From 1993 to 2007, 1928 patients (478 males, 1450 females) with varicose veins consulted our hospital. Of them a total of 1314 patients were treated. In treatments of non-saphenous varicose veins, sclerotherapy was the most often carried out. The number of the patients treated with sclerotherapy alone was 250. In the early years we used to treat patients with saphenous vein incompetence by high-ligation of sapheno-femoral junction combined with sclerotherapy using 14.5% hyperosmotic saline. In some cases ligation at the above and below knee was also done as an additional procedure to prevent recurrence. However, in recent years, the incidence of stripping increased, while that of ligation decreased, because recurrence rate of high-ligation was higher than that of stripping. If the diameter of the saphenous vein was greater than 8 mm, stripping was performed. Low invasive selective stripping was recommended rather than standard stripping as a surgical procedure. The number of the high-ligation and stripping were 704 and 360 respectively for the past 15 years.

From 2003 we began foam sclerotherapy using 1% and 3% polidocanol. The sclerosing foam was formed using a three-way stopcock and two syringes, mixing air with liquid polidocanol. The mixing ratio for sclerosant: air is 1:4. We use polyurethane trapezoidal pads and self-adhesive bandage for compression following sclerotherapy. Post-treatment compression was used for 2 days. The results obtained with foam sclerotherapy are better than those with fl uid sclerotherapy. Because the foam has a stronger sclerosing action, the treatment goal can be achieved with a sclerosant of a lower concentration than in the case of sclerotherapy with a fluid sclerosant.

After injection of foam, the foamed sclerosant remains locally in the venous segment to be sclerosed for a longer period of time. Although some phlebitis and hyperpigmentation can be seen after treatment, foam sclerotherapy is useful, noninvasive and cost effective for the treatment of varicose veins.

Nowadays we primarily treat the patients with saphenous vein incompetence by the selective stripping combined with foam sclerotherapy. The recurrence rate of stripping with sclerotherapy was equivalent to that of stripping with varicectomy. Hence varicectomy can be replaced with sclerotherapy. The use of sclerosing foam may become an established therapy in the treatment of varicose veins with a high success rate, low cost and low major complication rate.

Polidocanol (POL) is originally developed as a local anesthetic, and is now the most frequently-used detergent sclerosing solution in Europe. In Japan, it is the only sclerosant that was approved by the Japanese Ministry of Health, Labour and Welfare in 2006. It is also commonly used in the United States, although, FDA has not yet approved it as a pharmaceutical product at the moment. After introduction of sclerosing foam, many phlebologists are now in favor of the use of POL-foam instead of the use of POL-liquid. However, few studies have focused on the efficacy of POL-foam compared with that of POL-liquid in sclerotherapy of venous insufficiency. We have conducted comparative study between POL-foam and POL-liquid in the treatment of superficial venous insufficiency. Follow-up duplex scanning demonstrated that the proportion of complete occlusion in the great saphenous vein was significantly higher in patients treated with ultrasound-guided POL foam sclerotherapy (UGFS) than ultrasound-guided POL-liquid sclerotherapy (UGLS) at 12-month follow-up point. In UGFS, values of venous filling index remained normal during the subsequent follow-up examinations, whereas in UGLS, venous filling index began to increase, and there was a significant difference at 6 months between UGFS and the UGLS. This study confirmed that POL-foam has extensive advantages over POL-liquid in the treatment of superficial venous insufficiency. In Europe, the 1st and 2nd Consensus Meetings on Foam Sclerotherapy were already taken place in Germany. In this paper, many solved and unsolved questions on foam sclerotherapy are also discussed.

Change of sclerotherapy after varicose vein surgery was discussed. Former group with 88 limbs in 56 patients (1998–2001 year), and latter group with 76 limbs in 54 patients were studied. Incidence of sclerotherapy was 51.1% in Former group, and 30.3% in Latter group (p < 0.01). Surgical incisions were 2.21・1.08 in Former group, and 3.31・1.27 in Latter group (p < 0.001). Frequency of sclerotherapy per limb was 0.94 in Former group, and 0.43 in Latter group (p < 0.01). Amount of sclerosant was 1.93・1.37 ml in Former group, and 1.61・1.23 ml in Latter group (ns). Although incidence of postoperative sclerotherapy is decreased, 30% of patients

still need sclerotherapy.

