Pelvic venous circulation is complex and the pathophysiology remains poorly understood. Pelvic venous disorders is the general term for a variety of syndromes caused by venous stasis in the pelvic region, including pelvic congestion syndrome, May-Thurner syndrome, and Nutcracker syndrome. Because these syndromes have been named after specific symptoms and have been treated separately by various departments, pelvic venous disorders have not been systematically treated or studied. Generally, women who has given birth with pelvic venous dilatation are often asymptomatic. However, the symptoms may vary depending on the site of venous reservoir, and it is fact that a standardized treatment plan is not possible. The Symptoms-Varices-Pathophysiology (SVP) classification proposed by the American Vein & Lymphatic Society is an attempt to comprehensively understand pelvic venous disorders based on symptoms, varices, and pathophysiology. In this article, we will discuss the usefulness of the SVP classification based on our own experience.

Using NDB open data and demographic statistics published by the Japanese government, this review investigates the status of VTE among Japanese people. The average annual number of deaths from pulmonary embolism was 1741.1±31.1 people from 1995 to 2021, with 2011 having the highest number of deaths, at 2034, during the study period, which was thought to be related to the Great Eastern Japan Earthquake. Inferior vena cava filter (IVCF) placement has declined since 2014 during the DOAC era. However, only about 50% of cases have had the IVCF removed. The number of pulmonary artery thrombectomies is rising, a trend that conflicts with the decline in IVCF implantation cases. The number of recipients of designated intractable diseases due to chronic thromboembolic pulmonary hypertension (CTEPH) has increased progressively, and the number of such recipients in 2021 was approximately double that in 2014, In contrast, the number of pulmonary artery thromboendarterectomies has not increased progressively. Iliac femoral vein thrombectomies are on the decline, and there were no cases in 2021. Additionally, in several Japanese VTE registry studies, cancer-related venous thromboembolism accounted for about 30% of cases, Hopefully, all direct oral anticoagulants (DOACs) used for VTE in Japan, where low molecular weight heparin (LMWH) is unavailable, will be indicated on the same reduced dose criteria as nonvalvular atrial fibrillation.

Elastic stockings (ES) are commonly used to prevent postoperative venous thrombosis; however, their use has been reported to cause several adverse events, including skin problems in some patients. At our hospital, although ES are routinely used, preventing skin problems has not been a priority. Therefore, we investigated the incidence of issues due to ES and efficient evaluation methods to prevent skin problems. Patients were evaluated twice daily after wearing knee-high ES to determine whether ES were worn appropriately without incorrect positioning at three points: the ES’ superior end, heels, and toes. The “3-point check” was considered failed if ES were worn inappropriately. Incidence of failures of the “3-point check” and onset of skin problems were investigated in 57 patients who underwent a pulmonary embolism prevention program after surgery under general anesthesia. We found that 12 patients (21.0%) had skin problems and that those who failed the “3-point check” had significantly higher incidence of skin problems. Thus, it is important to consider failure in the “3-point check” as a risk for skin problems and provide preventive measures. The “3-point check” can serve as a measure of whether ES are worn appropriately, and allows identification of patients susceptible to intervention before the onset of skin problems.

