Masayuki Hirokawa

Comparison of Bare-Tip and Radial Fiber in Endovenous Laser Ablation with 1470 nm Diode Laser

OBJECTIVE Major side effects after endovenous laser ablation (EVLA) are pain and bruising. The aim of this study was to compare outcome and side effects after EVLA for primary varicose veins with 1470 nm diode laser using bare-tip orradial fiber. METHODS From October 2007 to December 2010, 385 patients (453 limbs) with primary varicose veins treated with 1470 nm laser were studied. Bare-tip fiber was used in 215 patients (242 limbs) (BF group) and radial fiber (ELVeS(TM)Radial, Biolitec AG, Germany) was used in 177 patients (211 limbs) (RF group). This study is a retrospective study and radial fiber was started for use from November 2008. Laser energy was administered at 6-12 W of power in the BF group and 10 W of power in the RF group with constant pullback of laser fiber under tumescent local anesthesia. The patients were assessed by clinical examination and venous duplex ultrasonography at 24-48 h, one week, one month, 4 months and one year follow-up postoperatively. RESULTS Mean operating time, length of treated vein and linear endovenous laser energy of all cases were 42.6 min, 36.2 cm and 83.4 J/cm, respectively. Major complications such as deep vein thrombosis and skin burns were not noted. Bruising (1.9% vs. 19.4%) and pain (0.9% vs. 7.4%) were significantly lower in the RF group. Cumulative occlusion rates by Kaplan-Meier method were 100% at 32 months in the RF group and 99.5% at 4 years in the BF group. CONCLUSION EVLA using 1470 nm laser with the radial fiber minimized adverse effects compared with bare-tip laser fiber. (English translation of Jpn J Vasc Surg 2013; 22: 615-621).

Effects of Acupressure on Lower Limb Blood Flow for the Treatment of Peripheral Arterial Occlusive Diseases

PurposeTo investigate the effects of acupressure on lower limb blood flow for the treatment of peripheral arterial occlusive diseases (PAOD).MethodsFrom February 2004 to February 2005, 30 patients with stage II PAOD underwent measurements of the lower limb blood flow. Six patients (group A) were assigned as controls without any acupoint stimulation, while 24 (group B) underwent stimulation at acupoints by acupressure. The acupoints Yanglingquan (GB34), Zusanli (ST36), Yinlingquan (SP9), and Sanyinjiao (SP6) of the symptomatic lower limbs were stimulated for 3 min. Transcutaneous oximetry (tcPO2) was used to determine the blood flow of the chest wall, bilateral distal crura, and bilateral dorsa of the foot before and during the stimulations at the acupoints.ResultsGroup A showed no significant change in the lower limb blood flow. In group B, the tcPO2 values of chest wall, bilateral distal crura, and the dorsum of foot of the stimulated lower limb increased significantly during acupressure (P < 0.01), whereas no significant change was shown in the dorsum of the foot of the non-stimulated lower limb. Moreover, the blood flow of the lower limbs that had undergone an ipsilateral sympathectomy increased significantly (P < 0.01).ConclusionsAcupressure was found to cause significant increases in the lower limb blood flow of stage II PAOD patients. This treatment modality may therefore be effective for improving the symptoms of such patients.

Comparison of 1470 nm Laser and Radial 2ring Fiber with 980 nm Laser and Bare-Tip Fiber in Endovenous Laser Ablation of Saphenous Varicose Veins: A Multicenter, Prospective, Randomized, Non-Blind Study

OBJECTIVE The aim of this study is to compare the clinical efficacy and safety of two laser wavelengths and fiber types in endovenous laser ablation (EVLA) of saphenous varicose veins of the lower limb. DESIGN Multi-center prospective randomized non-blind clinical trial. PATIENTS AND METHODS From January 2007 to December 2011, 113 patients (113 limbs) with primary varicose veins were randomized into two groups. They were treated with radial 2ring fiber and 1470 nm laser in Group I (57 limbs) and bare-tip fiber and 980 nm laser in Group E (56 limbs) in order to ablate the saphenous vein. Vein occlusion rates at 12 weeks and pain in treated region were recorded as primary endpoint. Visual analogue scale (VAS) for assessment of pain, rates of bruising, complications and equipment failure were recorded as secondary endpoint of safety. RESULTS Occlusion rates at 12 weeks were 100% in both groups. Rates of pain (0% vs. 25.0%) and bruising (7.0% vs. 57.1%) were significantly lower in Group I (p <0.0001). VAS of pain was significantly lower on postoperative day 1, day 5 and 2nd week in Group I. CONCLUSION Treatment of saphenous varicose veins by EVLA using a 1470 nm laser and a radial 2ring fiber resulted in comparable occlusion rates at 12 weeks and less postoperative pain and bruising than EVLA with a 980 nm laser and a bare-tip fiber. (This article is a translation of Jpn J Vasc Surg 2014; 23: 964-971.).

