Introduction: This article is the first report of midterm outcomes of the treatment of incompetent great saphenous veins (GSV) with radiofrequency ablation (RFA) using VNUS^® ClosureFast^™ in Japan. Methods: A prospective study was conducted to evaluate the midterm outcomes of RFA treatment through post-operative assessment using ultrasonography (US) and air plethysmography (APG). Results: Within fourteen limbs of 12 cases treated with RFA, twelve limbs of 11 cases were followed up from 6 to 60 months and periodically analysed. The first case and one limb in the second case showed partially recanalization of the GSV at 5 months and 42 months after treatment. The rate of complete obliteration of the GSV at 6 months,1 year and over 2 years up to 5 years were 100% (12/12 limbs), 100% (9/9 limbs) and 71.4% (5/7 limbs). Mean (S.D.) preoperative venous volume and venous filling index determined through APG were significantly reduced from 120.4 (33.1) ml and 6.63 (4.00) ml/sec to 97.1 (35.0) ml and 1.69 (0.93) ml/sec at the last day of the follow-up. Minor complications such as ecchymosis and pigmentation could be observed, although no critical complications such as DVT or skin burns developed. Ecchymosis and pigmentation disappeared within 1 month and 1 year after RFA treatment. Conclusion: Radiofrequency ablation using VNUS^® ClosureFast^™ is a safe and highly effective treatment technique as it shows good midterm results in the treatment of incompetent GSVs.

View full abstract

To assess the results of the treatment with radiofrequency ablation (RFA) for the varicose veins, our clinical experiences with the ClosurePlus^™ and ClosureFast^™ were reported. Twenty-four patients (24 limbs) were treated with ClosurePlus^™ from 2006 to 2007, twenty-four patients (35 limbs) were treated with ClosureFast^™ from 2009 to 2010. The treatment temperature was at 85°C with ClosurePlus^™, and 120°C with ClosureFast^™. The occlusion rate was 100%; 24/24 with ClosurePlus^™ and 30/30 with ClosureFast^™. The mean of venous filling index decreased after operation in both groups. No deep vein thrombosis and pulmonary embolism occurred in our cases. Mild or moderate eccymosis were seen 38% in ClosurePlus^™, group and 29% in ClosureFast^™ group, but no severe hemorrhage was seen. It is considered that the intravenous ablation with RFA is safe and effective for treatment of varicose veins.

View full abstract

Incompetent perforating veins (IPVs) participate in the onset of venous stasis skin lesion by chronic venous insufficiency and are important as a cause of recurrent varices after surgery. IPVs are divided into the one which connects it with main saphenous vein and the one which doesn’t. Between February 2010 and June 2013, 632 legs of 446 patients underwent venous echo for the diagnosis of IPVs. In their way, pressure loading to detect the reflux other than usual pressure loading test such as a milking method of the lower leg or a Valsalva maneuver in standing position, was also devised and tried. For the former 31 IPVs, direct ligation and resection above the fascia was performed on the connection with saphenous vein where the stripping was also conducted. For the latter IPVs, 110 IPVs of 98 limbs without stasis skin lesion underwent direct ligation and resection above the fascia. And 91 limbs of 78 patients underwent subfascial endoscopic perforator surgery (SEPS) for the IPVs under the stasis skin lesion in the superficial posterior compartment. The other 2 IPVs were treated by echoguided foam sclerotherapy. No serious complications were observed. Especially in 23 limbs with stasis ulcer, SEPS was conducted and all ulcers healed and ulcer recurrence was seen only in 1 limb (4.3%). Our treatment strategy for IPV based on the exact diagnosis by venous echo is thought to be proper.

View full abstract

Objective: To evaluate incompetent perforating vein (IPV) treatment in chronic vein disease patients. Materials and Methods: Fifty-four limbs with IPV in chronic vein disease patients (CEAP classes C4a–C6) were treated by subfascial endoscopic perforator surgery (SEPS) or direct IPV dissection. Each patient underwent duplex ultrasonography, and IPVs with diameters >3 mm were marked. SEPS was performed on 48 limbs and direct IPV dissection via healthy skin incision on 6 limbs. A dual port system and CO₂ insufflation enabled IPV dissection using an ultrasonic surgical system. SEPS plus great saphenous vein stripping were performed in 30 cases, SEPS plus small saphenous vein stripping in 2 cases, SEPS plus varicotomy in 4 cases, SEPS plus great and small saphenous vein stripping in 1 case, and SEPS alone in 6 cases. Results: Patients with CEAP classes C4a–C5 had fewer serious complications. No advancement in CEAP classification class was observed in any group after treatment. Ulcers in 13 out of 15 cases healed. Minor infection developed at the port incision site in 3 cases. The outcomes and wound healing after direct IPV dissection were excellent. Conclusion: SEPS is the preferred treatment of severe dermatitis and ulcers with IPVs. Direct IPV dissection is useful when incision can be made on healthy skin.

