[Background] There is a need for a simple method for the quantitative evaluation of lymphedema swelling. In this study, we performed a direct segmental multi-frequency impedance analysis in patients with leg lymphedema.

[Methods] The subjects were 36 patients (6 men and 30 women) with 46 lymphedema legs. The average age was 61 years. All patients had International Society of Lymphology stageII lymphedema. Swelling ratio and ultrasound subcutaneous tissue echo-free space(FS) were examined. InBody 770 was used to measure the extracellular water (ECW), intracellular water (ICW), and total body water(TBW) volumes. Changes before and after complex decongestive treatment (CDT) were examined.

[Results] In 26 unilateral cases, the ECW, ICW, and TBW volumes of the affected legs were higher than those of the contralateral unaffected legs, and the ECW/TBW ratio was significantly higher in the affected legs (0.41) than in the contralateral unaffected legs (0.391). There was a significant correlation between the leg swelling ratio and the ECW/TBW ratio between the affected and contralateral unaffected legs (correlation coefficient=0.882). Ultrasound findings of the 46 affected legs were classified into no FS (group 0), minimal or only horizontal FS (group 1), and cobblestone-like FS (group 2). The ECW/TBW ratio of the affected legs in each group was 0.393 (14 legs), 0.407 (10 legs), and 0.426 (22 legs) respectively, demonstrating significant differences among the 3 groups. After CDT, the amount of water decreased in the affected legs and increased in the trunks and both upper limbs. The ECW/TBW ratio decreased significantly, from 0.432 to 0.414 in the affected legs, from 0.401 to 0.392 in the unaffected legs, and from 0.413 to 0.402 in the trunks. The ECW/TBW ratio had not changed and remained below 0.4 in the upper limbs.

[Conclusion] The segmental water contents measured by direct segmental multi-frequency impedance analysis correlates well with the degree of lymphedema swelling, and subcutaneous echo findings and can demonstrate water distribution change before and after CDT, which is considered to be a useful quantitative evaluation method for lymphedema.

Flush ligation of the small saphenous vein (SSV) is only performed in a limited number of institutions because of the technical difficulty of the procedure and the risk of neuropathy and deep vein damage. In this report, we propose the concept of ligation under knee-joint bending as an approach to facilitate flush ligation of the SSV. We applied the technique in the treatment of aneurysms localized near the sapheno-popliteal junction (SPJ).

[Subjects] The surgical procedure was performed in six cases of varicose veins with an aneurysm localized near the SPJ. Diameter of the aneurysm was ≥20 mm in three cases, and the distance to SPJ was ≤5 mm in five.

[Surgery method] Following the induction of a combination of tumescent local anesthesia and intravenous anesthesia, a 7-mm incision was made in the popliteal fossae. The SSV was exposed, ligated, and dissected. Once the proximal end of the SSV was raised and several branches were cut off without further dissection, the knee joint was bent ≥45°. This technique raised the SSV approximately 15 mm, making flush ligation easier to perform.

[Results] The mean surgical time was 37 minutes. In all six cases, high-level ligation was completed proximal to the aneurysm. No complications, such as neuropathy, deep vein thrombosis, and pulmonary embolism, were reported following surgery.

[Conclusion] The ligation under knee-joint bending technique was simple and safe and can, therefore, be widely applied in the future.

(Purpose) Strategies for the treatment of venous ulcers are currently under debate. (Objective) We retrospectively evaluated the treatment efficacy of venous ulcer cases. (Methods) In 917 consecutive patients (307 men and 610 women), endovascular ablation (EVA) was performed between December 2014 and January 2019. The mean patient age was 65.6. The rate of venous ulcer cases was 1.9% (17/917). The main treatment strategy was as follows: (1) varicectomy including incompetent perforating veins was performed using stab avulsion methods, (2) venous ulcer was washed in the shower and covered with dressings twice daily, and (3) compression therapy was maintained until full healing. (Results) In 17 patients receiving EVA, the mean operative time was 49.1 min, and the mean number of stab avulsion incisions was 12.9 sites. For three cases over 6 months, the remaining erosion was healed using steroid ointment. These 17 ulcers were healed within a median of 54 days (13–365). (Conclusion) EVA, adequate varicectomy, moist wound healing, and compression therapy healed all venous ulcers in approximately 2 months.

In January 2019, we sent a questionnaire to 269 patients who underwent stripping surgery of incompetent saphenous veins in the year of 2010. We asked whether if there is a recurrent varicose vein or not. The presence of congestive symptoms, skin lesions, experience of re-intervention for varices, were also asked. Finally, 133 patients (55.2%) replied to the questionnaire. A total 25 patients (19%) answered “yes” for recurrence. There was no patients who underwent re-operation for recurrent varices. One patient re-visited to our clinic and received foam sclerotherapy. Patients satisfaction was asked in five stages and the answer was as follows: Very satisfied (64%), A little satisfied (28%), Either way (5%), Somewhat dissatisfied (3%), Very dissatisfied (0%).

BACKGROUND: Though direct oral anticoagulants are also used for venous thromboembolism (VTE) in patients with cancer, it is unclear for how long patients should be treated and whether the treatment is appropriate for asymptomatic patients.

METHODS: We retrospectively examined data of patients with cancer and VTE between 2016 and 2018. Cumulative incidence of recurrent symptomatic thromboembolism, major bleeding and time to thrombus disappearance were assessed, and risk factors for these were identified by multivariate analysis.

