Endovenous laser ablation with ELVeS radial 2ring slim fiber (diameter 1.27 mm) was performed on 154 patients (168 legs) with great saphenous vein insufficiency. A tributary varicose vein was punctured with a 16 G needle, a slim fiber was inserted into the lumen, and laser ablation was performed at 5 W. One month after the surgery, subdermal induration was observed in 61% of the cases. Six months after the surgery, 60% of the induration was disappeared, and the diameter was decreased to 44% of that at 1 month after the surgery. No adverse events such as skin burn, nerve injury, infection, thrombophlebitis were observed.

SEPS (subfascial endoscopic perforator surgery) was devised as a surgical procedure to dissect incompetent perforating veins (IPVs) under the skin of lipodermatosclerosis (C4b) and refractory ulcers (C6) at lower leg and in our country it was authorized by the National Insurance System in 2014. We have performed SEPS, but we have also experienced IPVs that SEPS cannot handle, and one of the solutions was percutaneous ablation of perforators (PAPs). PAPs were performed on 102 IPVs out of 65 limbs in 63 cases. Although the equipment used has changed, currently we uses a 1470 nm laser device and laser fiber with a small outer diameter, and the average linear endovenous energy density is 68.1±14.9 J/cm. The advantage of PAPs was that the IPV occlusion could be confirmed in real time by intraoperative ultrasonography, and our intraoperative occlusion rate was 100%. In addition, IPV at sites that could not be treated with SEPS for anatomical reasons could also be treated. We reported on the current status of PAPs that we are conducting in comparison with SEPS.

We compared postoperative outcomes between cyanoacrylate embolization and radiofrequency ablation. The study included 68 limbs of 50 patients who underwent radiofrequency ablation from July 2019 to June 2020 and 59 limbs of 50 patients who underwent cyanoacrylate embolization from June 2020 to February 2021. There was no significant difference in the frequency of postoperative complications and the obstruction rate 3 months after surgery between the two groups. The lengths of treated veins were shorter in the cyanoacrylate embolization group, but there was no significant difference in Venous Clinical Severity Score before and 3 months after surgery between the two groups. Cyanoacrylate embolization is important as a less invasive treatment method than radiofrequency ablation which has no complications associated with heat ablation and does not require tumescent local anesthesia.

The incidence of nerve injury after endovenous thermal ablation (ETA) was investigated. Patients with incompetent great saphenous veins (GSV, 2876 legs) underwent ETA. Nerve injury, which was defined as if a patient feels any neurologic symptoms at 1 month after the surgery, was occurred in 70 legs (2.4%). The incidence was 0.8% when the ablation length was less than 40 cm, thus, 4.6% when it was over or equal to 40 cm. This finding was observed in either group patients who received radiofrequency or laser ablation therapy. Ablation conditions for below-knee GSV should be reconsidered.

Objectives: The untreated segments at the saphenofemoral junction (stump) are reported to be long when the cyanoacrylate closure (CAC) is applied with the standardized procedure, which is indicated in the manufacturer’s instruction for use (IFU). For the purpose of reducing the stump length, a new method in which the ultrasound probe is used parallel to the GSV is developed (Slope method). In this article, the stump lengths after CAC with the Slope method for the GSVs are reported. Methods: Fifty-six incompetent GSVs of thirty-nine symptomatic patients were treated with CAC with Slope method from September 2020 to March 2021. The feature of the Slope method is the usage of the ultrasound probe. In the IFU, the probe is applied transversely to the targeted GSV in order to compress the vessel during the injection of the cyanoacrylate (CA). On the other hand, in the Slope method, the probe is applied parallel to the targeted GSV with its axis slanted toward cranial side enabling the physician to both compress the vessel and observe the reaction of injected CA simultaneously. Additional treatments such as CAC for small saphenous vein, phlebectomy and sclerotherapy were also performed in the same session if these treatments were necessary. The stump lengths were measured using ultrasound device 2–3 months after the procedure. Results: Fifty-six (100%) from the fifty-six treated GSVs were closed two months after the surgery. Thrombi, which did not extend into the femoral vein, were found in 27% of the GSVs. Hypersensitivity reaction along the treated GSVs were observed in 9% of the limbs. Then, these adverse effects resolved within two months. The stump lengths were 14.1±7.7 mm. No complication occurred during the observational period. Conclusion: The stump lengths were shortened to 14.1±7.7 mm with Slope method without any side effects related to the method. Slope method is shown to be a considerable option to sophisticate CAC treatment for physicians who have enough experience on IFU.