View full abstract

From July 2001 to October 2013, inferior vena cava (IVC) filters were inserted in 33 patients who suffered from deep vein thrombosis (DVT) for the prophylaxis against pulmonary embolism (PE). Seven patients had a history of PE. During the same period there were 349 patients with DVT and 21 patients with PE. The filter insertion rate for DVT and PE were 9.5% and 33.3%, respectively. A contrast computed tomography was always used for the diagnosis of DVT and PE. The patients were 27 to 82 years old age (mean 58.5 years). There were 12 male and 21 female patients. The mean duration of follow-up was 31 months (range 1 to 132 months). In 14 cases of gynecological, 6 cases of orthopedical and 4 cases of gastroenterological operations, filters were inserted before these operations for fear of thrombus migration during these procedures. A temporary filter was inserted in one female patient who became shock due to PE during the operation for the fracture of the lower limb. This patient was not diagnosed as DVT before surgery and she was not recovered. Except for this case no acute pulmonary thromboembolism occurred during implantation and at removing the filter. Inserted IVC filters were one permanent (Greenfield 1), 14 temporary (Neuhaus Protect 7, Antheor 7) and 18 retrievable (Günther Tulip 4, ALN 14). The filters were introduced by the Seldinger technique via the right femoral vein in 6 patients, via the left femoral vein in 4 patients and via the right jugular vein in 23 patients. Filters were placed at infrarenal level in all cases except for one case which had duplicated inferior vena cava and bilateral lower limb thrombus. All filter placements were safely and successfully performed. In one patient treated with temporary filter (Neuhaus Protect), a large thrombus was entrapped within the filter basket. Thrombolysis therapy was continued for several days and the filter was successfully removed. The absence of thrombus within the filter was always confirmed by direct cavography and the filters were removed within 10 days after the implantation. Eleven patients with retrievable filters were attempted to remove the filters and 10 patients were successful. Most of the retrieved filters were adhered a small amount of thrombus, however, it is difficult to conclude that these thrombus were truly entrapped. Seven retrievable IVC filters were left as a permanent filter because the prognosis of the patients was poor, such as in those with an advanced malignant tumor. In order to eradicate PE recurrence, supplementary treatments including anticoagulant therapy were used in these patients. Penetration of the IVC by the legs of the filter was detected in one patient who was implanted ALN permanently. We are following one case of completely thrombosed filter (TrapEase) which was implanted at another hospital. Retrievable filter is recommended for use to prevent PE because there are some complications associated with placement of permanent filter.

View full abstract

To investigate the post-operative improvement rate of the symptoms related to varicose veins, the questionnaire investigation was performed. Four-hundred thirty one patients with varicose vein on one side great saphenous vein from January 2010 to December 2012 were reported: 132 were males and 299 were females. Onehundred ninety two cases were treated by stripping, and two-hundred thirty nine were treated by LASER ablation. Fatigue that was complained by 312 patients preoperatively was improved in 91% patients. Cramp that was complained by 233 patients was improved in 88% patients. Swelling that was complained by 199 patients preoperatively was improved in 89% patients. Pain that was complained by 138 patients was improved in 83% patients. Itching that was complained by 131 patients was improved in 85% patients. Local heat that was complained by 96 patients was improved in 89% patients. Gonalgia was improved in 19% of all patients, coldness was improved in 12% of all patients, and lumbago was improved in 4.4% of all patients. The results were no significant differences between stripping group and endovenous LASER ablation group. The venous operation is recommended for symptomatic varicosities because high improvement rate of symptoms related to varicose veins is expected.