RESULTS: Of 151 consecutive VTE, asymptomatic cases constituted 74.8%. One-year cumulative incidences of thromboembolism and major bleeding were 6.5% and 15.4%, respectively. Significant risk for recurrence was high D-dimer concentration (≥3.0 µg/mL) at diagnosis of VTE [hazard ratio (HR)>10, P=0.003] and concomitant use of anti-platelet drugs [HR 7.59, 95% confidence interval (CI) 1.14–30.80, P=0.039]. The only risk for bleeding was bad performance status (≥ 3) [HR 3.94, 95% CI 1.48–10.66, P=0.007]. Median time to thrombus disappearance was 29 days. Three and six-month cumulative incidence of thrombus disappearance was 71.8% and 74.9%. Risk for residual thrombus was deep vein thrombosis without pulmonary embolism [HR 1.75, 95% CI 1.11–2.80, P=0.015] and recurrent cancer [HR 1.66, 95% CI 1.08–2.58, P=0.021].

CONCLUSION: Asymptomatic patients experienced symptomatic recurrence with the same probability as symptomatic patients and should therefore undergo anti-coagulation therapy. Three quarters of thrombi disappeared within three months. Complete remission of cancer at six months and early termination of treatment were not predictors for recurrence. High D-dimer concentration at diagnosis was a good predictor for symptomatic recurrence.

Interventions for the dialysis access-associated steal syndrome (DASS) are difficult because peripheral arterial flow has to be increased without losing vascular access function. We report a case with limited puncture sites and the DASS, treated successfully with basilic vein transposition (BVT) and proximalization of the arterial inflow (PAI). A 49-year-old woman with a 5-year history of hemodialysis due to diabetic kidney disease had suffered from the symptom of numbness of her left fingers during hemodialysis for two years. This symptom subsequently progressed to rest pain. The access sites for hemodialysis were limited to about a 5 cm length of the median basilic vein in the cubital region. Pulsation of the radial and ulnar arteries was not palpable, while left wrist blood pressure/contralateral brachial blood pressure was 50/130 mmHg. BVT for limited access sites and PAI using a 5 mm diameter prosthetic graft for DASS were performed. Soon after these surgical interventions, the symptoms disappeared and a sufficient length of autogenous vein puncture sites was obtained.

We encountered a case of cancer-associated thrombosis (CAT) due to endometrial cancer discovered by lower leg edema. A woman in her 40s was referred to our hospital due to left limb deep vein thrombosis and pulmonary thromboembolism. Endometrial cancer was suspected, and thrombus from the left common iliac vein to the popliteal vein, pulmonary thromboembolism, bilateral ovarian enlargement, intrapelvic lymphadenopathy, and paraabdominal aortic lymphadenopathy were confirmed based on an imaging examination. Based on these findings, we diagnosed the patient as endometrial cancer with CAT. After treatment with heparin, she started taking edoxaban 60 mg. Malignant tumors and venous thrombosis are strongly related. The accumulation of further cases is necessary to achieve the early detection of CAT and the establishment of treatment method.

A 70 years old female was admitted to Cardiovascular Surgery Department because of the aggravation of her left lower limb pruritis with eruptions and pigmentations. Her past medical history revealed deficit in protein S associated with pulmonary infarction, and had been pursued anticoagulation therapy. Ultrasound assessment of the vascular system revealed significant regurgitation in the varicose veins of small saphenous vein (SSV) without any sign of thrombosis at the deep vein in the lower limb (CEAP classification: C4a). Laser ablation was performed with 1470 nm ELVeS laser (ELVeS Radial 2ring). On the next day, ultrasound assessment detected endovenous heat induced thrombosis (EHIT) with class II to III at the junction of small saphenous vein and popliteal vein (SPJ). Laboratory study has shown PT-INR at 1.35. The reduction of the size of the thrombus within the small saphenous vein has been accomplished by the intensification of anticoagulation therapy. For patients with thrombophilia such as protein S deficiency, stable anticoagulation therapy may become one of the key factors to avoid thrombotic complications after laser ablation in the treatment of varicose veins.

Currently, minimally invasive treatment including ultrasound-guided foam sclerotherapy (UGFS) is widely applied. However, in our country, the report concerning about UGFS is extremely rare. Between January 2018 and April 2019, we have performed UGFS for the residual or recurrent varices of 55 limbs in 51 patients after endovascular thermal ablation or surgery. The injection sites of sclerosant, using 1–3% polidocanol foam (<1 mL) are as follows; Incompetent perforator below the knee 10 cases, saphenous vein (Great 12, Short 8), saphenous tributary vein 2, accessory saphenous vein 1 and Giaconomi vein 1 case, respectively. After sclerotherapy, the compression was continued using bandage with pads overnight, then elastic stockings at least one month. The Doppler ultrasound examination has revealed that the venous reflux was disappeared 52 of 55 limbs 4 weeks later (28–35 day) post-sclerotherapy. The reflux remaining three cases was due to incomplete compression without elastic stocking, but residual reflux was disappeared by the additional sclerotherapy. The UGFS is effective and safe strategy for residual or recurrent varices, because no complication has occurred during follow up period ;mean 10.2 month post-sclerotherapy.

While endovenous thermal ablation (ETA) become first choice of treatment for varicose veins, overuse of ETA for the inappropriate indication is growing problem. ETA is performed not only on varicose cases without symptom but also non diseased cases with segmental reflux of saphenous veins or no reflux. Indications of ETA was demonstrated in “the Clinical Practice Guidelines for ETA for Varicose Veins 2019” by Japanese Society of Phlebology. Purpose of this supplement is description of basics of correct indication for ETA. We also demonstrate the typical case of overuse of ETA for wrong indication.