After the Great East Japan Earthquake, the prevalence of deep vein thrombosis (DVT) in disaster shelters in Ishinomaki (Pacific coast, Japan) was found much higher than that ever reported in Japan. In Ishinomaki, twelve patients were found to have pulmonary thromboembolism for one month after the earthquake and DVT was found in 10 of those patients. The calf DVT was examined using sonography in the shelters (from March 2011 to July 2011) and in temporal emergency housings (from August 2011 to December 2011), and the results indicated that 190 of 701 evacuees had DVT. DVT prevalence was higher in evacuees in the tsunami-flooded shelters (127 of 371 evacuees, 34.2%) than in those in the non-flooded shelters (63 of 330 evacuees, 19.1%). This indicated that deteriorated and crowded condition in the tsunami-flooded shelters might induce thrombogenesis in calf veins. Therefore, evacuees were immediately recommended to leave tsunami-flooded areas. DVT prevalence in the shelters reduced gradually; however, this prevalence was found to be higher in the temporal emergency housings (32 of 360 evacuees, 8.9%) than in the non-disaster area in Japan (2.2% in Yokohama city). The risk of calf DVT in the temporal emergency housings increased because of reduced blood flow in the calf veins caused by immobility. The residents of the housings require to be physically active in order to avoid calf DVT.

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A prolonged high rate of deep vein thrombosis (DVT) has been reported among evacuated individuals staying at shelters after earthquakes. We undertook mobile ultrasound screening for DVT as part of the disaster response in the secondary shelters in Kurihara for the evacuees moved from Minamisanriku shelters. According to the Niigata Medical Association protocol, subjects within each shelter were selected if they were perceived to be at high risk for the development of DVT or were willing to be examined. DVT was diagnosed if there were direct ultrasound signs, including thrombotic echoes or a lack of venous compressibility. A total of five inspections were performed from April 11, 2011 to July 29, 2011, and 103 evacuees were examined (166 in total), and 10 evacuees (21 in total) were diagnosed to have a DVT. In four of seven evacuees who were taking anticoagulants, the thrombi disappeared during the examination period. The optimal conditions of the shelter and easy access to medical treatment enabled the rapid resolution of thrombi with the support of anticoagulant therapy.

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Venous thromboembolism in refugees in shelters after severe earthquake is one of emerging problems in disaster medicine. It was first recognized after the Chuetsu Great Earthquake in 2004. Since then, medical volunteers in local community hospitals and Niigata University group had performed check-ups of VTE for refugees in each large earthquake in Japan. In the Great East Japan Earthquake 2011, Japanese Society of Phlebolgy systematically participated in prevention act of VTE in refugees in shelters. Within one week after the earthquake, Elastic Stoking Conductor Committee requested stocking makers to supply elastic stockings to areas hit by Tsunami. Lots of stockings were sent to Tohoku area. President of Japanese Society of Phlebology made the announcement of importance of prevention in shelters. Leaflets describing important points for prevention such as appropriate hydration and exercises were delivered through University Hospitals in Tohoku area. A Medical engineer technician was deployed to Fukushima prefecture through the Society to assist check-up rounds to shelters. These activities were helpful to medical teams in disaster area. There were several problems in our aids. Because various types of elastic stockings were delivered, long stockings, which were not appropriate for refugees, were sent. Shortage of elastic stocking conductor was an obstacle to long-term management of VTE prevention in disaster area. Because the risk of another great earthquake or severe natural disaster is increasing due to activated diastrophism and the climate change, organized support to disaster area will be needed under the close communication between medical organizations. As members of Japanese Society of Phlebology have knowledge and skill in prevention of VTE, cooperation of members to aid VTE prevention may be important in the future not only in the front but also in the home front.

