Coronavirus disease 2019 (COVID-19) has been reported to be associated with a high incidence of venous thromboembolism (VTE). In Japan, a joint survey was conducted by the Japanese Society of Phlebology and the Japanese Society of Pulmonary Embolism Research, and a joint survey by the Japanese Society on Thrombosis and Hemostasis, the Japan Atherosclerosis Society, and the Ministry of Health, Labour and Welfare Research Group. Overall, the proportion of cases diagnosed with VTE was lower than that reported from other countries. On the other hand, it was suggested that there may be a reasonable incidence in severe cases. Currently, several randomized controlled trials are underway to evaluate the significance of anticoagulation for COVID-19 patients, and the results of these trials are expected to be useful in Japan. However, since the actual situation may differ from that in other countries, it is important to proceed with discussions based Japan’s own data. It is also necessary to prepare clinical guidelines based on continuously updated data, assuming that the latest updates and revisions are made sequentially, so as avoid confusion in clinical practice.

Compression therapy is essential for the treatment of venous disease affecting the lower extremities, promotes healing, decreases recurrence of venous ulcers, decreases the risk of DVT, and decreases discomfort after developing a DVT. Mechanisms of the benefit of compression therapy are shown to help improve venous return and reduce ambulatory venous pressure in part by using a Starling’s low that favors edema resolution and reduces the radius of the vein resulting in increases of the flow velocity. Furthermore, compression therapy has been demonstrated to reduce elevated levels of the inflammatory cytokines vascular endothelial growth factor and tumor necrosis factor-α in patients with venous ulcers. In clinical practice, we should understand the Laplace’s law, the pressure applied by compression is proportional to the tension at the interface with skin and inversely proportional with limb radius (P α tension/radius), and be familiar to PLACE indicating pressure, layers, component and Elasticity of the compression bandages. This review article presents the basic knowledge of physiology and some theories of compression therapy for venous diseases.

Elastic clothes, such as elastic compression stockings and elastic bandages, which are medical devices, are widely used to treat varicose veins and venous ulcers of the lower extremities, preventing DVT and PE. In 2002, the Elastic Stocking Conductor Committee of the Japanese Society of Phlebology was founded and established an accreditation system of the Elastic Stocking Conductor. This committee aims to develop skills of the medical professionals who are familiar with and achieve mastery of the compression therapies and related devices, instructing and advising patients to wear. Since April of 2020, compression therapy for venous ulcers has been covered by health insurance according to the revision of the national medical payment system. To correspond to it, the committee has expanded the fulfilling content of a workshop, changed the name into “Elastic Stocking and Compression Therapy Conductor Workshop”, and renamed the certification as “Elastic Stocking and Compression Therapy Conductor”. In this review article, we present an outline of the committee’s tasks, the accreditation system, authorized textbooks, and the “Hirai Compression Therapy Award,” which have been established to enhance the academic research of compression therapy since 2013.

Traditionally Lymphedema has been treated conservatively with the so-called Combined Physical Therapy method including compression therapy as a particularly essential component.

Lymphedema occurs due to dysfunction of the lymphatic system and a disorder of the lymph fluid transport which results in an accumulation of interstitial fluid.

Interstitial fluid leaks out of the capillaries and accumulates in the tissue. With the affected extremity under compression venous pressure decreases while interstitial pressure increases which prevents interstitial fluid from accumulating and therefore can prevent an exacerbation of lymphedema. At the same time the function of veins and lymphatics can be improved. However inadequately applied compression can due to overly high local pressure on the other hand cause an aggravation of the situation.

Elastic gloves and sleeves have a tendency to cut into hand or elbow joints or into the mid of the upper arm and stockings tend to easily cut into ankle or knee joints or into the mid of the thigh and therefore need to be applied carefully. In order to prevent compression garments from cutting into the affected extremity it is important to have the necessary treatment experience to choose the right compression level, fabric and type.

Venous leg ulcer due to chronic venous insufficiency is cause by venous hypertension of the leg. It is difficult to cure and easy to recurred. Basic treatment is compression therapy by elastic stocking and bandage. Reimbursement of compression therapy was initiated from April of 2020 in Japan. Investigation of venous and arterial insufficiency with venous duplex and ankle brachial pressure index is essential for diagnosis of venous leg ulcer. Mainstay of treatment is life style modification and compression therapy. Elastic stocking and bandage are used for treatment and prevention of recurrence with careful consideration of adherence. It is important for health care professional to learn how to choose and apply compression therapy with individualize manner for each patient.

