During the past 5 years, we experienced 9 cases undergoing surgical treatment for venous lesions associated with other operations. There were 8 males and one female, ranging in age from 41 to 76 years (mean, 62 years). In 4 cases of pancreatic tumors, combined resection and reconstruction of portal and superior mesenteric veins (PV and SMV) were performed with simple clamping in one case and under SMV-femoral vein (FV) shunting in 3 cases. Reconstruction procedure consisted of end-to-end anastomosis in 3 and interposition using superficial FV in one case. In 3 cases of renal cell carcinoma (RCC), infrahepatic inferior vena cava (IVC) tumor thrombi were removed with simple clamping concomitantly with radical nephrectomy. In a case of retroperitoneal fibrosis, the bilateral iliac veins and right ureter were involved, leading to leg edema and hydronephrosis. In addition to tumor biopsy and ureterolysis, venous bypass using 14 mm ringed expanded polytetrafluoroethylene was performed between the right external iliac vein and IVC. In another case of iliofemoral vein thrombosis complicated by the huge myoma uteri. hysterectomy was performed under temporary IVC filter. Postoperatively, the filter was distorted with a large quantity of captured thrombus, and was surgically removed through caval venotomy. In prognosis, 5 cases have survived now 6 months to 5 years after surgery, while 3 cases of RCC and one of pancreatic carcinoma died of tumor metastasis. Especially, in 3 benign cases, patients have obtained a good quality of life.

We report an adult case of absence left brachiocephalic vein without a persistent left superior vena cava or accessory hemiazygos vein connection. A 64-year-old man was admitted to our hospital for tinnitis and diagnosed with cerebellar infarction. During admission, heart murmur was noted and aortic regurgitation was diagnosed. At aortic valve replacement, left brachiocephalic vein was not revealed in the usual position. Venography showed that venous blood from left upper limb was returned in a retrograde manner through the left internal jugular vein, passing through skull venous connection and draining to the right internal jugular vein. The patient did not experience edema of left upper limb. Moreover, the relationship between this venous return and the onset of cerebellar infarction was unclear.

Case 1: A 43 years-old female. On May 6, 2006, a day after she had a massage on her arms, the patient became aware of swelling and an oppressive feeling in her right upper limb, and admitted on May 8. The circumference of the arm was 4.5 cm larger than the unaffected side and that of the forearm was 5 cm larger. Venography revealed a complete obstruction of the right axillary vein. Catheter directed thrombolysis therapy with urokinase (240 000 IU/day) and unfractionated heparin (10 000 U/day) was performed for 3 days. Follow-up venography revealed partial lysis of the thrombus. The patient was normal on hypercoagulability screening including antithrombin III (AT III), protein C and protein S. Oral anti-coagulant therapy with warfarin sodium was initiated, and she was discharged 9th day of the hospitalization.

Case 2: A 16 years-old male, left-handed baseball pitcher. On June 29, 2005, this patient noticed swelling of his left arm and admitted our hospital the next day. The circumference of the arm and the forearm were 3 cm larger than the unaffected side. Venography revealed an obstruction of the left subclavian vein. Catheter directed thrombolysis therapy as mentioned above was performed. Venography performed 5 days after the admission demonstrated partial lysis of the thrombus. AT III activity of this patient was 59.6% (normal 75.0-125.0%) and antigen concentration was 41.9 mg/dl (normal 15.0-31.0 mg/dl). His father had been diagnosed as deep vein thrombosis of the left lower leg 4 years ago and AT III activity of his father was 45.0%. These findings levealed the diagnosis of type II inherited AT III deficiency. Wafarin sodium was administered and he was discharged 8th day of the hospitalization.

Both of the two patients were relieved from symptoms and returned to social life without any complications. It is important to begin immediately fibrinolytic therapy combined with anticoagulant therapy after the diagnosis. In recent years, fibrinolytic therapy via a catheter has become the usual choice for the initial treatment of acute phase subclavian and axillary vein thrombosis.

We encountered 2 cases of malignant bone and soft tissue tumor of the femur who required resection of the vein. In case 1, left superficial femoral vein and minor tissue resection with preservation of the great saphenous vein was performed. Her superficial femoral vein was not reconstructed, but she had no venous-related postoperative complains. In case 2, wide tissue resection including left common femoral vein, superficial femoral vein and great saphenous vein was performed. His femoral vein was reconstructed with an ePTFE graft. Moderate swelling remained in his left leg. Graft obstruction was recognized at 4 months after operation, but severe stasis was not recognized. However long-term patency of vein reconstruction is not fine, vein reconstruction may play an important role in venous return until the development of the collateral veins. Vein reconstruction is required in case whom preservation of deep femoral vein is impossible or in case of wide tissue resection with cutaneous veins, especially with great saphenous vein, ePTFE graft may be an option for reconstruction.

The accurate diagnosis and selection of surgical indication are very important for the treatment of venous ulcers. A 63-year-old woman was admitted with bilateral venous ulcers for over 13 years, because of difficulty of its diagnosis and treatment. At the time of admission, both lower limbs were extremely swollen with infected giant ulcers, surrounded by pigmentation and sclerotic skin. We performed careful therapy for ulcers with strong compression, simultaneously, ascending and descending phlebography and also echography were carried out. Deep vein reflux (Kistner classification, grade III) was confirmed. Ligation of saphenofemoral junctions of great saphenous veins, its branches and incompetent perforator interruption at the just below knee level, resection of varicous veins were performed as the first line of repair. Ligations of incompetent perforators at the site of ulcer formations after adequate evaluation of perforators were performed as the second operation. The good result could be evaluated from the standpoint of clinical and physiological improvement after these procedures. The simple surgical ligation of saphenous vein and incompetent perforator interruption under the accurate and careful evaluation is thought to be first preferable surgical procedures for venous ulcers of lower extremities, regardless of the degree of deep vein reflux.