Purpose: This study aimed at clarifying the changes in treatments for primary varicose veins in Japan. Methods: A questionnaire was mailed to the members of the Japanese Society of Phlebology. The contents of the survey covered the treatment and treatment strategy of varicose vein cases in 2013. The results were examined and compared with the results of previous surveys conducted by the aforesaid society in 1998, 2004 and 2009. Results: Of 36,078 patients, 43,958 limbs were reported from 201 institutions. Saphenous type was the most common type of varicose veins that developed in patients aged 70‒79 years. The C4‒6 cases according to the Clinical-Etiology-Anatomy-Pathophysiology (CEAP) classification occurred significantly more in males than in females (p<0.01). For the treatments of saphenous type and of segment type (dilatation of peripheral branch), endovenous laser ablation (EVLA) was performed most frequently (51%), while the frequency of stripping and of high ligation decreased in 2013. EVLA was performed with tumescent local anesthesia, which required one day of hospitalization. Conclusion: In our study, the number of patients with varicose veins increased especially in the elderly. Surgical treatments were selected for a number of patients, and EVLA was the most commonly adopted method of treatment in Japan.

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Background: Recurrent varices after surgery (REVAS) remain a common problem. Some REVAS can be avoided using accurate manual skills and specific surgical treatment strategies at the time of the first surgery. Treatment strategies for REVAS are also important, and analysis of cases of REVAS may prove useful in determining systematic strategies to prevent recurrence after the first surgery. Patients and Methods: One hundred and eight limbs (7.1%) among a total of 1519 limbs which had varicose vein surgery, required surgery for REVAS between January 2008 and July 2015. Of those limbs, 66 limbs among 59 patients had REVAS due to reflux from incompetent perforating veins or saphenous vein trunks in the calves. The period between previous surgery and REVAS was ≥10 years in 15 limbs, ≥5 years and <10 years in nine limbs, ≥2 years and <5 years in 12 limbs, and <2 years in 30 limbs. According to CEAP (clinical, etiologic, anatomic, pathology) classification, the 66 limbs were categorized into C2 (n=11), C3 (n=2), C4a (n=11), C4b (n=19), C5 (n=10), and C6 (n=13). Deflection to severe cases was remarkably seen. Twenty-four limbs (36%) also had reflux origin from subfascial veins or saphenous vein trunks in the thighs. Analysis of REVAS was conducted using venous ultrasonography. Results: The original surgery consisted of high ligation and stripping of the greater saphenous vein (GSV) in 50 limbs, endovenous ablation of GSV in seven limbs, and resection of tributary veins in 12 limbs. For limbs in which reflux caused REVAS, incompetent perforating veins (IPVs) were observed in 62 limbs. These veins were ablated via subfascial endoscopic perforator surgery (SEPS) utilizing screw-type ports in 26 limbs, direct severing in 31 limbs, and ultrasound-guided foam sclerotherapy (UGFS) in five limbs. IPV localization was as follows: 51 Cockett’s perforators, 18 paratibial perforators, one Boyd’s perforator, and one posterior perforator. In other veins with reflux, eight distal GSVs in calves were found after high ligation and partial stripping of the GSV. Of those, distal GSVs were drained from small saphenous veins in four cases and from IPVs in three cases. Conclusion: The IPV is an important etiology of REVAS, and such IPVs should be treated in the first surgery if present. SEPS represents a very useful choice for surgical management of REVAS. Some cases require full stripping of the GSVs during the first surgery. It is important in order to avoid a recurrence to handle all the reflux diagnosed at the time of the first operation, but when it is left, it should be followed up properly, and it was thought to be treated appropriately.