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Endovenous laser ablation (EVLA) appears to be a safety and less invasive procedure, and can be performed under local anesthesia in an outpatient setting. Currently EVLA has become a standard technique for varicose veins and has replaced the surgical ligation and stripping. However ecchymosis and pain frequently occurred as early minor complication after EVLA. The aim of this study is to investigate the optimal technique of EVLA due to increase the effectiveness of treatment and to decrease the postoperative complications. Between December 2009 and October 2011, EVLA using a 980 nm diode laser was performed in 155 patients (180 limbs) with incompetent great saphenous veins (GSV). Treatment efficacy and complications were evaluated at 1 week, 1 and 4 months post procedure. The patients were divided into two groups: in group A (89 limbs) LEED was delivered < 65 J/cm and in group B (91 limbs) ≥65 J/cm. Between both groups, no differences were observed in the diameter reduction of veins after ablation, and the occlusion rate at 4 months was 98.9% in group A and 100% in group B. At the 1-week follow-up, ecchymosis was seen in 64.2% of group A and in 26.3% of group B, pain in 51.6% of group A and in 27.4% of group B. Significantly higher incidence of ecchymosis and pain were observed in group A. The light energy is absorbed by hemoglobin and water, which induce both intraluminal thrombosis and intimal damage. More selective vein wall destruction by appropriate LEED and accurate tumescent local anesthesia to saphenous compartment are important to increase the effectiveness of treatment and help to decrease the postoperative discomfort.

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Objective: We investigated the early experience of endovenous laser ablation (EVLA) with 980 nm diode laser for primary varicose veins. Methods: From June 2011 to April 2012, 97 (122 limbs) patients who underwent EVLA were studied. Patients were divided into two groups with a change of indications for EVLA on January 2012, group A (65 patients, 79 limbs) was performed EVLA prior to January 2012 and group B (32 patients, 43 limbs) was after January 2012. In two groups, the percentage of EVLA in all surgery and early outcomes and complications were compared. In all patients, laser fiber was inserted into saphenous vein by the percutaneous puncture method under the general anesthesia. Laser fiber was pulled back from just distal the superficial epigastric vein, EVLA with 980 nm diode laser was performed. Clinical outcomes, complications and venous occlusion were checked at 1 week, 1, 3, 6 months and 1 year after EVLA. Results: The percentage of EVLA in all surgery was 37.8% (65/172) and 56.1% (32/57) in group A and B respectively, it was significantly higher in group B. There was no significant difference in mean linear endovenous energy density (LEED) (66.6 vs. 66.2 J/cm), and postoperative complications (Bruising: 24.1 vs. 33%, Pain 27.8 vs. 53.5%). Endvenous heat-induced thrombus (EHIT) class 2 were seen 2 (2.5%) vs. 1 (2.3%) limbs, despite disappearing without any treatment. Deep vein thrombosis were not observed. Conclusion: EVLA with 980 nm diode laser for primary varicose veins are minimally invasive, safe and effective treatment.

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Background: The standard initial treatment of venous thromboembolism (VTE) patients in Japan is intravenous unfractionated heparin, requiring laboratory monitoring and hospitalization. Fondaparinux is a synthetic antithrombotic agent with specific anti–factor Xa activity. Its pharmacokinetic properties allow for a simple, fixed-dose, oncedaily regimen of subcutaneous injection, without the need for monitoring. We examine the efficacy and safety of fondaparinux in Japanese patients. Methods: Patients received fondaparinux (5.0 or 7.5 mg, adjusted according to body weight, age, creatinine clearance) subcutaneously once-daily and given for until the use of vitamin K antagonists resulted in an international normalized ratio above 1.5. Results: Forty-two patients were included. 4 patients (9.5%) received fondaparinux in part on an outpatient basis. Standard therapy (fondaparinux to warfarin) had been used for 28 patients (66.7%) Switching from unfractionated heparin for 14 patients (33.3%). There was no recurrence of symptomatic venous thromboembolism. Treatment-related adverse events occurred in 4 patients (9.5%). Major bleeding occurred in 1 patient required blood transfusion and minor bleeding occurred in three patients treated with fondaparinux. Two patients died during the observation period, however all of them were cancer related death. Conclusions: Once-daily, subcutaneous administration of fondaparinux without monitoring is effective and safe in the initial treatment of VTE patients.

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Objectives: This study was performed to define the incidence of perioperative venous thromboembolism (VTE) after operation of ruptured abdominal aortic aneurysm (AAA). Methods: Between August 2009 to July 2010, consecutive twenty-six patients underwent AAA repair, Eight emergent ruptured AAA repair (R group), eighteen elective AAA repair (E group), in our institution. We retrospectively compared various perioperative data, such as pre- and intra-operative factors, post-operative courses and incidence of perioperative VTE, between two groups. Results: Perioperative VTE tended to be more frequent in R group (four patients, 50%) than E group (two patients, 11.2%) (p=0.0298). Extension site of deep vein thrombosis (DVT) were three proximal DVT (37.5%) and one distal DVT (12.5%) in R group, two distal DVT (11.1%) in E group. In R group, one patient (12.5%) died of a massive acute pulmonary embolism (aPE). Conclusions: The incidence of perioperative VTE after ruptured AAA repair was high. It was thought that more stricter perioperative VTE prophylaxis, the early detection and medical treatment by agressive VTE screening were required.

