Keisi-bukuryo-gan was first described in Chinese medical classics Chin-Kuei-Yao-Lueh (金匱要略，200A. D.) and known as one of the most important “kampoh” prescriptions used as a remedy for the “oketsu” syndrome. This prescription contains Moutan Cortex, Persicae Semen and Paeoniae Radix, which are all thought to be improve the “oketsu” syndrome. Keisi-bukuryo-gan possesses the potential to improve peripheral microcirculation by reducing blood viscosity and platelet aggregation. In this paper, we have investigated the effects of oral administration of Keisi-bukuryo-gan on the improvement of the swelling of the lower extremity in the patients with deep vein thrombosis. A prospective controlled trial was devised.

The subjects were consecutive 12 patients with acute symptomatic proximal deep vein thrombosis diagnosed between January 2003 and December 2007. There were 5 men and 7 women and their ages ranged from 30 to 89 years old, with a mean of 65.8 years old. The affected limbs were 9 left lower and 3 right lower 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. Oral anti-coagulant therapy with warfarin sodium was continued for six months. The patients were categorized as follows: Group A–6 patients treated with Keisi-bukuryo-gan; Group B–6 patients treated without Keisi-bukuryo-gan. The two groups were comparable with respect to ages, sex and laterality. To eliminate bias during the period of study. selection of patients was randomized. Consent was obtained from individuals. A granulated preparation of Keisi-bukuryo-gan extract (Tsumura. Inc, Tokyo) was used for this study. The subjects ingested 7.5g of Keisi-bukuryo-gan extract t.i.d. for six months. Each patient was evaluated for the difference of the maximum calf circumference between the affected and the normal limbs. Improvement rate was defined as the following equation. Improvement rate = (Circumference difference before treatment - Circumference difference after treatment)/ Circumference difference before treatment x 100%. The values are expressed as mean±S.D. Statistical evaluation was performed by analysis of the paired Student’s t test.

The difference of the circumference between the affected and the normal limbs in Group A were 5.6±1.3cm (before treatment) and 1.8±1.1cm (after treatment). Those in Group B were 5.2±2.3cm and 3.5±1.9cm, respectively. The circumference difference were significantly decreased after treatment in both groups (p<0.05). The improvement rates of Group A and Group B were 66.1±20.5% and 34.0±13.7%,respectively. The former was significantly higher than the latter (p<0.05).

The results obtained suggest that Keisi-bukuryo-gan has a salutary effect on the improvement in the swelling of the limbs. Catheter directed thrombolysis therapy is more effective than conventional systemic therapy, however, it has some contraindications. Oral administration of Keisi-bukuryo-gan is easy and effective for the treatment of deep vein thrombosis. This result must he evaluated more strictly after collecting more cases in the future.

Background: The purpose of this study was to evaluate the significance of venous diameter as a parameter predicting severity of valvular incompetence in patients with superficial venous insufficiency. Correlation between duplex-derived parameters and diameters both of the great saphenous and small saphenous veins was assessed.

Objective and study design: Between August 2007 and April 2008, a total of 206 limbs in 103 patients with various clinical degrees of primary varicose veins were examined using ultrasound sonography. Eighty-six percents of 206 limbs were without any skin changes or totally asymptomatic. Valvular incompetence of saphenofemoral (SFJ) and saphenopopliteal junction (SPJ) was assessed using manual compression technique with patients in standing and bedside-sitting positions respectively. The great saphenous vein (GSV) diameter was measured on standing at just below the SFJ, midthigh and below the knee. The small saphenous vein (SSV) diameter was measured on sitting at the upper calf portion. The GSV and SSV diameters were compared statistically with the duplex-derived reflux parameters including peak reflux velocity (emfs) and reflux time (s).

Result: Peak reflux velocity at the SFJ correlated with the GSV diameter only at the midthigh (r=0.48) and that at the SPJ correlated well with the SSV diameter (r=0.79). Reflux time did not have significant correlation with diameters at any sites. The GSV diameter less than 3.5 mm or the SSV diameter less than 2.5 mm predicted no abnormal reflux, while the GSV diameter of 7 mm or greater or the SSV diameter of 5 mm or greater predicted critical reflux.

Conclusion: Duplex-derived peak reflux velocity correlated with venous dilation both in the GSV and SSV. The diameter of the saphenous veins appeared to be a useful measure in predicting the degree of the proximal valvular imcompetence.