For intractable venous leg ulcers, early surgical intervention is performed in our facilities to promote ulcer healing and reduce recurrences. This study investigated 38 consecutive patients (22 women :mean age, 64.2±2.4 years) with venous leg ulcers between May, 2007 and December. 2018. After initial compression therapy, we performed early surgical intervention (mean, 17.5±0.8 days: 6–22 days), then sclerotherapy after 2–3 weeks. We performed stripping in 29 patients, high ligation in 7 patients, and endovenous thermal ablation therapy in 2 patients. In all cases, phlebectomy or sclerotherapy were performed for incompetent perforating veins. Mean area of venous leg ulcers at the time of first visit was 4.4±0.4 cm² (range, 2–12 cm²). All ulcers healed within 10 months (mean, 3.8±0.3 months: 2–10 months), with no cases of recurrent infection or inflammation. Compression therapy, followed by early surgical intervention for venous leg ulcer resulted in good healing.

We report a case of gastrocnemius vein (GCV) thrombosis which could be treated by thrombectomy and anticoagulant therapy. A 71-year-old woman, who had been regularly treated right knee osteoarthritis, was referred to our department complaining of right calf swelling with pain and redness. Ultrasonography revealed a dilated calf vein alongside the right popliteal vein was filled with soft thrombus, and this vein joined the right popliteal vein at knee level. Considering management of deep vein thrombosis, anticoagulant therapy should be the first line and gold standard. However, the COVID-19 surge was putting a strain on hospitals across the country. Pulmonary thromboembolism (PTE) or other life-threatening emergencies might not be treated appropriately, therefore we decided to perform both anticoagulant therapy and thrombectomy for risk reduction of PTE. In a prone position, thrombectomy was completed under local anesthesia. After surgery, all symptoms were relieved quickly. Postoperative computed tomography (CT) angiographic findings revealed surgical treated vein was GCV, and ultrasonography detected GCV regurgitation without residual thrombus. The Patient who is given an elastic compression stocking and direct oral anticoagulant showed no recurrence of DVT at 4 months of follow up.

Inferior vena cava thrombosis (IVCT) is found in 3–15% of patients with deep vein thrombosis (DVT) and is more likely to occur in patients complicated not only with the common DVT factors but also with diseases such as congenital anomaly of the inferior vena cava (IVC), malignant disease, or trauma. Since pulmonary thromboembolism is complicated in 12% of patients at the time of IVCT diagnosis and post-thrombotic syndrome may occur in the chronic phase, IVCT needs to be managed appropriately from the acute phase over a long period of time. We report our experience of a patient who showed thrombus regression after rivaroxaban monotherapy for asymptomatic IVCT diagnosed on persistent diarrhea and leg weakness, although the involvement of a congenital thrombotic diathesis as a cause could not be clearly denied.

Duplex ultrasound (DUS) plays a crucial role not only in diagnosis of varicose veins, but also in decision of indication for invasive treatment. Therefore, appropriate recording and reporting of DUS results, as well as accurate methods of DUS, in varicose vein patients would be important. Furthermore, in the field of diagnosis and treatment of patients with varicose veins, the rules for reimbursement in national health insurance in Japan have changed in April, 2020. In response to the changes, Guideline Committee in Japanese Society of Phlebology developed a consensus document for standardization of ultrasonographic data recording and reporting in patients with varicose veins.

Endovenous laser ablation (EVLA) was undergone in 90 legs of great saphenous vein (GSV) insufficiency for prospective study to prevent saphenous nerve injury. EVLA was applied by the power of 7 W in the above-knee GSV (targeting LEED 50–70 J/cm) and 5 W in the below-knee GSV (targeting LEED 20–25 J/cm). A total ablation length of GSV averaged in 50.4 cm. At 1 month after EVLA, ultrasonography revealed complete obstruction of treated GSV. Saphenous nerve injuries were not observed in any patients.