Venous malformations (VMs) are the most common vascular malformation. Sclerotherapy is the first-line treatment for VMs because of the high reduction rate and lower invasiveness than surgery. Absolute ethanol, Polidocanol and Ethanolamine Oleate are the most commonly used sclerosants in Japan. The effectiveness of interventional radiological treatment for VMs has been reported with improvements in medical equipment. We explain the classification of VMs and practical treatment based on our experience.

Background: As a standard treatment for the varicose vein of the great saphenous vein (GSV) type, endovenous ablation (EVA) is the main approach. However, as a background to this, in the Europe and the United States, neovascularization (Neo) after the high ligation (HL) of the sapheno-femoral junction (SFJ) at the time of GSV stripping has been emphasized as one of the reasons for the high recurrence rate. On the other hand, almost no similar mid- or long-term results of GSV stripping have been reported from Japan.

Patients and Methods: From September 2011 to March 2014 when EVA was not my surgical option, 413 consecutive legs underwent GSV stripping by the author using the same procedure and were contacted by phone five years later and investigated about recurrence (REVAS) and reoperation (REDO), and 270 legs of the legs of the 391 living cases (69%) underwent venous ultrasonography (VUS). HL of SFJ was performed by central flash ligation with pulling out tow of peripheral side branches containing accessory saphenous veins. In principle, GSV stripping was conducted by means of invagination method in range of the entire reflux region from the HL cut section to the confluent section of the side branch causing the side branch varices. The range of stripping was to the upper thigh in 3 legs, to the middle thigh in 3 legs, to the lower thigh in 7 legs, to the knee in 46 legs, to the upper calve in 83 legs, to the middle calve in 52 legs, and over the full length in 76 legs. Stab avulsion was performed as much as possible for side branch varices. On VUS, the SFJ’s stump of GSV, the presence of side branch remnants and their reflux, the presence or absence of Neo, and recurrent lesions in other sites were evaluated. REVAS was classified as follows: Level 1, symptomatic recurrent lesion for which surgery is indicated; Level 2, asymptomatic recurrent lesion possibly requiring future surgery; Level 3, asymptomatic recurrent lesion that are unlikely to require future surgery.

Results: Of 391 legs of patients who could be contacted, REDO was performed in 23 legs (6%), including 15 limbs immediately after this investigation, and symptomatic REVAS was observed in 29 legs (7%). In 270 legs examined by VUS, REVAS legion was diagnosed as follows: 29 legs with Level 1 legion; 40 legs with Level 2 lesion; and 27 legs with Level 3 lesion. Level 1 REVAS caused at the SFJ was limited to only 3 legs (1.1%) whereas Level 1 REVAS from incompetent perforating veins (IPVs) was seen in 14 legs (5%), and Level 1 solitary tributary varices were seen in 9 legs (3%).

Conclusion: In this study, REVAS from SFJ was considerably less than in past reports. Instead, it was shown that REVAS due to IPVs or solitary tributary varices was more important.

Patients with varicose veins of the lower extremities with osteoarthritis of the knee often experience improvement in knee joint symptoms after endovascular treatment. We considered that it was important to decide the operation indication of lower extremity varices, to know the correlation between the two diseases in the treatment of varicose veins. To investigate the postoperative improvement of knee symptoms related to varicose veins with knee osteoarthritis, we conducted a questionnaire survey. The subjects were thirty-five patients with varicose veins complicated with knee osteoarthritis for a total of 12 months from December 2014 to May 2015 and from October 2018 to March 2019: 7 were male and 28 were females. We classified knee osteoarthritis according to the grading scale, and compared the improvement of knee symptoms after endovenous thermal ablation. The degree of improvement was lower as the knee grade was higher. However, the improvement was observed in all knee osteoarthritis grades, and as a whole, twenty five patients (71.4%) have experienced improvement of subjective symptoms. For patients with knee osteoarthritis, we strongly recommend surgical treatment of the varicose veins regardless of the progression of knee grade.

Objective: In 2017, the results of the analysis of acute pulmonary thromboembolism (PTE) related mortality were released by the Medical Accident Investigation and Support center in Japan. In this recommendation, it was clearly stipulated that “team in charge of PTE’s risk assessment, prevention, diagnosis and treatment should be maintained” and PTE should be prevented through team activities. Therefore, we recommended the establishment of the deep vein thrombosis (DVT) prevention team. Prior to this recommendation, a multidisciplinary DVT prevention team was established in our hospital obtaining an excellent outcome. In the current study, we report the results of the DVT prevention team.

Methods: Our multidisciplinary team consisted of several departments : Cardiovascular Surgery, ward nurses, medical safety managers, and clerks. The following themes were launched: 1) preparation of DVT prevention protocol; 2) preparation of DVT preventive manual; 3) regular round for evaluation of DVT preventive measures; and 4) education for staff. The strong point in the protocol was that on admission, nurses evaluated patients over 16-year-old with Well’s score for DVT. We retrospectively investigated the diagnosis rate of DVT and PTE for 9 months before and after protocol operation.

Results: The diagnosis rate of DVT was significantly improved after protocol implementation (before: 0.06% vs after: 0.56%, p=0.0017). However, no significant difference was observed in the diagnosis rate of PTE before and after the protocol execution (before: 0.03% vs after: 0.07%, p=0.98).

Conclusion: Our DVT prophylactic protocol improved the diagnostic rate of DVT resulting in a decrease of PTE in our hospital.

