An upper extremity deep vein thrombosis is rare and reported incidence of such a condition is 1-2%o of all deep vein thromboses. We treated 5 patients (6 cases) of primary axillary-subclavian vein thrombosis (Paget-Schroetter syndrome). The patients’ chief complaints were of upper extremity swelling. The patients were males aged between 21 and 52 years old (37±13.6 years old of age). Only one case was related to sports activity (baseball), another case’s occupation was a truck driver, the other cases did not seem to be related to either sports or occupation. Four of the thromboses were located in the right arm, while one was bilateral, but occurred on separate occasions. The symptoms of the all of cases were upper extremity swelling but not pain, which gradually improved with conservative therapy, including anticoagulant therapy or combined therapy (anticoagulant, antiplatelet and thrombolysis). No intravascular intervention, such as percutaneous transluminal angioplasty or stenting was performed, because the results of reported stent cases were not so good in Japan. No surgical procedures, such as resection of the first rib to decompress the subclavian vein, were performed. Pulmonary embolism occurred in only one case; the bilateral case. In this report, we discuss and document our clinical experience with 6 cases of Paget-Schroetter syndrome.

The purpose of this study was to compare ultrasonography (US) with ^99mTc-MAA (human serum albumin macroaggregates) venography (RI) for accurate diagnosis of deep vein thrombosis (DVT) of lower extremities. RI and US were performed on the same day for 42 consecutive patients with suspected DVT or pulmonary thromboembolism. RI images of venous flow were classified into 3 groups: obstructive, disturbed and normal. US images were classified into 4 groups: obstructive, stenotic, disturbed and normal. US and RI findings were compared for the iliac, femoral, popliteal and calf portions (n=332) of veins. Sensitivity and specificity of US compared to RI were 78% and 86%; some cases displayed different findings between US and RI, and the reasons for such inconsistencies were analyzed. As a result, RI images of disturbed venous flow were found to occasionally appear as obstructive even when an obstruction was not actually present. Conversely, US images of deep regions may be very poor and sometimes misleading. For accurate diagnosis, combined use of RI and US might be appropriate.

In eight legs of six patients, endovenous obliteration by radiofrequency energy was performed for the varicose great saphenous vein. One month postoperatively, air plethysmography and ultrasound echography were used to examine results of this treatment. By ultrasound examination immediately after the operation, complete occlusion of the saphenous vein was obtained in all cases. At 1 month after treatment, 7 of 8 (88%) legs had complete occlusion of the saphenous vein, and 1 of 8 (12%) hadrecanalization. There were no critical complications, such as thrombosis and skin burn. At 1 day after treatment, two legs had pain and the abnormalities in feeling were noticed in two legs. However, all complications were mitigated at 1 month aftertreatment. In all cases, venous filling index (VFI) improved after the operation. Preoperative VFIs were 1.611 to 11.48 (an average of 5.904+3.812) and those of one month after the treatment were 0.737 to 5.143 (an average of 2.091+1.712). This method is less invasive than stripping. However, this is impossible for a case with markedly tortuous varicosis. Further study is necessary.

Complaints of elastic stockings obtained by questionnaires were compared between patients with lymphedema and varicose veins. The most frequent complaint was "expensive" for patients with lymphedema and “difficulty to apply” for patients with varicose veins, 89% and 63%, respectively. Thirteen of the 21 complaints, such as expensive, not covered by health insurance, too hot, pinch and loss of elasticity, were observed more frequently in patients with lymphedema than in patients with varicose veins. These results might be explained by the specific characteristics of lymphedema; 1) long and continuous use of elastic stockings, 2) high compression pressure and compression of the whole leg, 3) considerations for deformation ofthe leg. From these results it is emphasized that careful support including relief of psychological stress are important in treatment of lymphedema. Although double stockings are useful for patients who have difficulty in applying one strong stocking, some problems should be solved before clinical application.

[Aim] Instead of conventional stripping, a partial stripping with sclerotherapy was designed for the purpose of decreasing operative wounds and invasion. We carried out sclerotherapy using venography to confirm the inflow of sclerosants into varicose veins. Sclerosants were injected while proximal compression was performed if insufficient perforator interruption was achieved by subfascial endoscopic perforator surgery (SEPS). Flow ofsclerosants into the proximal superficial veins was inhibited by compression, but the contrast medium entered the popliteal vein in many cases. As a result, we reviewed the compression method and pressure that could inhibit the flow of sclerosant into the proximal superficial veins and deep veins. [Subjects and Methods] A combined procedure including sclerotherapy under venography was performed in consecutive 67 recent patients with great saphenous varices’ Sclerosants (hypertonic saline and foam aethoxysklerol) were injected into the great saphenous trunk after performance of retrograde saphenous venography with isotonic contrast medium (Iopamiron 150). The spread of contrast medium and sclerosant was compared under two different compression pressures of 60 and 300 mmHg, which were applied by using a femoral air tourniquet. [Results] At a compression pressure of 60 mmHg, contrast medium that entered the crural varices flowed out into popliteal vein, and the peripheral extension of contrast medium and sclerosant were not observed. At a pressure of 300 mmHg, however contrast medium showed little flow into the popliteal vein. and both the contrast medium and sclerosant entered vessels peripheral to the crural varices. [Discussion and Conclusion] For adequate sclerotherapy of varicose veins, it is important to inhibit the outflow of sclerosant into normal veins and to confine the sclerosing agent into the varicose veins. Sclerosants were effectively confined to crural varices by a proximal femoral tourniquet at a pressure of 300 mmHg, which prevented drainage of sclerosants into the deep venous system.

