Background: Renal cell carcinoma (RCC) has a tendency to invade the renal venous system with tumor thrombus. In this study, we assessed the surgical strategy for RCC with tumor thrombus, especially those expanding into the inferior vena cava (IVC). Patients and Methods: We retrospectively reviewed our clinical records for all patients who underwent radical nephrectomy and tumor thrombectomy from January 1993 to December 2014. Among 66 patients who were treated surgically, we investigated patients with tumor thrombus extending into the IVC and <2 cm above the renal vein (RV) (Level I), extending into the IVC and >2 cm above the RV (Level II), and extending at the level of or above the hepatic veins, but below the diaphragm (Level III). All patents underwent operations without using a cardiopulmonary bypass or venous-venous bypass. Results: Level I included 10 cases, Level II 17 cases, and Level III 3 cases. In all cases, the entire tumor and tumor thrombus were completely resected, and no perioperative mortalities were encountered. Nine of 20 cases had perioperative morbidities, however, all morbidities were treated conservatively and cured. Conclusions: We should therefore select a surgical strategy depending on the cancer laterality, cephalad extension of the tumor thrombus, and IVC patency. Our surgical strategy with less invasive additional maneuvers can achieve adequate surgical outcomes.

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To prevent pulmonary embolism after orthopedic surgery for knee orthroarthrosis, we performed pre and postoperative duplex scanning of leg veins. Of the 293 cases undergoing operation, 101 patients (34.5%) developed deep vein thromobosis. Among demographic and clinical factors, chronic venous insufficiency and tourniquet time were identified to significantly influence the development of DVT. Of 101 cases with DVT, 68 cases (67.3%) disappeared in 34.4 days.

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Backgrounds: The purpose of this study is to evaluate inpatient symptomatic venous thromboembolism (VTE). Materials and methods: From 2005 to 2014, we experienced 107 symptomatic pulmonary thromboembolisms (PTE) and deep vein thrombosis (DVT). According to patients’ backgrounds, surgical group and non-surgical group were individually analyzed. Results: In surgical group, 20 had PTE and 35 had DVT. According to Japanese guideline, patients’ risks were as follows; Highest-risk 1, High-risk 29, Moderate-risk 23, and Low-risk 2. Pharmacological prophylaxis was used 1/1 in Highest-risk, 1/29 in High-risk, 4/23 in Moderate-risk. Therapeutic anticoagulation could be done in 51/55, and inferior vena cava filter was placed in 5 patients. In non-surgical group, 10 had PTE and 42 had DVT. According to Japanese guideline, basic risks were as follows; Strong 9 (8 had multiple risks, and 1 had acute phase risk), Moderate 39 (16 had multiple risks, and 6 had acute phase risk), Weak 4 (2 had acute phase risk). Mechanical prophylaxis was used in 10 patients. Conclusion: Many symptomatic VTE developed in High-risk surgical patients. Pharmacological prophylaxis should be used as soon after patient’s bleeding risk diminished. In non-surgical patients, periodic risk assessment and adequate prophylaxis should be performed.

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A 72-year-old man who suffered from chronic thromboembolic pulmonary hypertension (CTEPH) for 6 years and treated by medication was admitted to undertake pulmonary endarterectomy (PEA). His pulmonary artery pressure and pulmonary vascular resistance before the operation were 75/28 (48) mmHg and 701 dyn/s/cm⁻⁵, respectively. Neither thrombotic predisposition nor deep vein thrombosis was detected. PEA was performed and the broad intima of the right pulmonary trunk along with massive organized thrombi were successfully extracted. He became hemorrhagic from the right respiratory tract during the operation and died from progressive pleural effusion at 85 days postoperation. Autopsy showed severe hypertrophy of the right ventricular muscle. The right pulmonary artery showed the central type of CTEPH. At the pulmonary trunk, the intima was broadly dissected and secondary thrombi were partially adherent to the dissected lumen. Some muscular arteries formed vein-like lesions, especially at the peripheral side of the completely occluded proximal artery. In contrast, the left pulmonary artery showed the peripheral type of CTEPH. At the left pulmonary artery, the intima was well preserved in the pulmonary trunk and a “band and web-like appearance” was broadly observed at various sizes of arteries from lobar to small elastic arteries. Intimal thickening and organized thrombi were observed at peripheral muscular arteries. The vein-like lesion was a specific finding of sustained pulmonary hypertension. In cases of CTEPH, vein-like lesions are thought to occur by severe obstruction of the proximal artery. These lesions suggest a poor prognosis, resulting in alveolar hemorrhage after PEA.

