose veins, hemodynamics of the deep vein at supine position were examined using a duplex scan to assess the appropriate pressure of graduated elastic stockings (GES) to prevent perioperative deep vein thrombosis. During application of GES and intermittent pneumatic compression systems (IPC), blood flow velocity at the femoral vein was measured for 72 legs with varicose veins and 94 legs without venous disease. GES used in this study were class 2 stockings (Ultrasheer C. Beiersdorf-Jobst. USA) and class 1 stockings (Ansilk pro. Parema. UK and Comprinet pro. Beiersdorf-Jobst. USA). FLOW TRON DVT (Huntleigh, UK) was used as IPC. During application of class 2 GES, femoral vein blood flow peak velocity was significantly decreased in normal legs but unchanged in legs with varicose veins. During application of class 1 GES, femoral vein blood flow peak velocity was unchanged both in normal legs and legs with varicose veins. Femoral vein blood flow augmentation was significantly larger in legs with varicose veins than in normal legs, when only IPC was applied. It became equal when both IPC and GES were applied. Moreover, large femoral vein blood flow augmentation was obtained when IPC combined with class 1 GES, but not with class 2 GES. It was thought the blood in varicose veins was expelled with GES and class 1 GES was sufficient to prevent venostasis in a supine position in legs with varicose veins.

We investigated deep veins of bilateral limbs histopathologicaly among twenty-eight autopsy cases with massive pulmonary thromboembolism. Deep vein thrombosis containing fresh thrombi were observed at lower limbs in all cases, and those of 77% (34/44) were located at crural veins. Therefore embolic source was regarded as free-float thrombi at popliteal trunk. Bilateral deep vein thrombosis were found 85.7% (24/28) of the cases. Organized thrombi that were suggested previous thrombosis was located locally at crural vein in 90%. Fresh thrombi tend to locate at more proximal site than organized thrombi in each case. Therefore propagating process from distal to proximal side of lower limbs with repeated organization and recurrence of thrombi was suggested. Soleal vein was the most frequent site of deep vein thrombosis that was involved 91.1% (51/56) of the limbs. Therefore soleal vein thrombosis was important as the origin of life-threatening pulmonary thromboembolism.

Venous aneurysms are relatively rare lesions. Five patients with venous aneurysms were surgically treated in our institution between 1998 and 2003. Patients included 4 female and 1 male, with mean age of 58.4 years (range 53 to 66 years). There were two patients with cephalic venous aneurysms, two patients with lesser saphenous venous aneurysms, and one patient with superior mesenteric venous aneurysms. In all cases, surgical treatment was performed. One of two patients with lesser saphenous venous aneurysms were complicated with varicose vein. Early surgical treatment is required for venous aneurysms of the popliteal vein, the superior vena cava and the portal vein, because of the risks such as pulmonary thromboembolism and rupture.

Between January 1999 and June 2002, 558 patients with varicose vein were treated in our clinic. Of these, 108 patients (19.4%) were male. There was no difference in the type of varicose veins between male and female patients.

Duration of the disease was significantly shorter in male patients than in female patients (male 11.2±10.2 years vs female 18.2±10.2 years, p<0.001) and age at onset of the disease was higher in male patients (45.3±14.5 years vs 37.6±13.0 years, p<0.001).

Male patients showed a significantly shorter half refilling time measured by photoplethysmography (5.2±3.1 seconds vs 6.6±4.6 seconds, p<0.05). A higher incidence of skin change (46.7% vs 19.9%, p<0.001), and more frequently underwent stripping compared to female patients (18.5% vs 6.0%, p<0.001).

The middle aged male (40-59 years), compared with the younger male (<40 years) and elderly male (>60 years), showed a significant decrease in half refilling time on plethysmography (4.7±2.5 vs 7.2±4.3, 5.3±3.5 seconds). Stripping was performed more frequently (27.1 vs 12.5, 11.4%).

