Due to anatomical variability at the saphenopopliteal junction (SPJ), proximity to major nerves, and the deep dissection sometimes required, surgery for small saphenous varicose vein (SSV) is more difficult and thought to have a higher rate of complications than for great saphenous veins (GSV). My first treatment of choice is stripping from the level of the knee joint, at a safe distance from the SPJ. But in the case with proximal enlargement, I dissect SSV at the safe neck of dilatation. In 2008 and 2009, 431 patients (582 legs) underwent operation against varicose veins as a day case procedure. Of these, 86 patients (95 legs) had SSV. According to additional excision of GSV through communicating veins or SSV above the knee level, patients were divided into 4 groups. There was no statistical difference in CEAP classification, but dissection above the knee level extended operative time. There was no nerve damage but I experienced a case with deep vein thrombosis (DVT) and pulmonary embolism (PE) after dissection at the knee level. We must pay attention to DVT and PE after intervention of SSV.

Management of deep vein thrombosis (DVT) remains challenging. Anticoagulation therapy is effective in minimizing the incidence of recurrent thrombosis, and decreasing the risk of pulmonary embolism. However, in patients with severe and extensive DVT, anticoagulation treatment alone is not sufficient to relieve postthrombotic syndrome. We retrospectively evaluate mid-term outcome of endovascular treatment in two patients with DVT due to iliac vein compression syndrome (IVCS).

Case 1: 56-year-old woman was referred to our hospital because of swelling of left lower extremity. Computed tomography (CT) demonstrated intravenous thrombosis in the superficial femoral vein to the left common iliac vein. After IVC filter insertion, catheter-directed thrombolysis (CDT) was performed. Thereafter, 10×70 mm Easy Wallstent was deployed at the remaining stenotic site in the left common iliac vein probably because of compression by right iliac artery and spondylolisthesis. Anticoagulation therapy with warfarin was administered and it was continued. At the follow up of 54 months, no recurrent thrombosis nor stent obstruction are seen.

Case 2: 72-year-old woman presented in our hospital with swelling of left lower extremity. CT showed extensive venous thrombosis of the deep veins of the left leg extending into the left common iliac vein. Surgical thrombectomy was performed after IVC filter insertion. 12×100 mm Luminexx stent was inserted for the remaining iliac vein stenosis due to iliac compression. Anticoagulation therapy with warfarin was started. After 48 months, stent is patent and there is no sign of recurrent thrombosis.

Stent placement to alleviate stenotic lesion is safe and effective in the treatment of symptomatic lower extremity DVT caused by iliac compression.

For prophylaxis and early diagnosis of deep vein thrombosis (DVT) in the perioperative stage, we performed duplex scanning of leg veins and measured the serum D-dimer levels of patients under general anesthesia. Of the 289 cases, 190 were surgical and 99 were orthopedics operations. DVT occurred only in two cases (0.69%). In all cases patients had no symptoms, such as leg swelling and pain, and were cured without complication of pulmonary embolism. Duplex scan was very useful for the early diagnosis of DVT in perioperative stage.

In Japan, the surgical fee of lower limb varicose vein is covered by national insurance. However, little is known about the appropiety of this officially fixed fee about this surgery. Costs of 61 cases of varicose vein surgery (45 cases stripping surgery and 16 cases high ligation surgery) were calculated by using Opera Master System^TM (Hogy Medical^®). In cases of stripping surgery, the average cost was 87,279 yen and the average national return was 166,208 yen, leading to 78,929 yen gain to hospital per case. However, in cases of high ligation surgery, the cost was 40,126 yen and return was 35,968 yen, showing a loss for the hospital. Labor costs and depreciation costs are different in each hospital, in conclusion, it is not said too much that the official fixed fee of high ligation surgery is too low compared as its cost by this calculation.

Recently, surgery for varicose veins generally requires a short stay, thus methods for anesthesia for the surgery should be selected appropriately. In our hospital, the standard treatment for incompetent great saphenous vein (GSV) is a high ligation of saphenofemoral junction with selective stripping of the GSV using an inversion technique. From April 2007, we change the method of the anesthesia, introducing tumescent local anesthesia (TLA) with a low concentration of a local anesthetic (containing diluted solution of 1% lidocaine^®). Here, we compared perioperative findings of patients undergoing the GSV surgery under the TLA, with those under conventional methods of anesthesia, i.e., an inhalation anesthesia with N₂O and sevoflurane and spinal anesthesia. The TLA was accompanied with continuous injection of propofol for sedation. In the postoperative periods, the TLA had the biggest effect as analgesic compared with the inhalation anesthesia and spinal anesthesia. However, presumably due to pharmacological characteristics of propofol, the TLA was less satisfied as an intraoperative anesthesia than the others. These results suggest that the TLA was useful for a day surgery of varicose veins and that, instead of propofol, combination of another sedation with the TLA, might be able to improve the intraoperative anesthetic effects.

