Here the pathophysiology of venous thromboembolism is reviewed with respect to the anatomical features of the deep veins of lower limbs. A thrombus is less likely to form in the thigh veins compared with that in the calf veins; however, clinical symptoms are more likely to appear in the thigh veins owing to vascular occlusion. When a patient is bedridden, thrombosis is more likely to occur in the intramuscular vein, which mainly depends on muscular pumping and the venous valve, rather than in the three crural branches, which mainly depends on the pulsation of the accompanying artery. Thrombi are prone to be generated in the soleal vein compared with those in the gastrocnemius vein because of the vein and muscle structures. A soleal vein thrombosis grows toward the proximal veins along the drainage veins. To prevent a sudden pulmonary thromboembolism-related death in bedridden patients, preventing soleal vein thrombus formation and observing the thrombus proximal propagation via the drainage veins are clinically important. When deep vein thrombosis occurs, avoiding embolization and sequela caused by the thrombus organization is necessary.

Lymphedema is an intractable disease caused by anatomic or functional obstruction of the lymphatic system. There is no cure for lymphedema at this time. Human lymphatic endothelial cells (LECs) express the HGF receptor, c-Met (HGF receptor), and treatment of LECs with HGF results in the increase of LEC proliferation and migration in a dose dependent manner. Furthermore, weekly HGF gene transfer into rats with lymphedema results in amelioration of the lymphedema by tail thickness or forelimb volume, because of lymphangiogenesis and lymphatic-vessels remodeling. Given with these data, we started a phase 1/2a clinical trial of HGF gene therapy in 2013 October. We believe that these results will be of benefit to patients with lymphedema, and hope to overcome the lymphedema.

The changes of surgical procedure for primary varicose veins and clinical results in a day surgery clinic were evaluated. A total 5004 cases of primary varicose vein patients underwent day surgery for these 7 years. The surgical treatment was stripping of the incompetent saphenous veins or endovenous thermal ablation (EVTA) of those. Miniphlebectomy was added by stab avulsion technique. Postoperative complications were observed in 5.7% of the stripping group and 2.8% of EVTA group, however, severe complications such as pulmonary embolism, proximal deep vein thrombosis, Class 3–4 EHIT were not experienced in all patients. The percentage by year of EVTA was 0% in 2012, but increased to 12% in 2013, 55% in 2014, 82% in 2015, 95% in 2016, and reached to 97% in 2017. After stripping surgery, 6 patients (0.2%) needed late re-intervention because of recurrent varices. In contrast, no patients of EVTA group needed reoperation. The trend of varicose vein surgery may expect to shift to further low invasive technique.

(Purpose) An appropriate strategy is necessary to prevent nerve injury and deep vein thrombosis (DVT) in endovascular ablation (EVA). (Objective) We evaluated the benefit of local anesthesia and active walking as soon as possible after surgery for preventing complications. (Methods) In 439 consecutive patients (146 male and 293 female patients), EVA was performed between December 2014 and December 2016. The mean patient age was 65.0±11.3 years. The surgery was performed under local anesthesia in one leg, and the patients were hospitalized for 2 days and 1 night. The distal one-third of the GSV of the lower limb was marked for the prevention of saphenous nerve injury. Varicectomy was performed using the stab avulsion method. EVA guidelines were applied strictly for DVT prevention. After surgery, 4–5 walking sessions of 200 m/h were promoted. Pain was evaluated using the Okamura pain scale (OPS, score 0–5) objectively and the numerical rating scale (NRS, score 0–10) subjectively. (Results) In all patients, the mean TLA volume was 615.9±153.4 mL, stab avulsion was 12.3±8.3 sites, and operative time was 39.2±15.2 min. All patients could walk as soon as possible after surgery. In 164 recent patients, the mean OPS score was 1.8±1.3 and the mean NRS score was 3.2±2.0. DVT and pulmonary embolism were not noted. (Conclusion) EVA should be performed under local anesthesia to prevent nerve injury and DVT. In addition, adequate walking is important as soon as possible after surgery.

