Three primary influences predispose to thrombus formation, the so-called Virchow’s triad: (1) endothelial injury, (2) stasis or turbulence of blood flow and (3) blood hypercoagulability. Thrombotic formation is regulated by the thrombogenicity of exposed subendothelial constituents, local hemorheology, systemic thrombogenicity and fibrinolytic activity. Arterial thrombus is generally developed at disrupted atherosclerotic plaques. Platelet adhesion and aggregation are recognized as initial steps in arterial thrombus formation under rapid flow conditions. Since tissue factor is expressed in atherosclerotic plaques, coagulation pathways are also activated at plaque disruption sites, where thrombi comprising a mixture of aggregated platelets and fibrin develop. On the other hand, plaque disruption does not always result in total thrombotic occlusion. Although the mechanisms of arterial thrombus propagation in vivo remain unclear, not only increased vascular wall thrombogenicity and blood flow alterations, but also inflammatory reactions and circulating microparticles are considered key modulators of these mechanisms. Most venous thrombi occur in the deep veins of the legs. Hypercoagulability and blood stasis have been recognized as important factors in the genesis of venous thrombosis. Since the 2 factors facilitate activation of the coagulation pathway, it is generally understood that venous thrombi are mainly composed of a large amount of fibrin and erythrocytes, with relatively few platelets, known as red thrombi. However, venous thrombi and pulmonary emboli contained significant amounts of platelets and von Willebrand factor, in addition to fibrin and erythrocytes. The findings suggest that not only coagulation pathways but platelets play a significant role in venous thrombus formation.

It has been reported about the safety, feasibility, and excellent cure rate of SEPS for chronic venous ulcers of the C6 patients, according to the CEAP classification. Otherwise the SEPS operation is not still authorized by the national health insurance system yet in Japan. SEPS has authorized as the national advanced medical system by the Ministry of Health, Labor and Welfare in May, 2009. And the 3 institutions, including our hospital, have been authorized, and all are the members of the Society of Endoscopic Therapy for Vascular Disease.

This study was undertaken to report our latest results, and discuss about how to get the knack of SEPS for beginners.

From 1998 to 2009, we performed two port system subfascial endoscopic perforator vein surgery (TPS-SEPS) with or without superficial venous ablation (SVA) on more than 1000 limbs. In these periods, we had not had any case of post operative hemorrhage, which needs additional haemostatic operations, nor critical complications. Of these cases, we had the 101 ulcerated limbs of 95 patients until the 2008. The ulcers had not cured after various therapies, and all the patients were introduced to our institution as the obstinate venous ulcers. The cure rate of these C6 is 92.1% (93/101), and this result would be good enough for us.

The procedures of SEPS have been becoming easier than that of the beginning in 1998, mainly due to the changes of medical installments such as EndoTIP^® and UCS (ultrasonic coagulation system).

Hereafter, it is better for SEPS to be introduced the most up-to-date procedures by the members of the Society of Endoscopic Therapy for Vascular Disease. And also it is necessary for estimate the availability of SEPS for C6 through the institutions, which are authorized as the national advanced medical system. This progress will be useful for the spread of SEPS.

Evaluation by multidetector-row CT (MDCT) was carried out in a case of severe varicose veins (CEAP class 6) accompanied by stasis ulcers where ultrasonography had not allowed adequate evaluation. The contrast material, diluted 1 : 8, was injected with an injector via the dorsal venous arch. The images taken by 64-row MDCT were processed using volume rendering (VR). We obtained three-dimensional images of ulcer-affected epidermal tissue, depicting the superficial veins (deleting the cutaneous fat layer), the perforating branches and even the deep veins. Serial presentation of these images, delineating the anatomical relationship of the lesions and structures, enabled adequate evaluation. Generally, morphological evaluation of ordinary varices can be performed with CT using VR without contrast material. However, the technique described above allowed clear visualization of the arrangement of deep veins and saphenous vein as well as the presence of perforating branches using only a small amount of contrast material even in cases of severe varices complicated by changes in the skin or cases where ultrasonography was difficult due to physical characteristics. Furthermore, this technique enables clear visualization of the relationship of ulcer bottom to varices or to perforating branches although this was difficult with conventional leg venography. If needed, manipulation on the perforating branches can also be performed easily with this technique. Thus, MDCT seems to be highly useful as a means of preoperative mapping and is expected to provide a valid means of evaluating and diagnosing ulcers for the treatment.

Klippel-Trenaunay syndrome (KTS) is a congenital disorder, which is characterized by naevus, venous abnormalities, and deformities of soft tissue and bone in the affected extremity.

A 52-year-old male complained of severe dullness and presented with extensive varicose veins and hypertrophy of the right lower extremity. His right lower extremity also showed cutaneous port wine stains. Preoperatively, his right lower extremity was evaluated by ultrasonography to determine patency of the deep veins and reflux of superficial veins. Surgery for the varicose veins was performed under local anesthesia (ligation of the greater & small saphenous veins, lateral marginal vein and incompetent perforator). Two months later, additional venous ligation and sclerotherapy were performed. Without any complications, he was significantly relieved from the symptoms due to venous stasis.

Surgical management based on the ultrasonographic findings should be considered as one of the strategies to treat the KTS patients with severe symptoms.

A 34-year-old male was admitted to our hospital for the treatment of chronic venous insufficiency of the left lower extremity due to iliac venous outflow obstruction. He had previously undergone emergent surgery because of the blunt colon injury and pelvic fracture due to downfall accident. After that, he suffered severe pain and swelling of the left leg during exercise which could not be controlled by conservative therapies including elastic compression. Preoperative ultra sonography of the left leg showed the occlusion of the femoral vein at the level 1 cm above the saphenofemoral junction. Crossover saphenous vein bypass (Palma procedure) was performed. Calf pump was activated just after the completion of venous anastomosis to avoid early graft occlusion. His symptom was relieved. Although postoperative venography showed the Palma graft was diffusely thin, it was enlarged and became good venous outflow 5 months after the surgery.

Complication and additional procedure on insertion of temporary and retrieval vena cava filter was surveyed among 43 member facilities of Japanese Society of Phlebology from 2006 to 2007. Total number of inserted filters was 405, including 235 Günther Tulip retrievable filters and 106 Neuhaus Protect temporary filters. Forty cases associated with complications and additional procedures. These include 22 permanent filter insertion, 8 cases of filter infection, 4 cases of failure of filter retrieval, 5 cases of filter migration, 3 cases of surgical removal of temporary filter, 3 cases of vena cava occlusion and one case of cardiac injury. Because of these complications and additional procedures, proper guideline and careful management for temporary and retrieval filters is necessary.