Antiphospholipid antibodies (aPL) (anticardiolipin antibodies and lupus anticoagulant) have a specific pathoetiological role in the antiphospholipid syndrome (APS), an acquired thromphophilic disorder manifested by arterial or venous thrombosis and pregnancy morbidity. In this article, we review the clinical manifestations and diagnostic procedure of APS. Further, we discuss the appropriate prophylaxis of this syndrome, considering the potential effects of aPL on the coagulation and fibrinolysis systems implicated in the development of thrombotic complications in patients with APS.

The diagnostic methods and managements for acute pulmonary embolism are influenced by the severity of the disease. Pulmonary angiography is more frequently used in more severe cases, but lung ventilation and perfusion scan are more frequently used in less severe cases. Thrombolysis and catheter interventional therapy (inspiration and/or fragmentation) are more frequently used in more severe cases. Inferior vena cava filter and catheter interventional therapy were used in as many as 35.3% and 10.5% of the cases with acute pulmonary embolism, respectively.

It has been reported that the incidence of venous thromboembolism (VTE) in Japanese surgical population is not so low as previously thought. The clinical importance of thromboprophylaxis for pulmonary embolism (PE) has also been emphasized from the viewpoint of risk management and many different guidelines for prevention of postoperative VTE have been established in hospitals independently. Ideally, the guideline should be based on the solid evidence, but the reality in Japan is that there are quite few clinical data on VTE. From these circumstances, a comprehensive, standard guideline for prevention of VTE was recently established by applying the risk-prophylaxis relationship of the sixth American College of Chest Physicians (ACCP) consensus recommendations. Since the present guidelines are not sufficiently based on the Japanese evidence, they should be reevaluated by the prospective, nationwide epidemiological study, and must be revised if necessary. In this review article, the theoretical background and future perspective of the Japanese guidelines are discussed.

Venous thromboembolism (VTE), which had been considered a relatively rare disease in Japan, has been on the increase in recent years as eating habits have become more similar to those of the West. According to an analysis of 102 facilities surveyed by the Japan Society of Obstetrics, Gynecological and Neonatal Hematology, the incidence of pulmonary thromboembolism from 1991 to 2000 was 76 cases in obstetrics and 178 cases in gynecology, and is on the increase. The incidence in obstetrics consists of 0.02% of total deliveries, 0.003% of vaginal deliveries, and 0.06% of cesarean deliveries. The incidence in gynecology is 0.08% of total operations, 0.03% of benign diseases and 0.42% of malignant diseases. Based on this survey, guidelines for the prevention of VTE were drafted. Risk groups were placed in 4 categories of risk; low, moderate, high, highest. Recommended prophylaxis is early ambulation for low risk group, ES (elastic stocking) or IPC (intermittent pneumatic compression) for moderate risk group, IPC or LDUH (low dose unfractionated heparin) for high risk group, and LDUH + IPC or LDUH + ES for highest risk group.

The comprehensive summary of the annual surveillance of anesthesia-related mortality and morbidity (1994-2001) by Japan Society of Anesthesiologist (JSA) Committee on Operating Room Safety reported that intraoperative critical pulmonary embolism, including pulmonary thromboembolism (PTE), air embolism and fat embolism, occurred 0.63 cases per 10,000 cases in 5,383,059 cases. The predicted incidence of perioperative PTE was calculated to be 2.01 cases per 10,000 cases from above data and results of another report. First annual report of perioperative critical PTE in 2002 was published by the working group for prevention of PTE in JSA. It revealed that the overall incidence of perioperative critical PTE was 4.41 cases per 10,000 cases and mortality rate was 15.4%. Incidence of perioperative critical PTE (per 10,000c cases) referred to by surgical sites were as followed; extremities including hip joints 7.6 cases, thoracotomy with laparotomy 7.5 cases, spine 7.3 cases, Cesarean section 6.5 cases, thoracotomy 6.1 cases, craniotomy 5.7 cases, heart or great vessels 5.23 cases, laparotomy 4.7 cases, chest or abdominal wall 1.9 cases and head or ENT 0.6 cases. The percentage of preventative measures applied in PTE patients were as followed; nothing 43.8%, elastic bandage and elastic stocking 35.8%, intermittent pneumatic compression 31.7%, anticoagulants 8%. In summary, although the incidence of perioperative critical PTE in Japan was less than that in western countries in spite of less preventative measures for PTE, it was increasing year by year and distribution patterns in Japan referred to by age, preoperative physical status and surgical sites were comparable in western countries.

We report our prospective study of preservation of perforating veins (PV) and great saphenous vein (GSV) with review of the literature. Some incompetent PV become competent after saphenous surgery, therefore, not all of the incompetent PV needs operative ligation. Moreover, some PV becomes incompetent after surgery, which may be due to complex hemodynamics of superficial venous flow in addition to deep venous reflux. In many cases, GSV incompetence of the lower leg disappear after GSV stripping from the groin to just below the knee, if the GSV does not appear tortuous dilatation. We conclude that stripping of incompetent GSV below the knee portion could not be necessary, if the GSV does not present tortuous dilatation, in the view point of reducing saphenous nerve injury.