This is the first report of an experience with ultrasound-guided femoral nerve block (UFB) in patients undergoing greater saphenous vein stripping surgery in Japan. The first step in UFB is to visualize all the anatomical structures in the inguinal area. An 8.5 MHz linear probe located between the inguinal ligament and the inguinal crease was held transverse to the femoral artery. The puncture was performed 0.5 cm distal to the probe with 23G needle, injecting 6-10 ml of 1% xylocaine. One hundred and seven consecutive patients (male: 35, female: 72, mean age: 61.4) with greater saphenous vein insufficiency were treated by stripping under UFB. Data collection included the amount of adjunct tumescent local anesthetic (TLA) solution, dose of Midazolam used as sedative during operation and incidence of palsy of quadriceps femoris muscle. Twelve patients (11%) did not need TLA (mean: 26.6ml) and 48 patients (45%) did not require sedative (mean: 1.6mg). On the other hand, the incidence of the palsy of quadriceps femoris muscle was 93% (100 patients). Results show that UFB has a high accuracy and efficacy of femoral nerve block but high incidence of quadriceps femoris muscle palsy. It is nessesary to revise the technique to reduce such a complication.

Venous malformation is a rare condition categorized in the vascular malformation. Vascular malformation itself is also categorized as one of the two major categories for the vascular anomalies by the ISSVA (International Society for the Study of Vascular Anomalies) classification. However, there are many classifications for the vascular anomalies and it has led to the misunderstanding of the disease. The often used term “Cavernous hemangioma” might be incorrect and should be called venous malformation.

The present case is a 61-year-old female. She noticed a soft mass on her left leg 6 months ago and it grew larger. When she came to our hospital, the soft mass was about 4 cm in size and it looked like a lipoma. The ultrasonography with color Doppler imaging was done. Arteriovenous fistulas and arteriovenous malformations were ruled out and it was diagnosed as a solitary venous malformation. Total resection of them ass was done, however, there were no apparent connecting vessels. Histopathological examination diagnosed the mass as the cavernous hemangioma. The post operative course was uneventful and there are no recurrence to the date.

Most of the venous malformations are apparent from birth and usually enlarge until puberty, but this case seemed to have developed the venous malformation at the age of 61. Furthermore, venous malformations usually have connecting vessels, but this case did not. These points make this case unique and leave us the questions for the pathogenesis of the venous malformation.

In week 8 of pregnancy, a 33 year-old woman with no history of thrombosis noted swelling in her right leg. Deep venous thrombosis was diagnosed by ultrasound. Protein C deficiency was also diagnosed. In month 2 of pregnancy, CT (computed tomography) and radio immunoassay examinations could not be performed to check thrombosis status or test for pulmonary embolisms. Therefore, pregnancy was terminated. In contrast CT, blood clots were found from the right popliteal vein through the common iliac vein. In the lung region, blood clots were present in bilateral inferior lobe branches. An intra vena cava filter did not detect any clots.

Introduction: Stenoses of the iliac veins are mainly caused by deep vein thrombosis and malignancy. We experienced three rare cases of the external iliac vein stenosis not caused by them. Case 1: The patient was 54-year-old female. She complained of edema of the right leg, which was not relieved by wearing elastic stocking. Venogram showed severe stenosis of the right external iliac vein. Computed tomography revealed neither tumor nor thrombus in the pelvis. Lung perfusion scintigram showed no pulmonary embolism. She was treated with PTA (percutaneous transluminal angioplasty) and stenting (PALMAZ™). Postoperative course was uneventful and she was relieved from complaint. Case 2: The patient was 78-year-old female. She had a past history of cellulitis of the left leg. Venogram showed severe stenosis of the left external iliac vein. She had been treated with elastic stocking and Warfarin. After six years she complained of dyspnea and sepsis, which was effectively treated with artificial ventilation. But inflammation remained in the left thigh, which was not relieved by wearing elastic stocking. Computed tomography revealed calcified lymphnodes in the pelvis which was caused by tuberculosis. Lung perfusion scintigram showed no pulmonary embolism. She was treated with PTA and stenting (SMART™). Postoperative course was uneventful and she was relieved from complaint. Case 3: The patient was 49-year-old female. She complained of edema of the right leg, which was not relieved by wearing elastic stocking. She had a past history of frozen pelvis caused by endometriosis. She received anastomosis of the right ureter because of the right hydronephrosis. Venogram showed severe stenosis of the right external iliac vein. Computed tomography revealed neither tumor nor thrombus in the pelvis. Lung perfusion scintigram showed no pulmonary embolism. She was treated with PTA and stenting (Self X™). Postoperative course was uneventful and she was relieved from complaint. Discussion: Stenosis of the common iliac vein such as iliac compression is compensated by the abundant collaterals in the pelvis. However stenosis of the external iliac vein is not relieved. So far many cases were reported as iliac vein stenosis caused by deep vein thrombosis or malignancy. But there were few case reports except them. Elastic stocking helps patients in the point of venous stagnation. In cases of ineffective stocking, PTA and stenting is a very effective treatment. Ultrasound and computed tomography are convenient but not specific in this etiology. Venography is necessary which shows the stenotic area.