(Background) The natural history of asymptomatic isolated distal deep vein thrombosis (DVT) of the leg is unclear. This study aimed to describe a 3-month and 1-year clinical course after diagnosis of asymptomatic isolated distal DVT of the leg.
(Methods) This study included 127 patients with asymptomatic, sonographically proven isolated distal DVT who did not receive anticoagulant therapy and were retrospectively evaluated at our hospital between May 2014 and September 2016. After 3 months and 1 year, the presence or absence of venous thromboembolism recurrence and extension of DVT toward proximal veins was sonographically confirmed.
(Results) At 3-month and 1-year follow-ups, 125 and 109 patients were observed, respectively. All patients showed no symptoms or findings suspecting venous thromboembolism recurrence during the observation period. However, 43 patients underwent repeat ultrasonic examination, and thrombus extension was confirmed in 2 patients.
(Conclusions) Asymptomatic isolated distal DVT of the leg showed good prognosis, and thus uniform anticoagulation therapy was considered unnecessary.
Objective: Standard of an intensive drainage treatment in compression therapy for lymphedema is the use of bandages. However, bandaging is difficult for patients to get the desired interface pressure level. Few studies have been conducted to investigate the effectiveness on elastic stockings in the intensive drainage treatment. The previous study by joint with our clinic, aimed at the effectiveness of the treatment with elastic stockings, showed efficacy in both reduction in edema volume, and difference in circumference between affected and unaffected leg (edema rate). This study aimed to assess on the effectiveness, described above, of the elastic stockings from the perspective of the interface pressure measured in the previous study. Subjects and Method: Twenty legs of 20 patients affected by secondary lower limb lymphedema were targeted in the study. The patients visited hospital four times at weekly intervals. At the visit, elastic stockings were renewed based on the circumference of the leg measured after massaging and the severity of lymphatic dysfunction. A flat-knitted stocking was applied, and if needed higher compression, a round-knitted stocking was superimposed on flat-knitted one. After application, interface pressure was measured at four sites on the leg. The effectiveness was assessed from the stability and reproducibility of interface pressures measuered when wearing stockings (pressure levels, pressure gradient distribution profiles, and increase in interface pressure of two superimposed stockings). Results: As for the effectiveness of the treatment with elastic stockings, the previous study showed that compression reduced edema volume significantly from 6402 to 6025 mL (median, P<0.001) after one week. The degree of improvement in edema rate was in inverse proportion to the severity of lymphatic dysfunction. At the first visit, interface pressure (median) at site A (dorsum), site B (ankle), site C (calf), site F (thigh) was 43.6, 49.4, 48.4, 27.7 mmHg respectively. Interface pressure profiles normalized were the same at all four times to visit. An increase in the interface pressure of two superimposed stockings compared to the pressure of the first stocking was 1.2–1.7 times. A numerical model to predict interface pressure using a Generalized Linear Mixed Modeling was made with pressure measured at B as a response variable, circumference of the ankle as a covariate, and the severity of lymphatic dysfunction as a factor. The correlation between interface pressure measured and the pressure predicted showed highly significant (R=0.9881, P<0.001). Conclusion: Even though confirmatory studies are needed, this study demonstrated that interface pressures sustained stable regardless of the sites on the leg, of the number of visits, and of with or without two superimposed stockings, leaded to the effectiveness of compression therapy with elastic stockings. The numerical model suggested that it would be possible to standardize for elastic stocking having optimal compression pressure for individual patients.
The left brachiocephalic vein (LBV) is one of preference sites of central vein stenosis and compression with the sternum and the aortic arch is considered as one of the causes of the stenosis. The LBV has surrounding structures similar to the left common iliac vein, which is known as iliac vein compression syndrome. There are few anatomical studies on structures around the LBV. First, we examined 30 cases (mean age 63.9 years old) using thoracic contrast CT. However, there were a lot of variance in the number of cases by age, the distance between the brachiocephalic artery and the anterior bone was measured for 31 cases, and the change due to age was examined. The LBV often contacted with the brachiocephalic artery and the left common carotid artery. The distance between the LBV and the brachiocephalic artery, lesser diameter and cross sectional area of the LBV were significantly smaller in over 65 years old (p<0.05–0.01). In addition, the distance between the brachiocephalic artery and the anterior bone was negatively correlated with age (p<0.03). The distance between the sternum and backside artery sandwiching the LBV could shorten along age resulting of stenosis of the LBV. It was suggested that for dialysis patients, the LBV was one of the preference sites for stenosis due to compression by the surroundings tissues, and that shunt efficiency would decrease by aging.
Objective: Venous thrombus is occasionally encountered in patients with malignant tumors. The present study aimed to evaluate the association between deep venous thrombosis (DVT) and malignant tumors.