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Objective: We preoperatively assessed varicose veins by means of noncontrast three-dimensional CT venography (noncontrast 3DCTV) in the great saphenous vein area of the lower extremity. The goal of this study was to analyze the site, source, and contributory fators of recurrent varices after surgery (REVAS). Methods: 712 patients of varicose veins have been operated in our clinic from January 2011 to February 2015. Preoperative noncontrast 3DCTV was performed in 59 patients undergoing stripping (ST) or endovenous laser ablation (EVLA). The images were reconstructed with the volume-rendering method. We evaluated saphenofemoral junction (SFJ) branch, duplicated GSV and Neovascularization. Results: Noncontrast 3DCTV clearly visualized the superficial veins in the GSV area. With analyzing noncontrast 3DCTV, we could categorized SFJ branch patterns and recognized duplicated GSV which connected with thigh perforator. It was considered that Type2 (high accessory saphenous vein [ASV] type: 49.2%) and Type3 (common trunk type: 22.0%) have risk factors for future reflux in ASVs. The duplicated GSV associated with REVAS existed in 30.5% of all cases. Superficial epigastric vein (SEV), superficial circumflex iliac vein (SCIV) and stump of GSV had become the source of neovascularization after GSV ST. Conclusions: Diagnosis by using Duplex ultrasound is necessary in all cases of varicose veins. Compared with using only Duplex ultrasound, noncontrast 3DCTV makes us understand the form of superficial vein in more detail, which have contributory factors of recurrence and neovascularization in groin. Noncontrast 3DCTV is useful in the preoperative strategy of varicose vein, specifically in order to prevent REVAS.

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Objective: Endovenous thermal ablation is one of the most accepted treatment options for varicose veins. The aim of this study was to compare the early results of 1470 nm laser and radiofrequency systems. Patients and Methods: From May 2014 to March 2015, 2037 limbs with primary varicose veins were treated with endovenous ablation using a 1470 nm laser with radial 2ring fiber (1470 group) or radiofreqency with ClosureFAST^TM catheter (RFA group). The clinical data and postoperative complications were analysed respectively. Results: The age of patients was significantly older in the RFA group. There was no significant difference in sex and CEAP classification between the two groups. Significantly more greater saphenous veins were treated and ablation time was significantly shorter in the RFA group (p<0.0001). Occlusion rates at one month were 99.8% in the 1470 group and 100% in the RFA group. Proximal DVT occurred in one limb (0.1%) in the 1470 group and distal DVTs were found in 0.4% of limbs in the 1470 group and in 0.3% of limbs in the RFA group. The incidence of Class 2 EHIT was significantly higher in the 1470 group. There was no significant difference in the incidence of postoperative pain, bruising and nerve injury between both groups. Conclusion: The short-term outcome and complication rates were excellent and similar with both devices.

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Compression bandage is the most useful tool for the treatment of venous ulcers. It is important but difficult to know the pressure of the elastic bandage. Fifteen nurses tried to the accurate interface pressure. They were allowed to try five times. In first trial, the mean of the pressure was 41.8±20.2 mmHg, and 26.7±9.0 mmHg in second, 30.1±6.8 mmHg in third, 31.4±6.8 mmHg in fourth, and 28.4±8.2 mmHg in the end of the trial. At the six months later when the same trial was done, the mean pressure was 29.9±10.2 mmHg. The training using ParmQ^TM was useful for accurate interface pressure of elastic bandage.

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Objective: The reported complications of long-term placement of inferior vena cava filters including filter breakage, strut penetration, thrombotic obstruction, and displacement. This retrospective study investigated the incidences of penetration and breakage for two types of optional filters, the Günther Tulip (GT) and OptEase (OE), which were placed permanently at our hospital. Study patients and methods: The study included 75 patients diagnosed with deep vein thrombosis of the lower limbs who underwent permanent placement of optional filter (GT and OE in 21 and 54 patients, respectively); consecutive computed tomography (CT) scans of the filters were obtained at our hospital between 2003 and December 2014. CT scan data were reconstructed to generate 3D images using multiplanar reconstruction and volume rendering, and visually examined for potential strut penetration into other organs and filter damage. Results: Strut penetration was observed in 15 patients with GT placement (71.4%). The sites of penetration included the aorta (3 patients), right common iliac artery (2 patients), duodenum (3 patients), major psoas muscle (1 patient), intervertebral disc (1 patient), and adipose tissue (5 patients). Meanwhile, filter breakage was identified in 8 patients with OE placement (14.8%). These breakages occurred in the vertical framework on the aortic side (3 cases) and vertebral side (5 cases). The rate of breakage increased over time. Strut penetration was not observed with OE placement, and breakage was not observed with GT placement. None of the patients with penetration or breakage experienced adverse events. Conclusion: The frequency of confirmed complications with optional filters in the present study was very high. Therefore, unnecessary permanent filter placement should be avoided whenever possible. The decision for permanent filter placement should be made after thorough assessment of the risks and benefits while considering the potential for complications. In addition, development of a safer filter for permanent placement is desirable for patients at increased risk of recurrence of serious venous thromboembolism who require permanent inferior vena cava filter placement.