【Background】 Coronavirus disease 2019 (COVID-19) has been reported to be associated with a high incidence of thrombosis including venous thromboembolism (VTE). 【Method】 This study was a retrospective study enrolling consecutive hospitalized patients with COVID-19 in Yokohama Minami Kyosai Hospital from April 11th, 2021, to September 30th, 2021, including fourth and fifth waves of the COVID-19 infections in Japan. During this term, we took measures to prevent arterial and venous thrombotic complications including a high prevalence of VTE for COVID-19 patients based on Clinical Guidance of Prevention of Venous Thromboembolism in COVID-19 (Version 2.0) by a collaborative effort with the Japanese Society of Phlebology, et al. 【Result】 Among 94 patients with COVID-19, 75 (79.8%) received pharmacological thromboprophylaxis. The proportion of pharmacological thromboprophylaxis increased according to the severity of the COVID-19 in 11.1% with mild and moderate I COVID-19, 94.9% with moderate II COVID-19, and 100% with severe COVID-19. Among the patients with anticoagulants, 98.7% received unfractionated heparin (UFH) of a prophylactic dose, and 1.3% received Warfarin. During the hospitalization, 2 patients (2.1%) developed thrombosis, one severe COVID-19 patient developed non-massive pulmonary embolism with the left peroneal vein DVT, and one moderate II COVID-19 patient developed aortic thrombosis. Major bleeding complication occurred in 2 patients (2.1%), both received UFH of a prophylactic dose. The bleeding site were retroperitoneal in one patient and gastrointestinal in one patient. Five patients (5.5%) died, and all of them were due to respiratory failure from COVID-19 pneumonia. 【Conclusion】 In this study, the results of our study population with current guidance for thrombosis prevention support that the overall incidence of thrombosis was substantially low with an increased incidence according to the severity of the COVID-19, however the risk of bleeding adverse events seemed to be high with anticoagulation therapy in Japan.

We evaluated the outcomes of endovenous thermal ablation (ETA) combined with intraoperative foam sclerotherapy for varicose veins of the leg. Of the 324 legs undergoing ETA (October 2018 to April 2022), 245 (75.6%) underwent intraoperative foam sclerotherapy and 237 underwent venography and fluoroscopy-guided foam sclerotherapy after ETA. Intraoperative complications included transient leg pain in 3.3% of legs. Postoperative complications included thrombophlebitis (3.3%) at 7–10 days postoperatively, along with induration (35.5%) and pigmentation (2.9%) at 1 month after surgery. Five limbs developed asymptomatic soleus muscle vein thrombosis, but symptomatic deep vein thrombosis and pulmonary thromboembolism were not observed. Six months postoperatively, 8.2% had residual varicose veins, however no additional sclerotherapies were performed. The revised venous clinical severity score significantly improved from 5.4±2.5 preoperatively to 1.0±1.3 at 6 months postoperatively. The safety and efficacy of ETA combined with intraoperative foam sclerotherapy for varicose veins of the leg appear satisfactory.

The subjects of this study were 164 patients who were treated with direct oral anticoagulants for venous thromboembolism at our hospital. Group R consisted of 49 patients treated with rivaroxaban, Group A consisted of 97 patients treated with apixaban, and Group E consisted of 18 patients treated with edoxaban. The mean age in Group A (78.0 ys) was significantly older than Groups R (67.2 ys) (p<0.001). The proportion of women was significantly higher in groups A and E than Group R (p=0.026). The mean creatinine clearance in Group A (57.2 mL/min) was significantly lower compared to Group R (78.9 mL/min) and Group E (76.0 mL/min), respectively (p<0.0004), p<0.05. The rate of proximal type thrombus was significantly higher in Group A than groups R and E. The overall C-reactive protein positive rate was higher at 70.7%, but there was no difference between the groups. The average regression period of the thrombus was 8.0 weeks in Group R, 7.6 weeks in the Group A, and 11.2 weeks in the Group E, with no significant difference. The average duration of medication was 6.1 months for Group R, 6.0 months for the Group A, and 7.3 months for the Group E, with no difference observed. No significant difference was observed in the rate of recurrence cases:18.4% in Group R, 11.3% in Group A, and 22.2% in Group E. No cases of major bleeding were observed in all groups. There was no particular difference in the efficacy or safety of DOACs.

Inferior vena cava filter (IVCF) is intended to prevent pulmonary artery thromboembolism (PTE). Early retrieval of IVCF has been recommended because of complications associated with long-term implantation, but retrieval of IVCF with a large, trapped thrombus may cause PTE. From April 2017 to December 2021, we had 308 cases of venous thromboembolism (VTE). There were 271 cases of deep vein thrombosis (DVT) of the lower extremities (of these, 148 cases were proximal DVT). We examined twelve patients with IVCFs implantation (3.9% of all VTE and 8.1% of proximal DVT). Inserted IVCFs were 1 NEUHAUS PROTECT SE, 2 OptEase and 9 ALN. Three filters were not retrieved, four filters were retrieved without filter thrombus on imaging, three filters were retrieved with filter thrombi smaller than 2 cm, and two filters were retrieved with thrombi larger than 4 cm after intensive therapy of direct oral anticoagulants (DOAC). All patients had not symptomatic PTE. All patients on intensive therapy of DOAC had no bleeding complications. In case that thrombolysis has bleeding risks, it is suggested that IVCF retrieval is possible without symptomatic PTE by reducing the size of filter thrombus with intensive therapy of DOAC. While the frequency of IVCF use has decreased after the guideline revision, we also considered the appropriate use of IVCF.