Subjects and Methods: Of 243 patients with DVT examined between January 2012 and December 2016, 59 (24.4%) were diagnosed with malignant tumors. We compared D dimer and fibrin degradation product (FDP) levels, the location of DVT and the clinical stage of malignancy between non-survivor group (N=19) and survivor group (N=40).
Results: Totally, 26 males and 33 females were included and their mean age was 69.9±5.6 years. D dimer and FDP levels were significantly higher in non-survivor group than in survivor group (P<0.01). With regard to the location of DVT, the proximal type was significantly more common in non-survivor group (P<0.001). A more advanced stage was also significantly in the non-survivor group (P<0.001).
Conclusion: D dimer and FDP levels, location of DVT and clinical stage of malignancy are important factors for the prognosis of patients with DVT malignant tumors.
【Introduction】 We report our experience treating venous thromboembolism (VTE) with DOACs at our hospital. 【Subjects and Methods】 We retrospectively reviewed patients treated with edoxaban or rivaroxaban for VTE from November 2014 to September 2016 at our hospital. We compared the efficacy and safety of these two DOACs. We evaluated efficacy by incidence of thromboembolic events and safety by incidence of bleeding episodes. 【Result】 92 patients with VTE received treatment with edoxaban or rivaroxaban during the study period. 71 patients (77.2%) were treated with edoxaban and 21 patients (22.8%) patients were treated with Rivaroxaban. There were more patients with temporary VTE risk factors in the edoxaban group and more cancer patients in the rivaroxaban group. Many asymptomatic DVT patients and distal DVT patients who were not covered in previous RCT were included in this study. Many patients received treatment at a reduced dose and relatively few patients received the regular dose. Thromboembolic events in the edoxaban and rivaroxaban groups occurred in 4 patients (5.6%) and no patients (0%), respectively. There was no statistically significant difference between the two groups (P=0.362). Bleeding episodes in the edoxaban and rivaroxaban groups occurred in 10 patients (14.1%) and 2 patients (9.5%), respectively. There was no statistically significant difference between the two groups (P=0.719). Major bleeding occurred in 2 patients (2.8%) in the edoxaban group and 1 patient (4.8%) in the rivaroxaban group. During the study period, 6 patients (8.5%) in the edoxaban group and 1 patient (4.8%) in the rivaroxaban group died. There were no VTE-related deaths in either group (P=0.271). Cause of death was cancer in all cases. 【Conclusion】 Although patient characteristics were different, the efficacy and safety of these two DOACs for treatment of VTE were similar in our study.
Objective: After endovenous laser ablation (EVLA) of the great saphenous vein (GSV), the patent branches at the sapheno-femoral junction (SFJ) could be a cause of recurrence of varicose veins. The aim of this study is to evaluate whether the EVLA started near the SFJ with a 1470 nm diode laser and radial 2ring fiber decreases the number of patent branches at the stump of the GSV. Methods: From July 2016 to June 2017, 101 limbs in 78 patients with GSV varicose veins were evaluated. EVLAs were started 6.6±1.3 mm distal to the SFJ. The first follow-up (3–5 days), the second follow-up (8–11 days), and the third follow-up (1 month) were done using ultrasonography. Result: The incidence of EHIT was as follows: class 1, 15.8%; class 2, 13.9%; and class 3, 2.0%. The GSV stumps had 0–3 patent branches. In addition, the percentages of the GSV stumps without a patent branch at the first, second, and third follow-up were 54.5%, 50.5%, and 42.6%, respectively. At the third follow-up, the GSV stump length in all limbs was 7.1±5.8 mm. Furthermore, the GSV stump length without a patent branch was shorter than that with patent branches (2.4±4.0 mm vs. 10.7±4.2 mm; p<0.001). Conclusion: EVLA started near the SFJ with a 1470 nm diode laser and radial 2ring fiber resulted in a short GSV stump without a residual patent branch in about 40% of limbs. This could help decease the recurrence of varicose veins at the SFJ.
Popliteal cyst, also called Baker’s cyst, is a popliteal fossa enlargement filled with synovial fluid. Baker’s cysts can be symptomatic and cause considerable pathologies such as thrombophlebitis, compartment syndrome and even nerve entrapment. Vascular surgeon has a chance to find a Baker’s cyst during the diagnosis of deep vein thrombosis (DVT) or varicose veins. Although most of the Baker’s cysts are treated by orthopedic surgeon, vascular surgeon may treat them in selected cases. The purpose of this study was to determine the incidence and characteristics of Baker’s cysts discovered during venous duplex examinations to rule out deep vein thrombosis (DVT) or varicose veins.