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The management of endovenous heat-induced thrombosis (EHIT) following endovenous laser ablation (EVLA) for varicose veins has not been established yet. We compared the effect of oral factor Xa (FXa) inhibitors with warfarin for the treatment of EHIT. EHIT was examined with ultrasonography one day and one week after ELVA (980 nm diode laser) on 203 limbs in 193 patients. EHIT class 2 or 3 was treated with oral anticoagulants on 22 limbs in 22 patients until EHIT level became class 1 or 0. Ten patients received warfarin before September 2014. Twelve patients received FXa inhibitors after October 2014. The median number of outpatient visit times was significantly smaller in patients with FXa inhibitors (2.5 times vs 1 time, p<0.05). The median duration of the treatment was similar in both anticoagulants (7.5 days vs 7 days). In one patient, warfarin was converted to intravenous heparin for worsening EHIT. EHIT was resolved in all patients with FXa inhibitors. No adverse event was seen in both anticoagulants. There was no deep vein thrombosis or pulmonary embolism. Oral FXa inhibitors can be alternative to warfarin for the treatment of EHIT because of its rapid onset of action and convenience.

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Twenty eight patients (mean age, 43 years) with venous malformation in the limbs were underwent foam sclerothrapy at our clinic. Foam sclerosant was made by 0.5‒3.0% polidocanol with the mixing ratio of 1 + 5 for sclerosant plus air and injected up to the maximum dose of 10 ml per treatment session. Compression stockings or sleeve applied after sclerotherapy for three weeks in the lower limb, one week in the upper limb. We treated 19 venous malformation (7 upper limb, 12 lower limb) and 9 Klippel-Trenaunay syndrome. A total of 92 treatment sessions were performed (mean, 3.3 sessions per patient). Concentrations of polidocanol were 0.5% in 19 sessions, 1% in 39 sessions, and 3% in 34 sessions. Average foam volumes injected per treatment session was 8.6 ml (range: 2‒10 ml). The overall outcome was good in 10 (36%), fair in 12 (43%), and poor in 6 (21%). No serious complications were shown except one case with superficial thrombophlebitis. Polidocanol foam sclerotherapy is a safe and effective treatment method for venous malformation in the limbs.

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Background: Recurrent varices after surgery (REVAS) remain a common problem. Some REVAS can be avoided using accurate operative skills and specific surgical treatment strategies at the time of the first surgery. Treatment strategies for REVAS are also important, and analysis of cases of REVAS may prove useful in determining systematic strategies to prevent recurrence after the first surgery. Patients and Methods: One hundred and eight limbs (7.1%) among a total of 1519 limbs in which varicose vein surgery were conducted, required surgery for REVAS between January 2008 and July 2015. Of those limbs, 67 limbs among 56 patients had REVAS due to reflux from subfascial veins or saphenous vein trunks in the thighs that contained reflux from the region of the sapheno-popliteal junction. Analysis of REVAS was conducted using venous ultrasonography. Results: Previous surgery before REVAS limbs consisted of high ligation and stripping of the greater saphenous vein (GSV) in 35 limbs, resection of tributary veins in 12 limbs, and high ligation and stripping of the smaller saphenous vein (SSV) in 9 limbs. Veins with reflux causing recurrence were identified as SSVs in 29 limbs, GSVs in 18 limbs, and tributary veins from the stump on the sapheno-femoral junction (SFJ) after high ligation and stripping (sclerotherapy in one case) of GSVs in 12 limbs. In 79% of REVAS caused by tributary veins on the SFJ, the veins joined to the stump of GSV less than 1.5 cm from the SFJ. In three limbs, repeated resection and sclerotherapy to tributary veins resulted in REVAS and severe skin lesions. Conclusion: Veins with reflux should be addressed during the original surgery to avoid REVAS. Some cases require high ligation of the GSV and SSV, and to make sure of this point at the time of the first surgery is thought to be a future problem.