Central venous catheter (CVC) related thrombosis can occur with long-term insertion in general patients. About general CVC thrombosis, origin of CVC related thrombosis, frequency, time of onset, clinical findings, and diagnostic procedures were reviewed. CVC thrombosis is also major problem after cardiovascular surgery. We conducted a retrospective study to evaluate the occurrence and risk factors of CVC related thrombosis after cardiovascular surgery. In our study, CVC related thrombosis was found in 64% of all patients and most thromboses were discovered on the first postoperative day. Age was the only risk factor found in this study. The frequency of thrombosis was decreased in the early use of anticoagulation therapy but no statistically significant difference was noted.

Stripping of the greater saphenous vein (GSV) through its ligation at the saphenofemoral junction, combined with multiple avulsions has been suggested to bring about the best outcome when primary varicose veins are in the distribution of the GSV. However, it has several disadvantages. Varicectomy may result in nerve injury, often with manifest postoperative pain and numbness. Although the scars of varicectomy or stab avulsion are small, the appearance of treated limbs tends to be damaged. In this paper, we describe that the calf saphenous vein can be preserved in GSV stripping, that concurrent varicectomy can be deferred in most of the patients undergoing GSV stripping, and that residual varicose veins can be treated by sclerotherapy. We also report the excellent preliminary result of our scarless varicose vein surgery using the InvisiGrip® vein stripper.

Endovenous laser abalation (EVLA) is one of advanced intravascular treatments for varicose veins, however laser-tissue interaction in the blood is still controversial. As laser physics is fundamental for EVLA, physicians’ precise comprehension would contribute to the safe and effective procedure with patients’ satisfaction. Continuous wave (CW) lasers were applied in initial clinical experiences in EVLA, because they had been already used in the body surface irradiation. After selective photothermolysis had been proposed, pulse wave (PW) lasers were introduced to minimize the heat diffusion to the surrounding tissue and penetrate sufficiently to the target with minimal energy. Thus, concerns have been raised about the mechanism of action and the extent of mechanical damage that may be produced by PW lasers. This paper discussed the basic laser- tissue interaction in the blood and the current understanding of ablation mechanism. It is essential that popular wavelengths (980–1470 nm) in Japan applied to EVLA are theoretically absorbed to hemoglobin and water. In addition, laser oscillation mode also determines the irradiant power or peak power, which indicates the speed of laser action. Irradiance for CW or fluence for PW is an index of energy density (W/cm²) and we must know the irradiant area for their calculation. Nevertheless, as EVLA is a blind procedure, irradiant area cannot be measured and standardization of energy density is complicated. Linear endovenous energy density and endovenous fluence equivalent are proposed from this background, disregarding the diameter of veins or venous deformity by varicosity. The possible mechanisms of action are suggested by steam bubble, direct contact or heat diffusion. According to selective photothermolysis, PW laser seems to be more advantageous than CW by ablating within the thermal relaxation time, cleaning off the coagulum from the fiber tip by shock wave and non-thermal insult (photomechanical action) on the vein wall. In addition, the fourth mechanism could be proposed by laser penetration through bubbles, generated by waterselective wavelength laser. Fiber design is also crucial for preventing blood coagulation and carbonization. Jacket type and radial emitting fiber are underdeveloped for this purpose. In conclusion, as blood is one of biological tissue including hemoglobin and water, endovenous laser emission is totally different from emission in the air. Further investigation is necessary for optimization of EVLA and developing the future system.

We reported a case of right sided iliac compression syndrome. A 39 year old man was admitted complaining of swelling of the right leg. Examination revealed right side iliac compression syndrome which right iliac vein is compressed between right internal and external iliac arteries. We performed anticoagulant therapy and elastic stocking therapy. Otherwise, blood examination revealed thrombophilia and thrombosis like a superficial vein thrombosis might be referred to this thrombophilia.