We studied the outcome of vein stripping under local anesthesia and propofol in 1,705 patients with primary varicose veins of the lower extremities (2,341 limbs) on an outpatient basis. The patient population included 444 males and 1,261 females. Average of patient age was 57 years old, and 6% of the patients (n口101) were over 75 years old. The operative procedures consisted of great saphenous vein (GSV) stripping in 1,963 limbs and small saphenous vein (SSV) stripping in 570 limbs. Full-length stripping accounted for slightly less than 40% of the all cases. Combined GSV and SSV stripping operations were performed in 192 limbs. No anesthetic intoxication occurred in any patient, whereas ventricular extrasystole due to propofol was observed in 2 patients. The operative complications were postoperative hemorrhage requiring emergency surgery in 1 patient and intraoperative difficulty in hemostasis in 5 patients. Wound infections developed in 8 limbs (0.3%), but all of the infections subsided after treatment on an outpatient basis. Taken altogether, nerve injuries affected 97 limbs (4.9%) of GSV stripping and 14 limbs (2.5%) of SSV stripping. Even in cases of full-length stripping, nerve injuries occurred in 67 limbs (9.0%) and 10 limbs (4.5%), respectively. The sural nerve was excised erroneously in one case of SSV stripping, however. There were no other clinically significant complications (deep venous thrombosis, pulmonary embolism, etc.), and no postoperative delirium was induced in the elderly patients.

A retrospective study was performed on 469 limbs of 448 patients who were treated in our institute from June, 1999 to November, 2003. Among them, 31 limbs were performed sclerotherapy only, 394 limbs were high ligation and/or sclerotherapy on outpatient clinic, 44 limbs of 31 patients were stripping and/or concomitant operations on admission. In admission group, active ulcer was seen in 10 limbs, healed ulcer was in 3 limbs. Only 15 limbs in 99 limbs with pigmentation were treated by operations on admission. On the other hand, 10 limbs in 11 limbs with active ulcer were treated by operations on admission. These results suggested that the patients who had active ulcer were recommended to perform operation on admission. The patient’s satisfaction after treatment in both groups were achieved approximately 95%. In conclusion, it is most important to select an adequate treatment and procedure that meet each patient’s needs and produces the best clinical outcome without complications.

D-dimer has been extensively evaluated as a diagnostic test for acute venous thromboembolism. However, little is known about the time course of the markers of hemostatic system during the treatment with heparin and urokinase. This paper concerns the changes with time of fibrinogen degradation product (FDP) and D-dimer in the patients with deep vein thrombosis (DVT). The subjects were consecutive 24 patients with acute symptomatic proximal DVT diagnosed between September 1999 and December 2004. There were 11 men and 13 women and their ages ranged from 29 to 88 years old, with a mean of 61.5 years old. The affected limbs were 19 left lower, 4 right lower and one right upper extremities. All patients were treated with intravenous drip infusion of heparin (10,000 units/day) and urokinase (240,000 units/day) for 5 to 7 days. Blood was sampled before and during the treatment. FDP and D-dimer levels were determined using a immunoturbidimetric assay. The mean plasma levels of FD P and D-dimer before the treatment were 19.1±10.8 and 10.2±5.1μg/ml, respectively. They diminished gradually and normalized within about 2 weeks after the treatment. The relationship between FDP (Y), D-dimer (X) was Y=1.854+1.419X, R=0.767, p<0.0001. The plasma levels of PDP (Y₁), D-dimer (Y₂) before the treatment and the presumptive affected period before the treatment (x days) revealed the following relationship, respectively. Y₁=30.558-2.237x, R=0.678, p=0.0005, Y₂=13.883-0.689x, R=0.453, p=0.03. There is a possibility that one can speculate the affected period of the patients with DVT by the plasma levels of FDP and D-dimer.

The present authors previously reported that the symptom would be alleviated if the treatment of thrombolytic therapy on DVT shows the diagnostic efficacy on the computed tomography (CT).

In order to test this theory objectively, the following testing method was used. We measured femoral muscle area ratio (FMR: The ratio of femoral muscle swelling (affected/unaffected) was estimated by measuring the area of femoral muscles on (CT), duplex scan and air-plethysmography before thrombolytic therapy on DVT. We also measured those facts after thrombolytic therapy on DVT. After we compared those two sets of facts clinically, we found correlation among clinical changes, air-plethysmography and FMR. This finding suggests that FMR can be used as a criterion to see effectiveness of the treatment.

Superficial thrombophlebitis with varicose vein is relatively common disorder, and it is generally viewed as a self-limiting disorder. We experienced two cases of superficial thrombophlebitis after operation for varicose veins. A 57-year-old woman was treated with high ligation; thrombophlebitis occurred along the residual widened long saphenous vein. A 47-year-old man was treated with stripping and varicectomy; thrombophlebitis occurred along the residual widened varicose veins in the right lower limb. Conservative therapy such as aspirin and Hirudoid^® ointment were effective.

At three days after placement of vena cava filter was performed to prevent fatal pulmonary embolism, retropenetrial hematoma and vena cava filter occlusion was detected by abdominal CT. A 78-year-old man was diagnosed of deep vein thrombosis by venography and bilateral pulmonary thromboembolism by chest CT. After conservative therapy with heparin and urokinase, inferior vena cava filter (Simon-nitinol filter^®) was inserted in infrarenal vena cava. Three days after the insertion, the patient presented with lower abdominal pain. Abdominal CT revealed retropenetrial hematoma and thrombosis in deformed vena cava filter. A fter anticoaglant and thrombolytic therapy were stopped, retropenetrial hematoma and thrombosis in vena cava filter was improved in a week. Six months after discharge, there was no thrombosis in vena cava and deep vein and deformed vena cava filter was returned to normal shape.

The case of iliac vein thrombosis with pelvic arteriovenous fistula is very rare. A 78-year-old man admitted with a swollen left limb. He was complicated deep venous thrombosis (DVT) with internal iliac arteriovenous fistula after inguinal hernioplasty. At the time of admission, the left limb was extremely swollen and with severe secondary varicose veins. There was a small ulceration surrounded by pigmentation. Continuous murmur was present in the left inguinl region. Selective angiography from left internal iliac artery showed common iliac vein occulusion and pelvic arteriovenous fistula. Femoro-femoral cross-over bypass was performed with 8 mm expanded polytetrafluoroethylene (ePTFE) (Gore Tex^®). Iliac vein pressure decreased and swelling of the left limb was obviously reduced. Unfortunately, he died from wound infection with methicillin resistant Staphylococcus aureus (MRSA) following lymphorrhoea. We thought that the embolization therapy for arteriovenous fistula concomitantly with femoro-femoral venous cross-over bypass had to be performed.

A 60-year-old man, who had malignant lymphoma combined with pulmonary embolism due to deep venous thrombosis, was reported. The patient underwent an inferior vena caval filter insertion combined with anticoagulant therapy. After discharging our hospital, the anticoagulant was discontinued for starting a chemotherapy of malignant lymphoma. The patient complained of lumbago and gait disturbance 45 days after discharge from our hospital. The abdominal CT revealed the filter occlusion by caval thrombosis. The patient was treated again with fibrinolytic and anticoagulant therapy in our hospital. Symptom was disappeared after the treatment. The detection of deep venous thrombosis and pulmonary embolism became easy due to diagnosis device development, such as CT. Frequency to use caval filter appliance with increase of deep venous thrombosis is increasing, and the serious complications of filter are recently reported in the literature. In this case, the use of the filter was thought to be successful to improve his life convalescence, though his vena cava was occluded.