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Patients with amyotrophic lateral sclerosis (ALS) suffer muscle weakness of the whole body, often become bedridden, so they may have multiple risk factors for deep vein thrombosis (DVT). It is notable that pulmonary thromboembolism (PTE) and sudden death have been recognized as cause of death in patients with ALS. We assessed the incidence of DVT in 13 prolonged bedridden patients with ALS undergone mechanical ventilation using venous ultrasonography of lower extremities. We detected 3 patients (23.1%) with DVT. In the sites of DVT formation, there was one case in left superficial femoral vein, left peroneal vein and left soleus vein, one case in bilateral common femoral veins and left superficial femoral vein, and one case in right soleus vein, respectively. The range of mechanical ventilation of them was 21‒64 months. It is very important to assess DVT in medical care for ALS.

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The purpose of this study was to evaluate the long-term results of high ligation (Hi) combined with trunk foam sclerotherapy for the treatment of varicose veins associated with great saphenous vein (GSV) reflux. This study was a retrospective study. We compared the above-knee GSV occlusion rates and varicose veins recurrence rates (above CEAP classification clinical class 2) after surgery among the following four treatment groups: group H, Hi and partial resection of the GSV at the saphenofemoral junction (SFJ) and above the knee (AK) (181 legs); group HL, Hi and partial resection of the GSV at the SFJ and AK combined with trunk liquid sclerotherapy of the GSV (443 legs); groupHF, Hi and partial resection of the GSV at the SFJ and AK combined with trunk foam sclerotherapy of the GSV (490 legs); and groupST, Hi at the SFJ and stripping of the GSV (224 legs). Ten years after treatment, the above-knee GSV occlusion rate in group HF (67.4%) was higher than the rate of groups H (25.5%) and HL (20.1%) (p<0.01). The recurrence rate in group HF (33.1%) was lower than that in groups H (52.3%) and HL (57.5%) 10 years posttreatment (p<0.01). There was no significant difference in the recurrence at 10 years between Group HF (33.1%) and ST (35.1%). We conclude that high ligation and partial resection of GSV at the SFJ and AK combined with trunk foam sclerotherapy is a minimally invasive and effective method for treating varicose veins associated with GSV reflux and GSV diameter under 8 mm. Ten years posttreatment, this therapy resulted in a better GSV occlusion rate, with a recurrence rate similar to that after GSV stripping.

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In our varicose vein center, on a trial basis, among the patients with asymptomatic calf deep vein thrombosis (CDVT) we carefully selected the patients for varicose vein surgery using the requirements as follows; 1) the patients had varicose veins with incompetent saphenous veins, 2) sequential examination including DUS confirmed stability and clinical insignificance of asymptomatic CDVT, 3) the patients do not have any risk factors for DVT such as a coagulation profile disorder (antithrombin deficiency, protein C deficiency, protein S deficiency, or antiphospholipid syndrome) or malignancies, 4) surgery is possible under local anesthesia alone, and 5) the patients can understand the concept of asymptomatic CDVT and undergo the surgery on their own will and informed consent. The patients who fulfilled these conditions underwent the varicose vein surgery. Twenty-eight patients with 30 limbs with varicose veins had asymptomatic CDVT, found by preoperative duplex ultrasonography (DUS). Among CDVT, 91 % of CDVT existed in the soleal veins. After the diagnosis of the asymptomatic CDVT, serial DUS was performed and showed no changes in the status of the thrombus. Then varicose vein surgery (high ligation of the saphenous junctions either with or without stripping of the saphenous veins) was performed. After the surgery, the CDVT was re-evaluated by DUS. In 27 limbs, CDVT did not show any changes in the status of the thrombus, and in 3 limbs the CDVT was partially resolved. These data suggest that, at least, as far as the patients fulfilled these conditions, varicose vein surgery did not worsen the asymptomatic CDVT.