The International Committee of Japanese Society of Phlebology is preparing a Japanese version of the international evaluating systems of phlebology. The outline and method of the translation process in the committee is reported. The CEAP (Clinical-Etiology-Anatomy-Pathophysiology) classification is used in clinical papers for most chronic venous diseases today. It is a categorical classification. without assessing quantitative severity. The latest version of the CEAP classification was updated this year, 2020. The official Japanese translation and actual usage are described.

To describe the severity of chronic venous disease or measure clinical outcomes quantitively, Venous Severity Scoring (VSS) System was developed in 2000 to supplement Clinical-Etiology-Anatomy-Pathophysiology Classification (CEAP) Classification which is a worldwide standard for describing the clinical features of chronic venous disease. VSS system consists of three parts; Venous Clinical Severity Score (VCSS), Venous Segmental Disease Score (VSDS), and Venous Disability Score (VDS). VCSS was revised in 2010 after clinical experiences and validations. VSS system covers various types of chronic venous diseases and treatments. International Committee of Japanese Society of Phlebology provided a translation of Japanese translation of VSS system.

The PTS (post-thrombotic syndrome) is a common long-term complication following acute deep vein thrombosis of the lower limbs. There is no single scale that can diagnose and evaluate PTS perfectly. Villalta scale was developed in 1994 as a disease-specific questionnaire to diagnose and classify severity of PTS. Considered reproducible and sensitive enough to reflect clinical changes, Villalta scale is widely accepted as the gold standard and has been used in many cohort studies and multicenter randomized trials. The International Society on Thrombosis and Haemostasis recommended use of Villalta scale for diagnosis and grading severity of PTS. On the other hand, Villalta scale may potentially lead to overdiagnosis, have inadequate diagnostic specificity, or not cover various typical patitent’s complaints, symptoms and signs of PTS patients completely. Although Villalta scale should be combined with other chronic venous insufficiency scoring systems and questionnaire, it is the most commonly used of PTS-specific scales. We herein report the Japanese translation of Villalta scale.

After previous earthquakes, high prevalence of cardiovascular diseases including venous thromboembolism (VTE) has been reported. We performed venous screening at the site of Hokkaido East Iburi Earthquake which happened at 6th September 2018. VTE screening using ultrasound sonography was performed for total 7 days at Atsuma town, Mukawa town and Abira town (total 9 shelters). Deep vein thrombosis (DVT) was found in 19 of 195 evacuees (9.7%), including 8 fresh thrombus cases (4.1%). On multivariable analysis of evacuees and shelter environment factors, systolic blood pressure, use of cardboard bed and toilet environment were significant predictor of DVT. Introduction and setting-up of cardboard beds were found as an important shelter environment factor.

Objectives: Ablation is a treatment modality involving the destruction of diseased tissue through direct contact or direct energy absorption. This comparative experimental study aimed to understand the differences between 2 types of ablation, continuous and intermittent ablation. Methods: Using albumen and agar as media, we compared medium denaturation and temperature, respectively, between the continuous wave (continuous ablation) and pulse (intermittent ablation) modes using a 1470-nm Radial 2ring slim fiber laser (output=6.5 W). Experiment 1: We measured the amount of denatured albumen following ablation by comparing the continuous wave mode with three types of pulse wave modes with duration and pause rations of 1 : 1 s, 1 : 2 s, and 1 : 3 s. We then calculated the mean area of denatured albumen using photographs. Experiment 2: We assessed the temperature with a thermistor probe positioned 0 mm and 3 mm from the catheter prism in the ager medium. We measured the mean maximum temperature, mean temperatures at 65.0 J and 130.0 J, and the mean time to reach at 40, 50, 60, 70, and 80°C. Results: Experiment 1: There were greater changes in the albumen around the fiber prism center than that at the fiber prism tip. Longer pause periods led to less degenerative changes in the albumen. Experiment 2: The temperature increased rapidly in the continuous wave mode both at 0 mm and 3 mm. In contrast, in the pulse wave mode, temperature increased slowly and in a ‘sawtooth’ wave pattern. The mean maximum temperature in the continuous wave mode was 108.0±13.4°C and 98.0±3.1°C at 0 and 3 mm, respectively, while the corresponding values in the pulse mode were 95.5±8.4°C and 71.6±2.8°C. Temperatures at 65.0 J were 98.8±3.1 and 91.4±8.1°C at 0 and 3 mm in the continuous wave mode and 76.8±11.2 and 48.4±9.5°C in the pulse wave mode, while the corresponding values at 130.0 J were 88.7±2.6 and 91.5±6.5°C for the continuous wave mode and 76.1±13.2 and 69.3±13.0°C for the pulse wave mode. Conclusion: Intermittent ablation increases temperature slowly, is more effective on distant sites, and may cause less tissue damage depending on the duration: pause ratio. Continuous ablation causes a rapid increase in temperature and may be more effective for targeted ablation. Our findings suggest that there was less heat diffusion into the surrounding tissue when using intermittent ablation than when using continuous ablation.