The patients who were diagnosed as Baker’s cyst at our department between 2009 and 2017 were reviewed retrospectively. All patients in the study underwent ultrasonographic examination. Six (1.9%) of 310 patients who were suspected of DVT and 13 (0.6%) of 2135 patients with varicose veins were found to have Baker’s cysts. The total of 19 patients consisted of 2 males and 17 females. The ages ranged from 55 to 81 (median 72) and affected sides were 13 left and 6 right. No thrombus was visualized by ultrasonography in the all 6 patients who were suspected of DVT. Four of them were diagnosed as ruptured Baker’s cysts and one patient was treated with aspiration of the residual fluid. Two patients had non-ruptured Baker’s cysts and they were treated with aspiration. Eight patients had the incompetence of the long saphenous vein and Baker’s cysts were detected on the same limbs. Five of them were undergone operation (EVLA, EVLA and aspiration, stripping and aspiration, sclerotherapy, only aspiration). Five patients had non-saphenous type varicose veins and two of them were treated with aspiration of the cysts. No complications occurred secondary to percutaneous treatment. Repeat ultrasonography demonstrated that the size of the cyst decreased.
The rupture of a Baker’s cyst results in a swollen, painful leg that is clinically indistinguishable from acute deep vein thrombosis. The therapeutic implications of pseudothrombophlebitis are of major significance with respect to the avoidance of anti-coagulation and ultrasound-guided aspiration of the cyst. Careful examination of the popliteal fossa should be performed during venous duplex examinations regardless of the indication for the study. There are few reports discussing the Baker’s cysts associated with varicose veins. We think that it is acceptable for the vascular surgeons to treat the cysts by aspiration at the same time of the treatment of varicose veins from the standpoint of patients’ benefits.
The aim of this study was to investigate the rate and cause of recurrence after endovenous laser ablation (EVLA) of the great and small saphenous vein (GSV & SSV) from 3-year follow-up results using duplex ultrasound in Japanese patients with varicose veins. We reviewed 149 limbs (follow-up rate 83%) in 141 patients undergoing EVLA with 980 nm diode laser. After EVLA of the GSV (127 limbs), accessory saphenous vein (ASV) insufficiency was detected in 3 (2%) at 1 year, 5 (4%) at 2 years and 7 (6%) at 3 years, thigh perforator vein reflux in 3 (2%) at 1 year, 5 (4%) at 2 years, 7 (6%) at 3 years, recanalization with reflux in 0 (0%) at 1 year, 2 (2%) at 2 years, 3 (2%) at 3 years and neovascularization with reflux in 0 (0%) at 1 year, 1 (1%) at 2 years and 1 (1%) at 3 years. After EVLA of the SSV (29 limbs), saphenopopliteal junction (SPJ) incompetence was found in 1 (3%) at 1 year, 6 (21%) at 2 years and 8 (28%) at 3 years. Reoperation was performed in 2 limbs for ASV insufficiency and thigh perforator vein reflux respectively. In conclusion, ASV insufficiency, thigh perforator vein reflux, GSV recanalization and SPJ incompetence can be significant causes of recurrence after EVLA for varicose veins.
In Japan, the Multi-Layered Inelastic Lymphedema Bandage (MLLB) is recommended for Phase1 Lymphedema treatment. However, MLLB has high elongation stiffness, but compression pressure tends to decrease with the passage of time. In our clinic, Phase1 treats outpatient clinic using wavy type urethane garment and Flat-knit Elastic Stocking (FES) instead of bandage. The FES has higher elongation stiffness than compared to Round-knit Elastic Stocking (RES), and since it is a stocking, the pressure is stable. Because the elongation stiffness is high, a specialized auxiliary tool is required to put on and take off the stocking.
However, if the stocking is put on the correctly, high drainage can be expected. In cases where we can treat with FES, normal clothes and shoes can be worn as usual, with little impact on dairy life.
There are many reports of ovarian varicose vein most of which are due to Nutcracker syndrome. However, primary internal iliac varicose vein is an extremely rare vascular abnormality in men. We report a case of primary internal iliac varicose vein in a 70-year-old man. The varicose vein was detected during the examination for sigmoid colon cancer. He noticed melena in September 2017 and colonoscopy was done at a clinic. It revealed type 2 sigmoid colon cancer, however, there was no teleangiectasia or varices in the colon. He was referred to our hospital.
The patient had no relevant medical or family history and no history of trauma or intense athletic activity. He did not complain of pain or tenderness in the hypogastric and inguinal areas, and there were no palpable mass. Hematologic examinations yielded no significant findings except for slight anemia. Contrast-enhanced CT revealed a dilated tortuous vascular structure of bilateral internal iliac vein and dilated inferior mesenteric vein. However, there was no stenosis of portal vein and metastatic liver tumor. Our patient did not have splenomegaly, esophagocardial varices, or any other collateral vessel such as a spontaneous splenorenal shunt, all of which are ordinary responses to portal hypertension. It remains unclear whether internal iliac varicose veins are congenital or acquired. We speculate that our patient might have had an underlying anomaly.