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Amelioration of fibrosclerotic subcutaneous Tissue in Lymphedema Therapy is often difficult. One of the Issues that need to be addressed is the Reduction of Labor and Burden in Compression Therapy. With the Aim to improve the Situation for severe Lymphedema Cases we compared a Combination of our newly developed simplified Compression Material (Wave Garment, WG) and several Bandages to conventional Multilayer Bandaging. Furthermore we examined Pressure Levels and Burden of Compression Therapy. Results: In all WG Bandage Combinations the same Level of Pressure as in Multilayer Bandaging was achieved, if applied by one of our Lymphedema Therapists. Time was reduced by 23–65% through the Usage of WG and Patient’s Labor and Burden was reduced to a large Degree. Comparing the uneven Surface of WG with flat Sponge Material showed that the convex Part of WG exerted constantly high Pressure with a Pressure Level Difference of more than 30 mmHg between the concave and convex Part of the Material. These Findings indicate that even with low Outer-Pressure on the WG Pressure is well transferred to the Skin and to the indurated subcutaneous Tissue.

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Neovascularization was investigated in 14 patients (18 legs) selected from those with recurrent varicose veins after surgery. Recurrent varicose veins were diagnosed via duplex scanning and intraoperative findings. Preoperative duplex ultrasound imaging in the groin revealed the reflux findings, those in which there was a plurality of thin vessel walls and multiple tortuous small channels. Neovascularization was identified by duplex scanning in 8 limbs. In 9 cases, we were not able to observe neovascularization for lack of cognition before surgery, but it was recognized as an instance of recurrence for neovascularization because the guide wire did not pass through the sapheno-femoral junction (SFJ) during surgery. Neovascularization of the middle thigh was recognized as a cause of recurrence in one limb. In all cases endovenous laser ablation (EVLA) could be safely performed. The reflux disappeared after EVLA in those which neovascularization was identified through duplex scanning. However, it is necessary to follow the course of the neovascular channels after EVLA because the vessels remain such that they surround the great saphenous vein.

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Varicose veins and peripheral arterial disease (PAD) are common diseases of the lower extremities. However, it is rare that both require surgical treatment at the same time. At our hospital from May 1993 to August 2016 there were 3,252 patients (1,069 males, 2,183 females) of varicose veins with saphenous vein incompetence which were diagnosed by duplex scanning. In the same duration there were 882 patients (685 males, 197 females) of PAD which were diagnosed by enhanced CT or MRI. There were eight patients (five males, three females) who were associated with varicose veins and PAD in the same limb. The incidence of PAD complaining varicose veins were 0.5% in male and 0.1% in female, respectively. On the other hand, the incidence of varicose veins complaining PAD were 0.7% in male and 1.5% in female, respectively. One patient (65 y/o female) was diagnosed as antithrombin III deficiency and another patient (44 y/o male) had a past history of pulmonary embolism and he was strongly suspected of unknown thrombogenicity. Five patients were treated conservatively with antiplatelet medicine or warfarin. The following three patients were done operation. Seventy-one-year-old male was treated by stripping of the saphenous vein and antiplatelet medicine. Fifty-seven-year-old male was treated by angioplasty of the artery and elastic stocking. Eighty-year-old female was successfully treated by angioplasty and endovenous laser ablation. Ischemia of the suffered limbs didn’t deteriorate in the all eight patients during the 21 months of mean follow up period (range 6–48 months). It is not common that varicose veins and PAD are detected in the same limb. However, it is important to examine not only the venous insufficiency but also the arterial disorder. We also need to check vein reflux in patients with PAD by duplex. Venous insufficiency may have some role in the improvement of ischemia due to arterial disease. If varicose veins and PAD are found in the same limb, arterial revasculalization should be performed initially.

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So-called “hemangiomas” mainly seen in children and adolescents contain various diseases biologically distinct from each other. To classy such vascular lesions according to the pathogenetical etiology, the ISSVA classification first adopted in 1996 divided them into proliferative vascular tumors and vascular malformations. Vascular malformations are developmental errors in vascular morphogenesis, and consist of various vascular components including capillary (CM), lymphatic (LM), venous (VM), arteriovenous malformations (AVM), and combined variants. They can occur in any part of the body, and generally progress or enlarge proportionally to age. Because additional disease entities or causal genes have been identified in the last decade, the ISSVA classification was revised in 2014 from the perspective of molecular biology. In the new ISSVA classification, the vascular tumors are classified as benign, locally aggressive or borderline, and malignant. The vascular malformations are divided into four sections: simple-type malformations, combined-type malformations, malformations of major named vessels, and malformations associated with other abnormalities. Among them, VMs are included in the simple-type malformations, composed of common sporadic VMs and rare inheritable VMs including familial VM cutaneo-mucosal (VMCM), blue rubber bleb nevus syndrome (Bean syndrome), glumuvenous malformation (GVM), and cerebral cavernous malformations (CCM). In clinical practice of venous diseases, it is important to recognize the ISSVA classification for proper diagnosis and appropriate management of vascular malformations.

