The action to prevent EHIT (endovenous heat-induced thrombosis) due to RFA (radio frequency ablation) for GSV (great saphenous vein) insufficiency is still under consideration. We have tried to utilize compression pads to obstruct GSV from SFJ (sapheno- femoral junction) to the peripheral end after RFA. No EHIT was observed in 132 limbs of 115 patients under Doppler ultra-sound examination at 7 days post RFA. The compression pad has enough pressure (>50 mmHg) to close GSV dressed by compression bandage. Not only that, but residual varices were also compressed using pads. The varices were diminished by sclerotherapy at 2～3 months post RFA without stab avulsion. Compression therapy using compression pads could avoid EHIT and stab avulsion after RFA in varicose vein treatment

The author previously reported that, on a trial basis, varicose vein surgery (high ligation of the saphenous junctions either with or without stripping of the saphenous veins) did not worsen the status of incidental distal deep vein thrombosis (IDDVT) as far as patients with varicose veins fulfilled the following criteria; 1) the patient has varicose veins due to the incompetent saphenous veins, 2) serial duplex ultrasound (DUS) confirms stability and clinical insignificance of IDDVT, 3) the patient dose not have any risk factors for DVT such as a coagulation profile disorders (antithrombin III deficiency, protein C deficiency, protein S deficiency, or antiphospholipid syndrome) or malignancies, 4) surgery is possible under local anesthesia alone, and 5) the patient can understand the concept of IDDVT and undergo the surgery on their own will with informed consent. Here, to clarify whether endovenous thermal ablation (ETA) is feasible for the patients with incompetent saphenous veins and IDDVT, the author reviewed the records of 137 patients with the varicose veins due to the saphenous veins incompetence at the varicose vein center from June to December 2017. Among 137 patients, DVT was incidentally detected in 8; 1 with the linear-shaped thrombus in the common femoral vein, 1 with the organized thrombus in the popliteal vein, and 6 with IDDVT. Among 6 cases with IDDVT, serial DUS for 3 months disclosed resolution of IDDVT in 3 cases, no change in 2 cases, and an extension in 1 case. For 5 patients with IDDVT diagnosed as resolution and no change, ETA was performed for the incompetent saphenous veins. In the postoperative course for 1 month, serial DUS revealed none of these patients worsened or had a relapse of IDDVT after ETA. These results suggest that, at least, as far as the patients fulfilled the criteria above, ETA did not worsen the IDDVT. The number of cases that the study was conducted on is rather low and although more studies are to be conducted, the results so far are promising.

Objective: In Japan, many surgeons perform subfascial endoscopic perforator surgery (SEPS) without tourniquet control. However, a poor endoscopic operating field is a problem in some cases. Esmarch bandage and tourniquet control (ETC) of the leg excludes the blood and interstitial fluid of the muscles and could create a larger subfascial endoscopic operating field. The aim of this study was to evaluate whether ETC improves the SEPS field. Methods: From December 2015 to December 2017, 18 limbs in 18 patients with stasis dermatitis were treated by SEPS without ETC followed by SEPS with ETC. The number of transected perforating veins before and after ETC was used as an indicator of the quality of the operating field. SEPS involved the insertion of two 6-mm metal ports into the proximal medial calf and carbon dioxide insufflation into the subfascial space. First, perforating veins were transected as much as possible without ETC. After removing the ports, ETC was done, and additional transection of the perforating veins was performed with the same technique. Results: The number of perforating veins that were transected by SEPS before ETC was 2.1±1.5. The number after ETC was increased by 1.1±1.2 to 3.2±0.9 (p<0.005). Conclusions: The ETC improves the SEPS field. It could be useful in cases with a poor SEPS field.