Buerger’s disease is known to be a chronic arterial occlusive disease characterized of combining venous diseases such as phlebitis migrans. Our studies are conducted from recent Buerger’s disease 34 cases 67 limbs (one female) and the studies are consist of phlebitis migrans, deep vein thrombosis, deep vein insufficiency, and varicose veins using ultrasound. Diagnostic criteria were applied strictly using Shionoya’s one. The results showed active or old phlebitis migrans 16 cases (47.1%), deep vein thrombosis 5 cases (14.7%), deep vein insufficiency 9 case (26.5%) and varicose veins 22 case (64.7%). The extremities echogram including hands and feet showed various lesions compared with previous studies. These understandings are available to treat Buerger’s diseases in adequate methods.

Upper extremity deep vein thrombosis is less common than lower extremity deep vein thrombosis. Clinicians should be aware of the presentation of the upper extremity deep vein thrombosis and consider this diagnosis in patients with unilateral upper limb swelling.

We reviewed 20 cases of this entity treated at our hospital over the past 26 years (from 1993 to 2018). All of them were diagnosed by phlebography or computed tomography. We treated 655 cases of deep vein thrombosis including the lower extremity in the same period and the rate of the upper extremity was 3.1%.

The most common symptoms were swelling and heaviness of the upper extremity. The patients included 11 males and 9 females whose ages ranged from 16 to 90 with a median of 50 years old. The affected sides were 9 in the right and 11 in the left. Causative factors were Paget-Schroetter syndrome (n=7), malignancies (n=5), venous catheters (n=2), thrombophilic states (n=2) and others. Thirteen patients were diagnosed within two weeks from the onset of clinical signs.

Eleven patients were treated with unfractionated heparin and urokinase for 3 to 5 days followed by oral anticoagulant. Catheter directed thrombolytic therapy was done for the six patients with Paget-Schroetter syndrome. Five patients were treated by systemic infusion. Another five patients were treated by only oral anticoagulant. Used anticoagulants were warfarin (n=13) and edoxaban (n=3). They were continued for 6 to 24 months. No therapy was done for the rest four patients because of delayed diagnosis or advanced malignancy. The mean follow-up duration was 2 years. The symptoms were improved in 10 patients. There were no change of symptoms in 6 patients and 4 were died of malignancy. None of the patients developed pulmonary embolism and severe post thrombotic syndrome.

The normal anatomic course of the left renal vein from the kidney to inferior vena cava is usually preaortic. It is called retroaortic left renal vein (RLRV) when located between the aorta and vertebra. The reported frequency of RLRV is approximately 2%. Only a small minority of RLRVs causes symptoms. However, this variation is of importance because of its implications in renal surgery, vascular surgery and so on. We herein report a case of a RLRV injured during the lymphadenectomy of the aorta. A 61-year-old female underwent hysterectomy and lymphadenectomy of the aorta for the purpose of curative operation of the left ovarian mucinous carcinoma in October 2016. Accidentally, the RLRV was injured, and the support of vascular surgeon was requested. Temporally tourniquet of the left renal artery was necessary to control the bleeding. The left renal vein was extremely damaged and ligation was needed. Fortunately, the patient had uneventful recoveries and she was discharged on the 23rd postoperative day without renal complications. The function of the left kidney is kept because of the collateral veins. Venous variant as reported herein should be kept in mind when interpreting imaging of the posterior abdominal wall or performing surgery or other invasive procedures near the RLRV. This anomaly can be identified in routine abdominal CT examinations with a careful inspection.

Graduated medical elastic stockings providing a decreasing pressure profile from distal to proximal has been mainly adopted during the maintenance phase in compression therapy with a two-phase treatment program for patients with lymphedema. In this case study we showed an efficacy of decreasing edema by devising how to wear conventional medical elastic stockings, the ways to be negative interface pressure gradient when donning the stockings with graduated compression profile, during an intensive drainage treatment. A 55-years-old woman with secondary lymphedema having severe severity of lymphatic dysfunction on the right side leg was targeted in the study. The patient visited 4 times. Circumference and interface pressure at three sites on the affected leg (B: ankle, C: calf, F: thigh) were measured at each visit. From the second visit the patient wore two superimposed stockings. Interface pressures, pressure gradient profiles, and the effect of two superimposed stockings (increase in the interface pressure of two superimposed stockings compared to the pressure of the first stocking) sustained stable regardless of the number of visits.

Venous aneurysms of the jugular vein are one of the rare causes of neck swelling, and primary venous aneurysms of the external jugular vein are extremely rare. We here present a case of this entity. A 45-year-old woman presented with a painful and suddenly growing mass in the left neck. The neck lump enlarged on Valsalva maneuver. A computed tomography angiography revealed a saccular venous aneurysm of the external jugular vein containing intraluminal thrombus. The maximal dimeter was 43×37×35 mm. We performed resection of the aneurysm and ligation of the external jugular vein. The histopathology of the mass showed a grossly dilated vein, with continuous aspects of the entire three layer of the venous wall, classifying it as a venous aneurysm. A brief review of the Japanese literature of this entity has been discussed. From 1987 to 2019, we found 36 cases of reported external jugular vein including our case. There were 4 male and 32 female patients, ranging in age from 4 to 86 years old with a median age of 53 years old. They were diagnosed by flow duplex imaging, CT or MRI. Almost all patients had saccular aneurysm. Aneurysms size ranged from 6 to 50 mm (median 30 mm). The affected sides were 16 in the left and 20 in the right. In all patients except for two cases, aneurysms were resected and venous continuity with a graft was found unnecessary. Venous aneurysms may cause thrombophlebitis and thrombus formation. However, no pulmonary embolism due to the thrombus in the external jugular venous aneurysm has been reported in the Japanese literature to the best of our knowledge. Surgical excision is indicated if they are symptomatic, enlarging or disfiguring.