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A 41-year-old female was referred to our department with swelling in her left leg. An ultrasound investigation and computed tomography (CT) imaging revealed an acute deep vein thrombosis (DVT) in the popliteal and superficial femoral veins of her left leg and giant leiomyoma of the uterus. She was initially treated intravenously with unfractionated heparin (UFH) and urokinase. On the 4th day of anticoagulant treatment, the patient presented with massive pulmonary embolism (PE) due to poor anticoagulation response. We switched UFH to fondaparinux (FPX) 7.5 mg subcutaneously once-daily. A CT scan reexamination showed filling defects in the bilateral main pulmonary arteries were remarkably improved after 9 days. After a 14-day course of hospital treatment, she was discharged on oral vitamin K antagonist (VKA) therapy resulted in an international normalized ratio above 1.5. However, she had inadequate international normalized ratio with dyspnea on exertion, and thus, warfarin was switched to non-VKA oral anticoagulant (NOAC) as edoxaban, with significant clinical improvement after 2 weeks of edoxaban treatment. NOACs provide a simplified option and greater convenience compared with traditional anticoagulants. Early and consistent efficacy may be observed in young venous thrombi patients. NOACs may be preferred as a first option for DVT patients with high risk of PE and low risk of hemorrhage.

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We experienced a case of deep vein thrombosis and pulmonary embolism after endovenous laser abltation of great saphenous vein in treating symptomatic varicose vein with superficial vein thrombosis. A 72-year-old woman came to our hospital with pain in her leg and duplex ultrasound examination revealed superficial vein thrombosis at tributary varicosities of great saphenous vein in her right leg. She had suffered superficial vein thrombosis in her left leg 7 years before. We treated her great saphenous vein with endovenous laser ablation the next day and no propagation of superficial vein thrombosis was observed POD1 and POD8. Post operative course was uneventful with compression stocking till she noticed her right leg swelling POD21. She came to our hospital POD29, and ultrasonography revealed thrombus in her deep vein. Contrast enhanced CT scan identified a shadow defect in her gasrtocnemics vein, soleal vein, popliteal vein, femoral vein and pulmonary artery. Under the diagnosis of pulmonary embolism due to deep vein thrombosis, she admitted to our hospital and was treated with anticoagulants, urokinase, and compression stocking. After 8 months, no thrombus was detected in contrast enhanced CT scan. In patients with varicose vein and superficial thrombophlebitis, serial compression ultrasonography must be done, and it is important to treat it cautiously taking anticoagulants in consideration.

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We report a case of obstructed hemodialysis shunt causing venous hypertension which could be treated by reconstruction of arteriovenous fistula using translocated peripheral cephalic vein. A 62-year-old woman on chronic hemodialysis was referred to our hospital complaining of right hand swelling with enlarged pulsatile veins of dorsum nanus. Ultrasonography revealed arterio-venous fistula was created by side-to-side anastomosis, and shunt vein was focally obstructed in just proximal of anastomotic site. Due to proximal obstruction of shunt vein, arterial blood flow turned to peripheral vein, which caused peripheral venous hypertension. Considering management of venous hypertension and reconstruction of hemodialysis shunt, we performed re-operation. Dilated distal cephalic vein was mobilized and cut for translocation. After translocation of this vein, end-to-end anastomosis to proximal intact shunt vein was performed. In this manner, we could treat venous hypertension without shortening of shunt vein.