Laparoscopic sigmoidectomy was done and postoperative course was uneventful. The dilated inferior mesenteric vein was ligated at the proximal side. He discharged 10 days after the surgery. Histological analysis of the dissected inferior mesenteric vein revealed no remarkable findings. The patient was healthy and symptom free when last seen at his sixth month follow up. Contrast-enhanced CT six months after the operation revealed shrinkage of the residual varicose vein. However, careful follow up is recommended.
This case involved a 41-year-old female who experienced pain in the right lower leg for a few days, Although swelling and reddening were observed, no treatment was sought because her condition improved. However, she visited our hospital after becoming aware of similar symptoms in the left lower limb two days ago. Vascular echocardiography revealed thrombus filling the bilateral great saphenous veins, and thrombus was found in the branches of both pulmonary arteries on contrast CT. A lot of thrombus was observed in the saphenous vein extending into both femoral veins. Surgery was performed by incising the large saphenous vein at a high level and removing the thrombus, followed by high ligation. The operative course was good. In this case, the thrombus arising in the main great saphenous vein and progressing to the femoral vein was diagnosed as ascending thrombophlebitis, which can cause deep vein thrombosis and pulmonary embolism, As this condition is sometimes fatal, caution is necessary.
We experienced a case of varicose veins of a leg with thrombophlebitis complicated by a malignant disease. Case: 81-year-old male. Chief complaint; left internal femoral pain, varicose veins in both legs. Approximately 10 years ago, he had varicose veins of his both legs. Redness and pain of the left thigh appeared about 1 month ago, and he visited a near physic. After that, he was introduced to us for treatment. Varicose veins of both legs and thrombophlebitis of the left leg were observed. In the vascular echo, reversed flow in the both great saphenous veins and thrombus in the left great saphenous vein were observed. A simple computed tomography scan showed a 5 cm mass in the right kidney. We suspected it a renal cell carcinoma. We did stripping operation of the left great saphenous vein and thrombus removal for the varicose veins of the left leg. Three months later, right nephrectomy was done. Six months later, catheter-assisted procedures using radiofrequency was done for the varicose veins of the right leg. After 1-year follow-up, there were no recurrences either of malignancy or varicose veins. It is necessary for us to consider varicose veins of a leg with thrombophlebitis are complicated by a malignant disease.
80 years old man underwent osteosynthesis operation for trochanteric fracture. After two month, a pulsating tumor was detected to the right inguinal region and gradually enlarged. The pseudo aneurysm was noted by CT scan and ultrasound. After the blood flow blocking balloon was inserted into the perforated deep femoral artery, the pseudo aneurysm was exposed and incised. But surgical control of bleeding was difficult by the backflow of the pseudo aneurysm and arteriovenous fistula in the deep femoral artery was identified.
Inferior vena cava (IVC) filters are commonly used to prevent acute pulmonary thromboembolism in patients with deep venous thrombosis who have a contraindication to anticoagulation or show failure of anticoagulation. The number of IVC filter implantation procedures performed has shown an increasing trend.
We report a case of an inferior vena cava (IVC) filter penetrating the aorta. A 54-year-old woman had undergone placement of a Bird’s nest IVC filter for deep vein thrombosis 20 years earlier, after the birth of her third child. Computed tomography (CT), performed for suspected uterine myoma, showed struts of the IVC filter penetrating the aortic lumen. It was not fractured or tilted. There was no evidence of aortocaval fistulas or pseudoaneurysms. The patient was closely followed without surgical therapy for 7 years, and no additional complaints were found.
A 45-year-old woman was receiving hemodialysis due to diabetic nephropathy with an arteriovenous fistula (AVF) in the left upper arm. Six years after hemodialysis starting, she had the edema of left side face and left upper extremity due to shunt venous hypertension and was referred to our hospital. Contrast-enhanced computed tomography (CT) revealed severe stenosis of the left brachiocephalic vein. First, we performed percutaneous transluminal angioplasty (PTA) with balloon for stenosis of the left brachiocephalic vein. Three weeks after first PTA, she had exacerbation of left facial edema. We performed PTA with 14 mm×40 mm stent (SMART, Cordis, Dublin, Ohio) for stenosis of the left brachiocephalic vein. Although the edema of face and upper extremity improved after secondary PTA with stent, the left pleural effusion appeared one month later. Because ultrasound sonography (US) revealed the flow volume of AVF was 1537 mL/min, she was diagnosed as heart failure and underwent banding correction of a shunt vein with synthetic PTFE graft (PROPATEN, GORE, Newark, Delaware) using US. The flow volume of AVF was 491 mL/min after operation. The heart failure has improved, the edema of face and upper extremity has not got worse.