Although the main truncus occlusion by endovenous laser ablation (EVLA) is established as a standard treatment, it is still controversial regarding treatment of tributary varices. Stab avulsion or sclerotherapy is generally performed for tributary varices. Stab avulsion has problems such as pain, bleeding, and a time-consuming procedure. Sclerotherapy has problems such as pigmentation, prolongation in shrinking the size of large varicose veins, and wearing of compression stockings for a long time. In order to solve these problems, we report on EVLA with concomitant tributary varices ablation (TVLA) using radial 2ring fiber. Subjects: One hundred and thirteen patients underwent EVLA in between October and December in 2017. There were 181 GSVS and 16 SSVS included. METHOD: All cases were performed under TLA. ELVeS 1470 nm with radial 2ring fiber was used for EVLA. As for trunk reflux, EVLA was carried out as usual. For TVLA, after injection of TLA, varicose vein was punctured using a 14 G needle under ultrasound guidance. Then laser ablation was performed at 8 W. Additional ablations were performed if there were residual varicose veins. Results: Comparison with TVLA (−) vs TVLA(+) as follows. Length (cm) 43.0±18.0 vs 51.4±17.0, surgical time (min) 14.4±7.1 vs 16.6±7.3, total energy (J) 1532±710 vs 1946±739, TLA (mL) 597±247 vs 888±277. TVLA was conducted at 67/210 (31.9%), the average number of punctures 2.6 times, 2–29 minutes (average 7.5 minutes), the total energy 624±367 J, average amount of TLA 291 mL. No bleeding, burning, and nerve damage was noticed. Conclusion: It was thought that TVLA was a useful method as tributary varices treatment concomitant with EVLA.

Currently, Nara Prefecture is home to the major producers of socks in Japan. Approximately 40% of all socks sold in Japan are made in Nara. We cooperated with a sock manufacturer in Nara to produce and bring to market knee-high compression stockings. We performed a series of activities to promote the spread of compression therapy over the previous year, titled the “NARA Socks Project.” We investigated changes in the circumference of the leg below the knee and improvements in the blood circulation of the legs before and after using the compression stockings and performed a survey of users’ feelings while wearing the stockings. The results revealed that the circumference of the leg below the knee showed a decreasing tendency after wearing the compression stockings. The peak velocity of the popliteal vein tended to increase 20 min after wearing the compression stockings. The compression stockings seemed to be effective for promoting venous return and preventing deep vein thrombosis of the lower limbs in healthy people, although they have not yet received pharmaceutical approval.

A 30-year-old man with a complaint of dyspnea and swelling of his left lower limb was referred to our hospital. He had a few years’ history of stab injury to his left thigh. A chest radiography revealed severe cardiomegaly with 72% cardiothoracic ratio, and the amino-terminal pro-brain natriuretic peptide (NT-proBNP) level was elevated at 1,005 pg/mL. Contrast-enhanced computed tomography and angiography revealed a dilated left iliofemoral artery and vein, and superficial femoral arteriovenous fistula (AVF). We performed an endovascular repair of the traumatic AVF using a stent graft (GORE Excluder, PLC181000J, W. L. Gore & Associates, Inc, USA), which was deployed in the superficial femoral artery. After the surgery, his symptoms improved immediately and significantly. Endovascular repair with a stent graft is an excellent alternative treatment for traumatic AVF of the extremities.

Venous stasis ulcer occurs at high frequency in the lower leg ulcers especially in female and older patients. We experienced a case with an intractable infected venous stasis ulcer. A 66-year-old female suffered from a primary varicose vein complicated by a venous stasis ulcer. The ulcer was treated with only conventional gauze dressing and ointment without bandage for several years. After the ulcer was infected, she visited our outpatient department. After having done control of infection, we performed stripping of left great saphenous vein, ligation of lower perforating veins, removal of varicose veins and surgical debridement of sphacelus under the lumbar spinal anesthesia. A split-thickness skin grafting was performed after making sure of good granulation of the ulcer. To treat the venous stasis ulcer (C6), we think it is important to perform prompt management and to collaborate among dermatologists, plastic and reconstructive surgeons, and vascular surgeons.

This case is a 66-year-old man. He came to our hospital for main complaint for blood vessel swelling of the left back of hand. He was aware of vasodilatation of the back of hand two years before. In physical views, smooth soft vein expansion of diameter around 30×15 mm on the left back of hand was seen. Ultrasound showed blood flowed in the inside of the swelling blood vessel, and simple CT (Computed tomography) showed a flat, distinctive, and no invasive mass under the back side of skin between the left metacarpal bone, so the clinical diagnosis was cephalic venous aneurysm. In the operation, blood vessels into the venous aneurysm were ligated to be isolated and the venous aneurysm was removed completely. In pathology view, venous malformation was seen to surround around the adventitia site of central dilated blood vessel. This suggested that a venous malformation developing outside of the elastic lamina might lead to weakening of the organized tissue around the vein and development of a venous aneurysm. The differential diagnosis of a swelling blood vessel should include a venous aneurysm accompanied by a venous malformation.