A total 4441 patients underwent endovenous thermal ablation (ETA) for primary varicose veins in our day surgery clinic for these 8 years. Seven cases (0.2%) received re-operation because of the recurrent varicose veins which including 2 cases of same site recurrence and 2 cases of different site recurrence after GSV ablation, and 3 cases of same site recurrence after SSV ablation. Out of 2698 patients who had undergone stripping surgery for these 11 years, 16 cases (0.6%) received re-operation because of the recurrence varicose veins. The long-term clinical results of our varicose vein surgery were considered to be acceptable.

As compared with pressure injuries, the mechanism the development of medical device related pressure ulcers (MDRPU) is not revealed enough. According to studies on severity and frequent site of occurrence, MDRPUs are surmised to occur the surface of the skin. In this study, we assess theoretical and experimental analysis by two-dimensional mechanical model for elastic stockings (ES) wear the lower limbs with or without dug into the skin by the wrinkles and curling up of ES. The Finite Element Method (FEM) was used to calculate the stress on the skin and subcutaneous tissue, because of elucidating the mechanism of MDRPU. The FEM used a triple-layered cylindrical model simulating the skin, subcutaneous tissue, and bone. Regarding the interface pressure (compression pressure), two samples were created: the one is applying a uniform pressure of 5.3 kPa on the skin surface simulating the correct wearing of ES, and the other is applying a pressure of 16 kPa on the part of the skin on which ES dug in. The results were as follows: the internal stress on the skin and subcutaneous tissue was maximum at the site where ES dug in, producing stresses of 54 kPa, 50 kPa, and 21 kPa in the circumferential, longitudinal, and radial directions, respectively. The uniform pressure produced an internal stress of 5–9 kPa on the skin surface. Unlike the mechanism of pressure injury formation, we considered compressive strength from tensile of the circumferential and longitudinal directions, furthermore the additive radial pressure at the digging site on the skin due to the wrinkles and curling of ES, which is one of the factor to cause strong external force in the MDRPU formation.

We report a case of venous stasis ulcer that recurred after the administration of bevacizumab (Bmab), with some literature review. The patient was a 60-year-old woman who underwent endovenous thermal ablation of the right great saphenous vein indicated for refractory stasis dermatitis due to varicose veins of the right lower extremity. She also underwent sclerotherapy of varicose veins of the lower leg in another hospital four years earlier. After the surgery, the patient wore elastic stockings, and the venous insufficiency of the right lower leg was maintained at stage C5 of the CEAP classification. She later received chemotherapy for lung metastasis of colon cancer using a protocol containing Bmab. One month after the onset of the chemotherapy, a recurrence of an ulcer in the right lower limb was observed. The patient was then referred to our hospital for better management. Bmab was discontinued and a surgical treatment for varicose vein dysfunctions of the lower extremities by endovenous thermal ablation of the remaining great saphenous vein and subfascial endoscopic perforator surgery of the incompetent perforating veins was performed. The ulcer healed six months after the surgery, and no recurrence was observed.