Foam sclerosants have the advantage of creating a homogenous distribution with greater sclerosing ability than corresponding liquid sclerosants. In Japan there are many reports of foam sclerotherapy for the treatment of saphenous vein. However, few reports can be seen concerning foam sclerotherapy for the non-saphenous type varicose veins. A total of 21 limbs in 16 patients (4 males and 12 females) with non-saphenous type varicose veins were treated with only foam sclerotherapy from 2005 to 2016 at our hospital. Patient’s mean age was 63 years (range 34–81). The foamed sclerosant was produced with polidocanol (1% or 3%) and air, in a ratio of 1 : 3, using the Tessari method. A 21G or 23G venipuncture needle was inserted into the varicose veins. One or two injections in one session (total of 5–10 mL foam sclerosant) were administered slowly while the patient lay in the supine position with the affected leg elevated. After injection, compression pads and elastic bandages were applied and maintained in place continuously until the next day. Elastic stockings were used afterwards. Varicose veins were almost disappeared in all patients within several months. The major adverse events of foam sclerotherapy were superficial thrombophlebitis and pigmentation. However, no serious complications were shown. Foam sclerotherapy is a safe and effective treatment method for non-saphenous type varicose veins which are not suitable for surgery and it is recommended as the first choice. It is necessary to improve the techniques, and to reduce the complications and the recurrence rate.

A patient is reported with varix arising from between the 3rd and the 4th hand finger associated with phlebolith. The varix is shaped as venous aneurysm without valve failure. The report of the varix with phlebolith arised from extremity is rare. We discussed briefly varix with phlebolith.

A 73-year-old woman visited our vein center complaining of right ankle pain. Duplex ultrasonography revealed superficial thrombophlebitis on the right ankle, with asymptomatic deep vein thrombosis in the right soleal veins. A computed tomography scan showed multiple thrombi in bilateral pulmonary arteries. She underwent anti-coagulation therapy with edoxaban as well as elastic compression stockings. Blood examination did not show any coagulation profile disorders (i.e., antithrombin deficiency, protein C deficiency, protein S deficiency, or antiphospholipid syndrome). Since the cause of venous thromboembolism (VTE) was unknown, we suspected her hypercoagulable state due to malignancy. After whole body examination, colonoscopy finally exhibited a colon carcinoma in the hepatic flexure. She underwent right colectomy with lymph node dissection under laparoscopic assistance. After 1-year follow-up, there were no recurrences either of malignancy or VTE.

Popliteal venous aneurysm (PVA) is rare disease that may cause the potentially fatal pulmonary embolism (PE). A 62-year-old woman complaining of severe dyspnea was admitted to our hospital. Contrast-enhanced computed tomography (CT) revealed bilateral PE and right multiple PVAs with thrombus. Thrombolytic therapy with recombinant tissue plasminogen activator and anticoagulant therapy was started. After her dyspnea was improved, we performed tangential aneurysmectomy of the proximal PVA with lateral vein reconstruction and aneurysmectomy of the distal PVAs with end-to-end anastomosis via a posterior approach. The postoperative CT scan showed popliteal venous patency without recurrence both venous aneurysm and pulmonary thromboembolism. The patient was discharged from our hospital on the ninth postoperative day.

Standing position for long time is thought to be a cause of refractory stasis ulcers arising from chronic venous insufficiency. In some cases, improvement in activities of daily living is required. We encountered a patient who developed this condition as a result of mental retardation. The patient was a 53-year-old woman who had developed ulcers in both lower limbs after sustaining injuries. The patient received treatment for her wounds by her local physician, but wound healing was difficult to achieve due to venous stasis caused by varicose veins in both lower legs. The patient was subsequently referred to our hospital for surgery. The medical history showed that she had mental retardation associated with Prader-Willi syndrome and was forced to work with standing up or sitting down position for long time at a community workshop. The varicose veins were treated with endovascular radiofrequency ablation, and ongoing compression therapy was provided by wrapping them in elastic bandages and elevating the lower limbs. Healing of the ulcers in both lower legs was achieved one month after surgery. Patients who develop mental retardation rarely have a good social background, including cases who are forced to stand for long time at their place of work or elsewhere. It is necessary that proactive therapeutic intervention including daily improvement of venous stasis and surgical therapy, as well as raising awareness of such interventions.

Stab avulsion is an operative procedure for the tributary veins of varicose veins that is performed not only to improve the cosmetic result, but also to improve the symptoms and long-term result of the surgery, such as the recurrence rate and the frequency of the need for second-stage procedure. In this article, the operative process of stab avulsion is explained in detail. First of all, large amount of anesthetic solution, which mostly consists of saline with 0.1% lidocaine, is infiltrated around the preoperatively targeted vein. Then, an incision is made with an 18-gage needle or a common number 11 scalpel which are ideal tools for making 2 mm incision. A hook is inserted from the incision and the targeted vein is identified by being put between the hook and the fingers. After hooking the vein, it is separated from the surrounding tissue by shaking not the vein but the surrounding tissue gently. And the separated vein is easily exposed out of the incision. The exposed vein is hold with forceps. After looking over the direction and the branches of the vein, the vein is taken out not by pulling the vein but by shaking the surrounding tissue. There are few and slight complications which are directly concerned with stab avulsion, such as bleeding, nerve disturbance, infection and so on.