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We investigated the result of invagination stripping of the great saphenous vein. From September 2007 to April 2012, invagination stripping of the great saphenous vein were performed in 123 patients with 164 limbs. Forty-four men and 79 women were aged from 24 to 87 years old (average age 61.4). We had performed selective invagination stripping from sapheno-femoral junction to below knee as the standard procedure. The success rate of invagination stripping was 76.2% totally, and 82% in case of using exclusive stripper especially. We added the ligation of incompetent perforating vein in 45 limbs (27%). As for complications, there were bleeding in one case, contact dermatitis in 3 cases, and nerve injury including slight numbness in 11 cases (6.7%). These ten of eleven cases had been added ligation of incompetent perforating vein. There were two cases developed varicose veins induced incompetent perforating veins of calf 19 months after surgery, and they received ligation of it. There was no recurrence associated with sapheno-femoral junction.

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This study was made to clarify the changes of treatment for primary varicose veins in the last 5 year, by comparing with the previous results which was carried out in 2004. Sixty-four institutions belonging to the Japanese Society of Phlebology answered questions using a questionnaire, and 11,832 new patients with primary varicose veins of the leg were analyzed. The following results were obtained.1) Number of patients increased when compared with the previous study. Patients tend to concentrate in the some clinics.2) When compared with the previous study, the incidence of stripping operation increased, while ligation of the saphenous vein decreased.3) Foam sclerotherapy, trunk foam sclerotherapy and endovenous therapy were adopted in past five years.

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Goal of venous thromboembolism (VTE) management is to relieve symptom promptly, to avoid post-thrombotic sequel, and to prevent symptomatic pulmonary thromboembolism (PTE). We herein describe acute phase management of patients with VTE, regarding ambulation, compression therapy, anticoagulation therapy, thrombolytic therapy, and inferior venal cava filter (IVCF). Ambulation is permitted immediately after optimal anticoagulation level is achieved. Compression therapy is adopted soon after diagnosis and admission. Anticoagulation therapy is essential part of VTE treatment, and so almost all patients receive any anticoagulation. Thrombolytic therapy is adopted for severe deep vein thrombosis or PTE with circulatory failure. IVCF insertion is considered when anticoagulation therapy is contraindicated. Bleeding complication was encountered in one patient who received anticoagulation therapy, and three patients who received thrombolytic therapy. No symptomatic PTE was observed during VTE treatment. Early ambulation and compression therapy is preferred under anticoagulation in the management of acute phase VTE patients.

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Lymphedema is difficult to cure completely once it occurs. However, its proper diagnosis in the early stage of occurrence, and conservative treatment suitable for affected extremities can stabilize symptoms. Conservative treatment of lymphedema includes daily life guidance, and skin care, manual lymph drainage, compression therapy and exercise therapy for affected extremities, but there is little high level evidence-based literature examining the efficacy of each treatment. Although there is a lot of literature showing the efficacy of compression therapy, inappropriate compression therapy led to worsening of symptoms in some patients. Although therapeutic efficacy of manual lymph drainage alone is considered to be insufficient, upper extremity lymphedema in the early stage of occurrence improves with manual lymph drainage alone in some patients. The efficacy of skin care and exercise therapy in affected extremities is difficult to evaluate, but lymphedema whose aggravating factors are repeated inflammation in affected extremities and obesity is likely to be prevented from worsening by control of extremity inflammation and body weight through daily life guidance. Because the conditions of the affected extremities differ among patients, clinical experience is important for treatment selection.

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A consecutive 253 cases of stripping surgery for small saphenous vein (SSV) incompetence is reported. Their age averaged in 62.6 ± 12.3 years old and man/woman ratio was 1: 3.59. Anesthesia was composed of tumescent local anesthesia and intravenous administration of propofol and remifentanil. SSV was highly ligated and stripped with using rod type pin stripper. Operation time averaged in 26.7 ± 9.2 minutes. All patients could return home immediate after the surgery. No major complications, such as deep vein thrombosis and nerve damage, were experienced. Postoperative ultrasonography did not show any reflux findings at the saphenopopliteal junction in all cases.

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