Purpose: We have already reported that subfascial endoscopic perforator vein surgery (SEPS) promotes the healing of venous ulcers in patients with chronic venous insufficiency. However six of 53 limbs still had active ulcers after SEPS. The duration of ulceration had a significant influence on healing after SEPS, and unhealed ulcers were likely to be multiple and larger than 2 cm in diameter. However it was difficult to predict which ulcers could be cured by SEPS with or without superficial venous ablation (SVA). This study was designed to investigate whether the transcutaneous oxygen tension (tcPO₂) could be a predictor of venous ulcer healing in chronic venous insufficiency patients treated by SEPS. Materials and Methods: The tcPO₂ was examined in patients with active or inactive venous ulcers (C5, C6). Measurement was done with a 6-channel TCM400 (Radiometer Copenhagen) simultaneously on both thighs, both calfs, and above the medial malleoli in the supine and upright positions. The same measurements were also done in healthy adults and in varicose vein patients without stasis dermatitis (C2) as a control group. Results: In the control group, tcPO₂ increased in the upright position at the three sites of measurement. On the other hand, tcPO₂ above medial malleoli, (where venous ulcers are common) was lower in the patients with chronic venous insufficiency than in the control group, and did not change or decreased in the upright position (dip/flat pattern), unlike the results in the control group (bulge pattern). Discussion and Conclusion: Intractable ulcers are likely to be associated with more extensive fibrin deposition around capillary vessels, leading to impaired diffusion of oxygen. The decrease of tcPO₂ in the upright position (dip/flat pattern) may have resulted from peri-capillary fibrin deposition, and thus may be a sign of intractability. Therefore, we conclude that measurement of tcPO₂ with positional changes can be a predictor of venous ulcer healing in chronic venous insufficiency patients. In dip/flat pattern, there will be a possibility of recurrence and strict leg care will be needed ulcers heals.

Purpose of this study is to determine the effect of laser energy of endovenous laser treatment (EVLT) on venous occlusion and minor complications such as bruising and delayed tightness. Thirty six great saphenous veins were included in this study. Laser fiber was inserted in the vein under ultrasound guidance, and EVLT was performed by using 810-nm diode laser with energy at 14W (nロ27) or 10W (nロ9) in continuous mode. With 14W, complete occlusion was observed in all veins except I case of no-occlusion and I case of partial re-canalization (92.6%). With 10W, complete occlusion was observed in all veins except I case of partial re-canalization (88.9%, P>0.05). Bruising/delayed tightness were noticed in 33.3% and 74.1% with 14W, respectively, while 11.1% (P<0.05) and 77.81% with 10W, respectively. To reduce the laser energy from 14W to 10W may decrease a rate of bruising after maneuver and may not decrease a rate of venous occlusion.

Both heparin and warfarin are used extensively for the treatment and prophylaxis of thromboembolism as the anticoagulants in medical and surgical practice. At the point of using these anticoagulants, it is taken particular care to a relative high frequent complication, as hemorrhage easily. However, what happens is that it is not known further complication. We reported a patient whose clinical course suggested that the immune-mediated heparin-induced thrombocytopenia during the treatment of acute artery occlusion associated with the gastric cancer might be a risk factor for the development of warfarin-induced skin necrosis. Failure of early diagnosis and treatment may result in death. Many reviews have now been given a complete description of heparin-induced thrombocytopenia. In this paper, we comment on the thrombolytic complications of venous limb gangrene and warfarin-induced skin necrosis as the serious side effects that all clinicians should be aware of these existences, although its precise pathogenesis is still unclear.

The patient was a 73-year-old male who was administered umkinase (UK) and heparin treatment for deep-vein thrombosis (DVT) in the left leg at a dosage of 10,000-units/day/7 days. Twelve days after the start of heparin administration, the number of platelets rapidly decreased and the swelling in the leg worsened, thus resulting in his being transferred to another hospital where he was diagnosed to have heparin-induced thrombocytopenia (HIT) and DVT which had worsened due to HIT. A total of four treatments of alternating anticoagulation using argatroban and thrombolytic therapy at a large UK dosage of 720,000 units (3,000 units/kg/hour) were performed. The pain in the leg immediately subsided after the large amount of UK was administered, and the swelling in the leg started to improve two days later. Thereafter, the UK dosage was first reduced to 120,000 units and then further gradually decreased until the administration was finally terminated. The number of platelets gradually recovered and no complications in either arterial tlu•ombosis or thmmbophlebitis were newly observed when the patient was discharged from the hospital. This patient represents one example m which DVT worsened due HIT, however, it was successfully treated by a large dosage of UK.

A 68-year-old woman was admitted to our hospital under a diagnosis of melena due to cavernous transformation of the hepatic hilar lesion. Choledochojejunostomy was performed for choledochal cystoma over 30 years ago, and she sufferd from chronic pancreatitis for a long time. Portal vein thrombosis had been pointed out for 3 years, although her liver function was normal. Therefore, it was thought that portal vein thrombosis caused collateral circulation via lifted jejunal vein and made hepatic hilar cavernous transformation. We performed, at first, mosocaval shunt, but it was obstructed in 5 months. Therefore, with minimal laparotomy, we led a catheter from peripheral mesenteric vein to the feeding vein of cavernous transformation, and performed the transcatheter coil occulusion for the feeding vein. This combined therapy for hepatic hilar cavernous transformation, minimal laparotomy and endovascular surgery (EVS), was very effective and minimal invasive one.

A 43-year-old man who had peviously undergone a high ligation of the long saphenous vein and sclerotherapy of the right lower limb, underwent stripping of the long saphenous vein- The stripper in the long saphenous vein was inserted into the common femoral vein through the saphenofemoral junction (SFJ) and then it was stripped over a length of approximately 2 cm. A sclerotic perforator near the SFJ was pulled off at the superficial femoral vein and this resulted in extensive bleeding. Fortunately, the tom superficial femoral vein could be sutured and the defect of the common femoral vein could be repaired with a splice graft by splicing 3 pieces of the left long saphenous vein. This case suggests that the SFJ must be clearly displayed with meticulous attention before the long saphenous vein is stripped, especially m cases who have previously undergone either a vein resection or sclerotherapy.

A 32-year-old pregnant woman, gravida 2, para 1, with an enlarged uterine myoma, were admitted to our hospital with stronger feeling of abdominal tightness at 30th weeks of pregnancy. The cesarean was performed under ordinary prevention of thrombus as high risk group according to Japanese venous thromboembolism prevention guideline at the 37th pregnant week. The patient suddenly complained of syncope at first walking after childbirth. Computed tomography revealed multiple pulmonary thromboembolism and compressed pelvic veins and a huge solid mass in the pelvis, probably a myoma. There were also mild bilateral hydronephrosis and a large thrombosis in the femoral and common iliac veins, and inferior vena cava. The treatment with anticoagulation and thrombolytic therapy was successfully cleared the multiple pulmonary thrombi. After the 8th week of childbirth, there was little improvement in uterine myoma size. It was decided that surgical removal of a huge uterine myoma was indicated to eradicate the etiology ofthe continued venous compression. With a temporary inferior vena cava filter preoperatively, the uterine leiomyomectomy was performed with an uneventful recovery, and then the patient was discharged. We describe a pregnant woman who had stasis of the pelvic venous system secondary to compression by a huge uterine myoma without any other identifiable risk factors for the development of deep venous thrombosis and pulmonary thromboembolism. The existence of deep venous thrombosis associated with a huge uterine myoma may often require inferior vena cava filter as well as elastic stocking, intermittent pneumatic compression and intravenous injection of heparin.