Surgery for primary varicose vein is consisted with ligation of saphenous vein (HL) and stripping (ST). We had been decided operative procedure according to the appearance of varicosity. In this article, objective parameters ofduplex scan and air plethysmography were used. One hundred thirty-eight limbs with great saphenous vein varicosities were retrospectively investigated. The limbs with reflux, which exceed the knee joint, were studied. Diameter of great saphenous vein measured at lower 1/3 of the thigh (SM diameter) of ST group and HL group was 7.6±1.5mm and 5.6±1.4mm, respectively. Venous filling index (VFI) of ST group and HL group was 7.5±3.4 ml/sec, and 4.5 ±1.4 ml/sec, respectively. VFI and SM diameter correlate to each other with 0.6 correlation coefficient. SM diameter more than 7mm, and VFI more than 6 ml/sec, which were mean+SD of HL group value, were considered to be the indication of ST.

The purpose of this retrospective study is to establish the management guideline for captured thrombus in a temporary vena cava filter. Fourteen patients with high risk of acute pulmonary thromboembolism during surgical treatment underwent implantation of a temporary vena cava filter (Antheor^TM) immediately before treatments, and were enrolled in this study.

The captured thrombus was assessed by venography the next day after treatments (group V: 10 patients), by intraoperative transesophageal echography (2 patients), and by no examination (2 patients).

Among patients in group V, a shaded defect of more than 10mm in diameter was shown in 3 cases. The filter captured an old thrombus of 30×15mm, which was removed under general anesthesia, together through right jugular venotomy. Red thrombus of 10 or 15mm in diameter was encased in the filter sheath and removed. A floating tumoral thrombus of 30×20mm of renal cell carcinoma was detected at the just-caudal site of the filter by transesophageal echography, and subsequently removed through IVC-tomy. There was no symptomatic pulmonary thromboembolism during/after the surgical treatment.

In conclusion, a temporary vena cava filter is very useful in preventing catastrophic pulmonary thromboembolism during/after surgical treatment. To assess the problematic thrombus captured in the filter, a venography after treatment or an intraoperative transesophageal echography should be performed according to the individual situation. We think that a potentially fresh thrombus of less than 15 mm in diameter can be safely encased in the filter sheath and removed. However, immediate removal operation is preferable for thrombus more than 30mm in diameter, which is a potentially tumoral thrombus or an old thrombus. The management guideline for captured thrombus with 15-30mm in diameter remains to be determined.

The patient is a 65-year-old man who had varicose veins with pigmentation and lipodermatosclerosis 13 years ago. CT scans showed abnormal dilated vessels in the left pelvis. Angiography showed a pelvic arteriovenous malformation (AVM). Feeding arteries for this AVM originated from the left internal iliac artery. Varicose veins were secondary due to a high venous pressure caused by AVM. Transcatheter arterial embolization (TAE) was performed on the AVM by steel coils and N-butyl-cyanoacrylate (NBCA). Follow-up pelvic CT scans 3 years after the TAE showed that AVM had not recurred. Therefore the operation for secondary varicose veins was performed. Post operative course was uneventful.

TAE could be an effective as the first choice for the treatment of AVM. It is important to treat a primary disease for secondary varicose veins.

A 52-year-old man, who was previously diagnosed as protein S deficiency, had acute abdominal pain without peritonitis. Abdominal computed tomography scan revealed the superior mesenteric vein thrombosis and segmental edema of small intestine. Systemic heparinization was chosen as the initial treatment, but was not successful. Therefore, continuous injection of urokinase via the superior mesenteric artery was performed, resulting in no improvement. Finally, with percutaneous transhepatic access, direct injection of urokinase into the superior mesenteric vein and systemic anticoagulation therapy was tried. The thrombus was partially dissolved and abdominal condition of the patient was remarkably improved. Percutaneous thrombolysis of superior mesenteric vein with transhepatic approach should be a promising treatment for the mesenteric venous thrombosis patients without peritonitis.

We report a case of acute pulmonary embolism immediately after 13 hours’ flight, namely economy class syndrome, who underwent sclerotherapy for varicose veins 12 days before the flight. Sclerotherapy might influence the development of pulmonary thromboembolism caused by prolonged immobility during an extended plane journey.