It has been reported that residual incompetent great saphenous vein after ligation results in recurrence. To reduce recurrence rate, we adopted the injection of the saphenous trunk with foam sclerosants at the time of surgery. Foam sclerotherapy with multiple ligation group was superior to multiple ligation group in short term obstruction rates of great saphenous vein.

We have already reported about the safety, feasibility, and cure rate (85.7%) of SEPS (subfascial endoscopic perforator vein surgery) for chronic venous ulcers of the C6 patients, according to the CEAP classification. However the SEPS operation is not still authorized by the national health insurance system yet, and has been tried among a few groups in Japan. This study was undertaken to report our latest results, and discuss about how to spread SEPS operation in our country.

From 1998 to 2006, we performed two-port system SEPS (TPS-SEPS) with or without superficial venous ablation (SVA) on 733 limbs. In these periods, access ports have been changed, and the dissecting forceps for SEPS were newly designed by us. Of these cases, we had not had any case of post operative hemorrhage which needs additional hemostatic operations, nor critical complications. Of the 72 C6 limbs of 67 patients the cure rate of stasis ulcers was 90.3%. According to the safety, feasibility, and cure rate of SEPS for chronic venous ulcers, this result would be good enough for the obstinate venous ulcers.

Allowing for the recently trend of reducing national medical expenses, it will be diffi cult for SEPS, which is now free of charge, to be authorized by the national health insurance system.

Under the present condition, we have better to apply SEPS for the national advanced medicine system by the Ministry of Health, Labour and Welfare. National investigation through the institutions with certain level which authorize for the Ministry of Health, Labour and Welfare may be effective to spread SEPS operation in Japan.

The changes in QOL (quality of life) before and after treatment of the varicosity of lower extremity were observed in 95 patients with primary lower extremity varicosity. The patients were allocated into the mild group consisting of 47 cases of CEAP class C2 and 12 cases of CEAP class C3 and the severe group consisting of 23 cases of CEAP class C4a, 2 cases of CEAP class C4b, 1 case of CEAP class C5, and 10 cases of CEAP class C6. In operative procedures, 58 patients had ligation of saphenous vein under local anesthesia and 37 patients received stripping under general anesthesia. Their QOL were observed using the SF-36 Questionnaire before, 3 months and 1 year after treatment. There were no significant differences between the groups before treatment. One year later, the scores of the role-physical, bodily pain, social functioning, role-emotion, and mental health in the severe group were significantly higher than those in the mild group. In the subgroup of C2 patients, the scores of vitality and mental health before treatment in the patients who had stripping were significantly lower than those in the patients who had ligature. After surgery, no significant differences were observed in operative procedures. QOL assessment by using the SF-36 Questionnaire was effective in assessment of the therapeutic effect. Mental parameters were also able to be evaluated.

Chronic venous insufficiency (CVI) is an important public health problem because of its prevalence, therapeutic cost, and impact on quality of life. Varicose veins are the most common manifestation of CVI. Although some drugs are used in patients with CVI as adjunctive and palliative treatments, few pharmacological options to limit the progression and discomfort of varicose veins are available. Previous studies suggested that matrix metalloproteinases (MMPs) cause the destruction of extracellular matrix in vascular diseases including varicose veins, and that HMG-CoA reductase inhibitors (statins) inhibit the secretion of MMPs from various cultured cells. In this review, we summarize our recent report demonstrating the effect of statins on MMPs in human varicose veins. Initially, we analyzed protein expression of MMPs in the vein walls by gelatin zymography. We found that MMP-9 was present at signifi cantly higher levels in varicose veins than in controls. Interestingly, MMP-9 was localized mainly in smooth muscle cells at the tunica media, where marked degradation of the extracellular matrix was observed. Next, we established the ex vivo culture of human varicose veins to determine the effect of statins. Simvastatin or pravastatin caused striking suppression of the activity of MMP-9 secreted from human varicose veins, while they showed a modest reduction of MMP-9 protein. In addition, urokinase-type plasminogen activator, an activator of MMP-9, was significantly inhibited by simvastatin. Therefore, statins signifi cantly suppress the activity of MMP-9 by inhibiting both production and activation steps in human varicose veins. Statins may have a clinical implication for the treatment of varicose veins and CVI.