To investigate the impact of surgical pulmonary embectomy, thirty-six patients who had acute massive pulmonary thromboembolism were analyzed retrospectively. Patients were divided into two groups and compared: group S (n=14), patients who underwent pulmonary embolectomy, and group M, patients (n=22) who were treated medically. Average age of patients was 57±14 years, ranging from 24 to 84 years. There were 10 males and 26 females. All patients had hypoxia and cardiogenic shock was common in both groups (86% in group S vs. 72% in group M). Cardiopulmonary resuscitation and artificial ventilation was necessary in 29% and 64% in group S, 27% and 36% in group M, respectively. Seventy-one percent of patients in group S had a history of recent surgery, while 46% of patients had it in group M. Median interval between definitive diagnosis of pulmonary thromboembolism and the operation was 90 minutes, ranging from 40 minutes to 36 hours. In group M, fibrinolytic therapy, catheter intervention and insertion of the inferior vena cava filter was performed in 19, 2 and 4 patients, respectively. Hospital mortality was 0% in group S and 28% in group M. Morbidity in group S was intracranial bleeding in 1 and respiratory failure in 2, whereas that in group M was vegetative state due to prolonged hypoxia in 1.

In conclusion, surgical embolectomy for acute massive pulmonary thromboembolism is safe and efficacious if it is performed within short term after the onset. Emergency call for cardiopulmonary resuscitation team, early differential diagnosis and immediate cardiopulmonary support are important factors to save a patient with massive pulmonary thromboembolism.

In 406 limbs with long saphenous vein incompetence, a number of ligations of the long saphenous vein and the recurrence rate were compared. In 3-ligation group in which ligations were perfomed at the groin, thigh (above knee) and calf (below knee), a significantly higher recurrence rate was shown when all tributaries were not completely dissected at the sapheno-femoral junction. The recurrence rate in 3-ligation group was 30.8% at 5 to 6-year follow up, and was significantly lower than that in 2-ligation groups with ligations at the groin and thigh or at the thigh and calf, and 1-ligation group with ligation at the thigh. From these results, it is obvious that the recurrence rate depends on the ligation techniques. We want to emphasize, therefore, that the treatment outcome should not be discussed collectively as “ligation followed by sclerotherapy”. When the outcome is reported, the ligation technique should be described in detail

Sclerosing thigh long saphenous trunk is routinely performed in SHPL. However, this maneuver is frequently associated with pigmentation, thrombosis, and cord-like induration in thigh, which patients complain after the treatment. To avoid these complications, we omit sclerosing thigh long saphenous trunk in performing SHPL for selected patients. Our empirical criteria for omitting this maneuver is varicosity less than 8mm diameter without reflux proximal to Dodd's perforator and skin lesion. To evaluate the adequacy of our criteria, 87 cases, 101 limbs after SHPL without sclerosing thigh long saphenous trunk from July 1998 to October 2003 were retrospectively reviewed. Disease free rates were 100%, 90.4%, and 70.7% at 1 year, 3year and 5year, respectively. Symptom free rates were 100%, 93.2%, and 77.2% at 1 year, 3year, and 5 year, respectively. These long-term results were similar to those reported after stripping surgery alone. Only one out of 23 recurrent cases had segmental recurrence associated with long saphenous trunk reflux. SHPL without sclerosing thigh long saphenous trunk is a less invasive and satisfactory treatment for patients selected by our criteria. For these patients, sclerosing thigh long saphenous trunk appears to have little influence on long-term outcome after varicose vein therapy.

We investigated twelve patients who were died of PTE being hospitalized for non-cardiovascular disease. Their primary diseases were: orthopedics in 5 cases, neurosurgery in 3 cases, psychiatry in 3 cases, and obstetrics in 1 case. Two cases showed preexisting symptoms before death.

Their embolic source were detected at leg deep veins except one case at internal iliac vein. Ten cases had bilateral DVT and two had unilateral venous thrombi.

Histopathological feature showed that 8 cases were suggested suffered by single attack that contained only fresh thrombi. Rests were contained both fresh and organized thrombi that suggested recurrent DVT.

Soleal vein was the most frequent site of deep vein thrombosis that involved 83% of the limbs.

These results suggest that DVT of most in hospital patients were made after admission. And that most effectible factor of thrombosis is blood stagnation that tend to occlude bilateral crural leg veins.

As the most frequent site of thrombosis, soleal vein is important for primary prophylaxis of DVT. However, life-threatening emboli were thought to made as free-float thrombi made at ilio-femoral vein secondly to primary thrombosis at crural veins.