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Venous aneurysms have been noted in the central vein, visceral vein and extremities. Venous aneurysms in the upper extremity are rare. We report herein a case of venous aneurysm in the upper extremity. 72-year-old man presented to our hospital with painful focal mass in the left upper extremity. The patient had noticed a mass 10 years ago. There were dilatated cephalic vein with the symptoms of induration, rubor, calor, dolor at the left upper arm. Ultrasonography showed thrombus in the fusiform dilated cephalic vein. We started anticoagulant therapy by warfarin with a diagnosis of the venous aneurysm with thrombus at the upper extremity. Three months later, inflammatory findings improved and almost all thrombus disappeared. Venous aneurysm was resected under the local anesthesia in order to prevent a recurrence of the thrombus. Venous aneurysms at the superficial veins are usually observed because pulmonary emboli are less risky. However, surgical treatment should be examined depending on the case because there is a possibility of thrombus arising in the superficial venous aneurysm such as our case.

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Popliteal venous aneurysms are an uncommon but potentially life-threatening disease because they can be a source for pulmonary emboli. However, most of the reported cases are saccular or fusiform. We describe here a very rare case of popliteal venous aneurysm associated with duplicated popliteal veins. To our knowledge, this kind of case has never been previously reported. A 69-year-old female consulted our hospital because of varicose veins of her left lower limb. About 9 years ago, she presented to another hospital with acute shortness of breath. She had been prescribed warfarin for one year under the diagnosis of pulmonary embolism. However, we could get no further information. Duplex ultrasound scan revealed reflux of the left great saphenous vein and a saccular aneurysm of the popliteal vein with a diameter of 2.2 cm. There was no sign of thrombosis. Computed tomography scan showed a segmental duplication of the popliteal vein, beginning in the popliteal fossa and joining in a single vessel again before the adductor canal. The distal joining portion of the duplicated veins was enlarged. The patient underwent an operation under spinal anesthesia via a posterior approach to the popliteal fossa. There was no thrombus in the aneurysm. The aneurysm was excised and the veins were repaired by lateral suture. The postoperative course was uneventful and duplex studies at 3 months after the procedure confirmed patency. Elastic compression was maintained, but anticoagulation was not prescribed. The inner wall of the true venous aneurysm exhibit fragmented elastic fibers replaced by fibrous tissue. The venous anatomy of the lower limb is highly variable and these variations have immense clinical significance particularly in cases of deep vein thrombosis and pulmonary embolism. We would recommend to all who perform venous duplex scanning for the diagnosis of deep vein thrombosis to look for two vessels in the popliteal fossa and for a duplicated femoral vein. Computed tomographic scanning is also considered to be important non-invasive diagnostic method. Because of the unpredictable risk of thromboembolic complications, surgical treatment is indicated in popliteal venous aneurysms.

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In renal cell carcinoma with the tumor thrombus extension in inferior vena cava (IVC), radical nephrectomy with thrombectomy has been reported to improve the prognosis. However, perioperative morbidity and mortality rates of the radical surgery are still high. Therefore a less invasive and more sophisticated way of surgery is necessary to improve the outcome. In this study, we retrospectively reviewed our experience of patients with tumor thrombus extension in IVC and assessed the results of the tumor thrombus extraction technique and the effect of preoperative neoadjuvant targeted molecular therapy on the thrombus size and surgical management.

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Mesenteric venous thrombosis (MVT) is an uncommon disease, but can cause acute mesenteric ischemia. Intestinal ischemia is associated with morbidity and mortality. We found that laparoscopic findings were helpful in determining treatment for a patient with mild symptoms in whom massive thrombus in the mesenteric vein was discovered on computed tomography (CT). A 23-year-old man visited a clinic complaining of lower abdominal pain and subsequently underwent contrast-enhanced CT, revealing portal and mesenteric vein thrombi. He was referred to our hospital for further evaluation and management. On admission, he reported slight abdominal pain with no signs of peritoneal irritation or ascitic fluid, although CT showed extensive portal vein thrombosis, superior MVT, and inferior MVT. To identify the degree of intestinal ischemia, we decided to perform a laparoscopic exploration, which found no overt mesenteric ischemia. Consequently, anticoagulation using heparin and thrombolytic therapy using urokinase were chosen with confidence. Oral anticoagulant therapy with warfarin sodium was started, and the patient was discharged 24 days after admission. Laboratory data showed no congenital or acquired thrombophilia. Follow-up abdominal CT 9 months later showed thrombus regression. He is currently being followed up on an outpatient basis while continuing warfarin treatment.