Primary lymphedema lacks a definitive treatment, and there are limited detailed reports on the long-term treatment outcomes since its onset. Treatment options include conservative treatment and surgical treatment, the former focusing on patient self-care and the latter including lymphatic vein anastomosis, lymphatic vascular and lymph node grafting, and liposuction. Since there is no curative therapy, some patients withdraw from treatment due to anxiety about permanent treatment or difficulty maintaining their condition. Early-onset primary lymphedema (Lymphedema paraecox) patients who develop the condition during adolescence experience changes in their bodies and lifestyles as they transition from students to adults. Therefore, there is a need for less burdensome and sustainable conservative treatments, as well as effective conservative treatment recommendations before and after surgical interventions. This report presents a case study of a patient who developed primary lymphedema in the left lower limb at the age of 14 and provides clinical data on conservative and surgical treatments over a 13-year period until the age of 27, along with the progression of the Japanese version of the LYMQOL assessment.

Cyanoacrylate closure for the treatment of incompetent great saphenous vein have accepted as insurance coverage in Japan. There are some cases develop postoperative complication. We describe allergic-like reaction caused by cyanoacrylate closure for the treatment of incompetent great saphenous vein. A 79-years-old woman had this treatment, developed swelling of diseased side leg after the treatment. This case got a DLST, and the result was positive. We diagnosed this case as type IV hypersensitivity. As a result, we decannulate left saphenous vein filling CA. After the operation, the symptoms were improved by degrees and the result of DLST turned negative in the end.

A 83-year-old man, underwent a left upper lobectomy after diagnosis of lung cancer. He had a syncope attack on the 15th postoperative day. A contrast CT showed thrombi in his peripheral right pulmonary artery and thrombotic occlusion of left internal jugular vein and left subclavian vein. The stenosis of left brachiocephalic vein between sternum and aortic arch was detected before operation. Duplex scanning revealed thrombus with low–moderate echogenicity in left lower limb soleal vein. He received continuous infusion of therapeutic unfractionated heparin, followed by oral rivaroxaban, thus achieving an improvement of thrombosis. We report a rare case of pulmonary thromboembolism associated with deep vein thrombosis of the upper and lower extremities after lung cancer surgery.

We developed a new endovenous laser ablation (EVLA) protocol to prevent nerve injuries after varicose vein surgery. The technique and clinical results of 1042 incompetent great saphenous veins (GSV) cases are presented. A slim-type radial 2-ring fiber with a diameter of 1.27 mm was used, connected to a diode laser equipment with a wavelength of 1470 nm. The EVLA system treated the incompetent GSV and tributary varicose veins. The above-knee GSV was ablated at 7 W (LEED 50–70 J/cm). If the below-knee GSV had reflux, it was ablated at 5 W (LEED 20–25 J/cm). Tributary varices were treated at 5 W (LEED 30 J/cm). All veins were accessed by puncturing with a 16 G venule needle. Stab avulsion phlebectomy was not performed. Saphenous nerve injury was not observed in any patients. Our new EVLA protocol was useful with less incidence of nerve injuries.

Along with advances in minimally invasive medicine over the past 40 years, treatment for varicose veins in the lower extremities has also changed approximately every 10 years. Each time, the problems of various treatments became apparent. Based on this, we formulated a basic policy for varicose vein treatment, and evaluated CAC, which is the latest treatment. Over 2 years, 615 cases and 792 limbs underwent CAC. As a result, CAC could be performed in accordance with the basic policy. And it can close the full length of GSV and SSV even in cases involving lipo-dermatosclerosis and skin ulcers.