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A 71-year-old female patient visited our hospital complaining of left leg joint pain and discomfort of lower extremities. Duplex ultrasound showed incompetent on bile femoral-saphenous vein junction. She was diagnosed of C2 Ep, As, Pr on CEAP classification and performed endovenous lser ablation (EVLA), varisectomy, form sclerotherapy on general anesthesia. On the first post-operative day, she collapsed after starting to walk, and presented with sudden loss of dyspnea. Portable US presented insufficiency of right heart and postoperative deep vein thrombosis (DVT) and pulmonary thromboembolism (PTE) were suspected to occur prior to transfer to CT room. In spite of IVC filter implantation and thrombolytic therapy, hemodynamic stabilization of the patient was not maintained to recover. Although fatal PTE is a rare complication after EVLA, one-stage operation and anesthesia technique require strict attentions.

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Nutcracker syndrome is the term used to describe the patient with clinical symptoms of entrapment of the left renal vein between the aorta and the superior mesenteric artery. Pelvic congestion syndrome, which is a cause of chronic pelvic pain in women, may be due to Nutcracker syndrome. There are many modalities of treatment of Nutcracker syndrome. This is a case report of a woman with pelvic congestion syndrome due to Nutcracker syndrome, who subsequently underwent balloon angioplasty of the left renal vein. A 52-year-old premenopausal woman with no medical history presented to us with left flank pain. Physical examination, blood test and urinalysis were normal. Computed tomography eventually revealed engorged left renal and ovarian veins due to compression between the superior mesenteric artery and the abdominal aorta, consistent with Nutcracker syndrome. A percutaneous endovascular procedure was performed under local anesthesia. After ultrasound-guided puncture, a sheath was introduced into the right femoral vein. A multipurpose catheter was directed into the left renal vein and a diagnostic renal venogram was performed. Hemodynamic assessment confirmed a pressure gradient 4 mmHg between the left renal vein and the inferior vena cava. Balloon angioplasty was performed by MUSTUNG 8 mm×40 mm at the maximum pressure of 6 mmHg. Subsequent clinical follow-ups ensure full resolution of the patient’s symptoms. Antiplatelet or anticoagulant therapy was not used after the balloon angioplasty. She has had complete remission of pain for one year after the procedure. There are some case reports of stent migration into the inferior vena cava or the right ventricle after stent placement in patients with Nutcracker syndrome. There is a possibility of restenosis, however, balloon angioplasty is a more safe and minimally invasive technique for the treatment of Nutcracker syndrome rather than metallic stent. Nutcracker syndrome, while rare, should be suspected in patients with persistent flank pain.

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Two types of vein surgery, which are sub-fascial endoscopic perforating vein surgery (SEPS) and sclerotherapy, have been performed to treat incompetence of perforator veins (IPVs). The SEPS method has high obstruction rate of IPVs, but more invasive. Whereas the sclerotherapy is less invasive, but has low obstruction rate of IPVs. Percutaneous ablation of perforators (PAPs) is novel method to treat IPVs. PAPs is able to be performed at the same time of EVLA for GSV or SSV in local anesthesia and has high obstruction rate of IPVs. We introduce our procedural techniques of ultrasound-guided PAPs using 980 nm Bare-Fiber laser.

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Compression therapy is essential treatment for venous and lymphatic disease. Although mechanism of compression device to exert subbandage pressure is complex, it is divided into four elements. PLACE: P (Pressure), La (Layer), C (Component), and E (Elasticity). Modification of compression therapy based on concept PLACE is useful. Another important factor which influence results is compliance for compression therapy. We have to modify compression method which is acceptable for each patients based on concept of PLACE.

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