Leiomyomas are benign smooth muscle tumors and very common in clinical work. However, leiomyomas originating from veins are rare. We report a case of leiomyoma originating from the great saphenous vein (GSV) misdiagnosed as a venous aneurysm with superficial vein thrombosis (SVT). A 60-year-old man presented to our clinic with a painful nodule located on his left thigh. Ultrasonography demonstrated a solid mass in the GSV, measuring 14.3 mm. The mass was diagnosed with a venous aneurysm with SVT and indicated for resection because of repeated pain. Preoperative ultrasonography confirmed that the tumor had abundant blood flow with color Doppler and was diagnosed as a localized GSV tumor rather than SVT. He subsequently underwent excision of the mass. Pathologic examination was consistent with a diagnosis of leiomyoma from the vein wall. If ultrasonography reveals a painful, solid mass adjacent to the venous wall, the tumor should be evaluated by the color Doppler ultrasonography in consideration of leiomyoma.

By developing smaller diameter optical fibers, endovenous laser ablation can be performed for the tributary veins as well as for the saphenous veins. Both the tributary veins and saphenous veins will need to be punctured with 16-gauge intravenous needles for endovenous laser ablation using smaller diameter optical fiber. However, the placement of 16-gauge intravenous needle into a tortuous tributary vein is technically difficult. Here, we report a novel vein puncture method using a 4 Fr sheath introducer set and a 16-gauge intravenous needles to facilitate easy insertion.

In our hospital, identification and holding of the great saphenous vein (GSV) for high ligation in stripping are performed through a 1.5 cm or smaller surgical wound by operating on the groin while visually confirming the stripper inserted from the peripheral side. The subjects were 231 patients who underwent stripping of the GSV between December 2012 and April 2020. Cases in which this method could be performed and the presence or absence of intraoperative complications were investigated. The method was applicable in 222 patients and no artery or deep vein was damaged. It could not be performed in 3 patients with ascending thrombophlebitis and 5 patients with a short GSV reflux range. In one patient in whom the disease recurred after high ligation, tissue dissection was difficult due to the presence of a scar. A mean time of 80 seconds was required to hold and lift the GSV and apply taping from initiation of skin incision in the first 10 cases. In this method, the risk of damaging deep arteries and veins was reduced by holding the GSV under echography while observing the stripper as a landmark. This procedure may increase the safety of the surgery.

Aim: To investigate the usefulness of compression therapy for chemotherapy-induced peripheral neuropathy (CIPN). Methods: This study included 40 limbs of 20 patients with CIPN. In 30 limbs wearing compression garments and 10 limbs receiving no compression, the CIPN symptoms of “numbness and pain” were evaluated using the face pain scale (FPS), before and immediately and at 1 month, 6 months, and 1 year after starting compression. Results: In the compressed limbs, the mean FPS scores immediately and at 1 month, 6 months, and 1 year after starting compression were 1.7, 1.6, 1.8, and 1.8 points, respectively, which were all significantly lower than the 3.0-point score before compression (p<0.01). The FPS scores in limbs receiving no compression remained unchanged. The FPS score change was higher in limbs with edema, lower limbs, and limbs with a high pre-compression FPS score and was not associated with age, history of cellulitis, type of anticancer agents, and length of time after completion of chemotherapy. Conclusions: Our findings suggested that reduction of fluid (blood, lymph, interstitial fluid) stasis, improvement of microcirculation, and protection/supporting/stabilizing of surrounding tissues by compression therapy may be effective in alleviating symptoms and preventing aggravation after the onset of CIPN.

The COVID-19 is frequently associated with thrombosis, mainly venous thromboembolism (VTE). Therefore, based on the questionnaire survey in Japan, we revised the Clinical Guidance of Prevention of Venous Thromboembolism in COVID-19 VTE preventive medical care guidelines for COVID-19 and propose preventive methods with reference to the medical care guides and other guidelines. “Mild disease”: Basically, anticoagulant therapy is not required and physical therapy (ambulation, lower limb exercise, elastic stockings) is the main focus. Physical therapy is the basis of VTE prevention. “Moderate disease I” (shortness of breath, pneumonia findings): Anticoagulant therapy is not required, and physical therapy (including intermittent pneumatic compression) is the main focus. “Moderate disease II” (requires oxygen administration): Consider the use of low-dose unfractionated heparin, which is a prophylactic dose. No dose adjustment by APTT measurement is required. Concomitant physical therapy during anticoagulant therapy is not mandatory. “Severe disease” (ICU management or mechanical ventilation): Administer unfractionated heparin. The dose should be a preventive dose in consideration of the risk of bleeding. Conduct continuous monitoring of D-dimer.

This guideline will be revised in the future.