A 71-year-old obese female took a long-distance bus trip for 16 hours. One week later she returned home by bus following the same route. After getting off the bus she began to feel discomfort in her left leg and suddenly developed shortness of breath after walking for about 100 meters. Nine days later she lost consciousness for a few seconds while walking to the rest room. Ten days later she lost consciousness again while changing her clothes. She was brought to our hospital in an ambulance. Acute pulmonary thromboembolism was provisionally diagnosed on the basis of her history, physical examination, laboratory data, and results of electrocardiography and echocardiography. An emergency pulmonary angiogram was performed, which revealed large thrombi in both the right and left pulmonary arteries. The pulmonary artery pressure was 73/31 (45) mmHg. Therefore, a temporary inferior vena cava (IVC) filter was placed below the renal veins. After she was admitted to coronary care unit, she was administered anticoagulation and thrombolytic therapies, which improved her condition. Magnetic resonance venography of both her lower legs revealed no deep vein thrombosis. The findings of all her blood tests were normal including coagulation ability. Chest computed tomography that was performed on the eighth day of admission revealed only small thrombi in the peripheral pulmonary arteries. The temporary IVC filter was extracted on the ninth day of hospitalization. She was discharged on the 12th day of hospitalization. Although she had shortness of breath immediately after the long-distance bus trip, diagnosis was not made until 10 days later when she lost consciousness. We have to consider the possibility of traveler’s thrombosis when patients develop symptoms such as shortness of breath after taking a long-distance

trip.

A 32-year-old expectant woman, who had been diagnosed with congenital antithrombin III (AT III) deficiency (type I) at 21 of age suffering venous thrombosis of the superior sagittal sinus, was admitted to our institute for treatment for deep vein thrombosis on her 8th week gestation. The patient underwent antithrombotic therapy with supplemental human AT III (three times in over the course of a week) and heparin infusion (daily) according to the serum D-D dimer level and AT III activity from the time of admission until 16th week gestation. Anticoagulant therapy with warfarin was initiated succession to daily heparin infusion to improve ADL (activities of daily living). Fetal cardiac sound suddenly stopped and ventricle of the brain expanded on the 24th week gestation. The fetus died as a result of cerebral bleeding. Since the patient had exhibited an allergic reaction to the iodine contrast material, she was immediately examined with pulmonary perfusion scintigraphy and magnetic resonance imaging for detection of any pulmonary embolism after the stillbirth. These examinations found no blood flow in the right upper lung and occlusion of the inferior vena cava.

A biodegradable stent for venous obstructive disease was developed. The stent is constructed of a material that is absorbed in a nontoxic manner, preventing restenosis during repair of injured sites. The stent woven from 0.3mm filament of poly-L-lactic acid (PLLA) has promising compression strength compared with a metallic stent. The PLLA stent of 6 ౷ 40mm was implanted into the canine common femoral vein in a self-expanding fashion. After implantation, the follow-up color duplex scanning was performed to confirm patency of the stent. Four months after implantation, the animal was sacrificed and the stented iliac vein was harvested. Elasticity of the vessel wall was still preserved. Thrombus formation or stenosis of the internal lumen was not observed. Intimal thickening was not apparent and the internal lumen was smooth, especially at both the ends of implanted stent. Histological examination revealed formation of a thin layer of fibrous tissue and minimal inflammatory reaction around the filament. These results suggest that the PLLA stent has promising strength and biocompatibility without thrombosis or stenosis in the canine iliac vein.

An international interdisciplinary consensus statement concerning the nomenclature of the veins of the lower limbs was published in the J Vasc Surg in 2002 by Caggiati et al. The terminology committee of the Japanese society of phlebology decided to inform the new nomenclature of the lower limbs without any changes to the members. For the understanding of a new proposal, differences of the three nomenclatures among the terminologia anatomica, proposed terminolory, and Japanese terminology in phlebology are summarized in the superficial, deep, and perforating veins.