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A 34-year-old man (174 cm in height and 77kg in weight) consulted our hospital because of the swelling of his left lower leg on September in 2014. Contrast enhanced tomography revealed thrombus in the left popliteal vein. There was no family history of thrombotic disease. Obesity and taking a sitting position for a long time were considered to be the cause of deep vein thrombosis. He was treated with 7.5 mg of fondaparinux for 7 days and 3mg of warfarin for 6 months.

Seven months after the discontinuation of warfarin he had abdominal discomfort and consulted our hospital again. Upon arrival he was in distress due to abdominal pain but on physical examination, his abdomen was soft and there was no rebound tenderness. Abdominal computed tomography scan revealed the portal vein thrombosis and segmental edema of small intestine. Because intestinal blood flow was likely to be intact, 240,000 units of urokinase and 20,000 units of heparin were administered systemically for 7 days. Laboratory examination on admission revealed normal protein S, antithrombin III, plasminogen levels. Protein C antigen and activity were 41% and 54 % respectively and inherited Protein C deficiency was strongly suggested. However, this patient didn’t want to take further studies including gene genetics. The patient recovered fully and was discharged on the 40th day after the admission while taking 3mg of warfarin to maintain the prothrombin international normalized ratio (PT-INR) within to 2.0. He is well and has no recurrence of venous thrombosis at follow-up 6 months after discharge.

Combination of deep vein and portal vein thrombosis due to Protein C deficiency is rare. Only four case reports similar to our case were found in the Japanese literature from 2004 to 2016. If a patient has unknown recurrent venous thrombosis, specific coagulation tests including Protein C, Protein S and Antithrombin III deficiency should be performed.

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A 68-year old woman was referred to our hospital with the complaint of persisting pain after a hit on the internal side of her thigh. We observed a mass protruding from her thigh. Doppler ultrasound examination revealed a cavity communicated with superficial femoral vein (62 mm×21 mm in diameter), which was diagnosis as traumatic venous aneurysm. At one month follow-up we observed no difference in dimensions of venous aneurysm and found mural thrombus in venous aneurysm. To prevent pulmonary embolism, the resection of venous aneurysm was undertaken. Six month after the operation, ultrasonography showed no recurrence of the venous aneurysm.

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From April 2008 to May 2017, Perforate-invaginate (PIN) stripping were treated in 1144 consecutive cases of saphenous varicose veins in day surgery. We routinely perform femoral nerve block and saphenous nerve blocks with 1% Xylocaine to each 3 ml and 6 ml under echo-guide. We made improvements in the length and angle Oesch PIN stripper and created by ourselves. We also further added new method to silk thread to Oesch PIN stripper. We obtained satisfactory results with less postoperative pain, bleeding and peripheral nerve damage.

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In the past, unfractionated heparin and warfarin requiring dose adjustment have been used as anticoagulants for treatment of venous thromboembolism (VTE) in Japan. These uses are accompanied by several pitfalls, which have led to research and the discovery of new additional groups of anticoagulants: parenteral factor Xa inhibitors, such as fondaparinux, and non-vitamin K antagonist oral anticoagulant: NOAC/direct oral anticoagulant: DOAC, such as edoxaban, rivaroxaban, and apixaban. These new drugs appears to be more effective and safer than conventional anticoagulants, because they are fast-acting, non-inferior to heparin and warfarin in preventing recurrence of VTE, and do not require monitoring, such as the following. NOAC/DOAC could offer new therapeutic options for long-term prevention for recurrence in cases of unprovoked VTE. It would be possible for the initial VTE treatment to start only with NOAC/DOAC, especially for deep vein thrombosis. Moreover, they have the potential to provide more convenient and benefit for cancer patients with VTE: while cancer is most common cause of VTE in Japan. For these reasons, NOAC/DOAC can be used as replacements of unfractionated heparin/warfarin for the initial and long-term treatment for VTE. However, the suitability of these drugs in fragile patients has not been established. Therefore, further studies are required to increase the utility of NOAC/DOAC in the treatment of VTE.

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