View full abstract

Graduated compression stockings (GCS) are widely used to prevent venous thromboembolism (VTE) caused by prolonged immobility owing to lower limb venous stasis. The effects of GCS on venous blood velocity have not yet been established. We investigated whether deep vein blood flow increased with the use of properly fitted GCS (below-knee type). Fifteen healthy adult participants were examined, and Doppler ultrasound measurements of popliteal venous blood flow were recorded on one leg over a 40-minute period. The primary outcome was time-averaged peak velocity (PV) in the popliteal vein at 20 and 40 min, and the secondary outcome was the change in vein diameter (VD). Results: PV of the popliteal vein increased with the use of GCS at both 20 and 40 min as compared to that before using GCS (6.4 ± 2.8 cm/s to 7.5 ± 3.1 cm/s at 20 min and to 7.5 ± 2.5 cm/s at 40 min) (P<0.001). Moreover, VD decreased significantly, after GCS use (8.8 ± 1.7 mm to 8.3 ± 1.8 mm at 20 min and to 8.3 ± 2.0 mm at 40 min) (P=0.034). GCS use increases lower limb venous blood velocity by decreasing VD during prolonged seated immobility, and it may reduce the risk of VTE in cases of prolonged seated immobility.

View full abstract

We studied whether noncontrast 3DCTV taken by 128-row MDCT could be a first line diagnostic imaging in varicose vein consultation. 1348 patients 2696 limbs were taken noncontrast 3DCTV from September 2009 to August 2013, we examined usefulness of noncontrast 3DCTV from the point of guessing venous function, description of incompetent perforating vein, relationship with deep vein abnormality and strategy of surgery. There was positive correlation between dilatation of great saphenous vein and Venous Filling Index. Identification rate of incompetent perforating vein on noncontrast 3DCTV was 86.7%. Noncontrast 3DCTV let us understand whole aspect of varicose vein sterically and objectively, which was useful on determing surgical method. Evaluation by using Duplex scan was necessary depending on the situation, noncontrast 3DCTV could be a first line diagnostic imaging on varicose vein consultaion.

View full abstract

Pulsatile Doppler sounds are sometimes demonstrated in saphenous veins of the patients with leg edema. In many of such cases, arteriovenous fistulas are not identified by CT angiography, duplex scanning or any other examinations. The clinical features of the 12 patients (18 limbs) with palsatile saphenous veins from January 2011 to December 2012 were reported. The causes of such cases were cellulitis, gout, and other non-specific inflammatory diseases. It was considered that adequate diagnosis was important for the therapy, and compression therapy was effective for many of such cases.

View full abstract

We reported a first case of a 62-year-old woman have ideopathic arteriovenous fistula. Duplex scan and angiography showed an arteriovenous fistula in the brachial artery. Because ischemic symptoms increased in the left arm, we performed arteriovenous fistula resection and partial brachial artery interposition using grate saphenous vein. In postoperative course, her ischemic symptoms and blood pressure were improved.

View full abstract

Deep brachial veins are deep veins accompanying the deep brachial artery, and are rarely used for the creation of an arteriovenous fistula (AVF) for hemodialysis. We herein report a case of the creation of a transposed deep brachial vein arteriovenous fistula in an end-stage renal failure patient with inadequate superficial veins in the upper limbs. A 59-year-old woman with end-stage renal failure undergoing hemodialysis, who had previously had an AVF created at the left antecubital fossa and who required repeated vascular access intervention therapies, was admitted to our hospital because of the formation of a pseudoaneurysm of the deep brachial vein, which was being used as an AVF. We first tried to repair the AVF by creating a basilic vein transposition AVF, but this procedure failed. As the deep brachial vein was well-developed, we decided to create a transposed deep brachial vein AVF to avoid the complications associated with creating an arteriovenous graft. The anastomosis of the previous AVF at the antecubital fossa was preserved. The deep brachial vein was freed and ligated distally. The freed deep brachial vein was transposed subcutaneously at the site of the anterior upper arm, and was anastomosed to the brachial vein. No complications other than occasional edema were seen, and the AVF was still patent 12 months postoperatively.

View full abstract

Various lympho-venous shunt operations, in which lymphatic tissue is inserted into an approximately 2 mm vein under general anesthesia through a long skin incision, have been tried to treat obstructive lymphedema, but failed to be a useful treatment options with unstable treatment results due to a higher rate of anastomosis site thrombosis. With establishment of supermicrosurgical technique which allows secure anastomosis of a vessel with 0.5 mm or smaller in diameter, lymphaticovenular anastomosis, anastomosis of a lymphatic vessel to a small vein or a venule in an intima-to-intima coaptation manner, has been developed. Pre- and intra-operative use of indocyanine green lymphography facilitates secure lymphaticovenular anastomosis under local anesthesia through a small skin incision, which leads to less invasive surgery for the treatment of lymphedema.

View full abstract