Clinical Study of Phlebitis Migrans and Incompetence of the Leg's Superficial Vein in Buerger Disease.

Three of four (75%) vein biopsy samples from four patients (all male, mean onset: age 33.0, mean biopsy: age 59.7) of chronic phase phlebitis migrans showed positive periodontal bacteria DNA under the PCR (polymerase chain reaction) method. Of the 24 cases of Buerger disease (22 males, 2 females, mean onset: age 31.9, mean examination: age 62.6) that were investigated in our vascular laboratory, 65% of the patients suffered from moderate to severe varicose veins. Eight cases had a history of phlebitis migrans and three had an active ulcer or uncontrollable erosion in the foot. The rate of incidence was significantly higher than that of the well-matched control group. Other findings included one instance of deep vein thrombosis, and one instance of deep vein reflux. We could suggest that some intractable ulcer or erosion cases of Buerger disease may be complicated by superficial vein incompetence or other deep vein insufficiency. We also we need to check Buerger disease patients with duplex for vein reflux and other insufficiencies. Treatment of the varicose veins (including elastic stockings) was effective for all of the patients. (English Translation of Jpn J Phlebology 2011; 22: 25-31.).

Postoperative Venous Thromboembolism in Patients Undergoing Endovenous Laser and Radiofrequency Ablation of the Saphenous Vein

Objective: Endovenous laser ablation (EVLA) and radiofrequency ablation (RFA) are safe and effective treatments for varicose veins caused by saphenous reflux. Deep venous thrombosis (DVT) and endovenous heat-induced thrombosis (EHIT) are known complications of these procedures. The purpose of this article is to investigate the incidence of postoperative DVT and EHIT in patients undergoing EVLA and RFA. Methods: The patients were assessed by clinical examination and venous duplex ultrasonography before operation and at 24-72 hours, 1 month, and 1 year follow-up after operation. Endovenous ablation (EVA) had been treated for 1026 limbs (835 patients) using an RFA; 1174 limbs (954 patients) using a 1470-nm wavelength diode laser with radial two-ring fiber (1470R); and 6118 limbs (5513 patients) using a 980-nm wavelength diode laser with bare-tip fiber (980B). Results: DVT was detected in 3 legs (0.3%) of RFA, 5 legs (0.4%) of 1470R, and 27 legs (0.4%) of 980B. One patient in three symptomatic DVT treated with 980B developed asymptomatic pulmonary embolus. In all, 31 of the 35 DVTs were confined to the calf veins. The incidence of EHIT classes 2 and 3 was 2.7% following RFA procedure, 6.7% after 1470R, and 7.5% after 980B. Conclusion: The incidence of EHIT following EVA was low, especially the RFA procedure. EHIT resolves within 2-4 weeks in most patients. DVT rates after EVA were compared with those published for saphenous vein stripping. (This is a translation of J Jpn Coll Angiol 2015; 55: 153-161.).

Anatomical variation at the sapheno-femoral junction.

OBJECTIVE The aim of this study was to assess the anatomical variations of the sapheno-femoral junction (SFJ) and the incidence of these variations. MATERIALS AND METHODS Between April 2005 and March 2010, 2552 limbs of 1563 patients with complaints of varicose veins underwent ultrasonography. Ultrasonography was used to identify the anatomical variations of the SFJ, especially the relationship to the femoral artery. RESULTS Variations were seen in six limbs (0.24%) at the SFJ. The most common anatomical variation was the great saphenous vein crossing posterior to the common femoral artery, which was present in three limbs. CONCLUSION It is important to investigate the anomalies of the SFJ using preoperative duplex ultrasound, although the incidence of such anomalies is lower than that of the sapheno-popliteal junction. An anomaly of the SFJ always should be taken into consideration in order to minimize surgical complications of varicose veins. (English translation of Jpn J Phlebol 2012; 23: 25-29).

Surgical Treatment of Popliteal Vein Entrapment Causing Symptoms

Objective: To review series of cases in which surgery was used to treat popliteal vein entrapment (PVE). Methods: Between 1984 and 2001, 11 patients (all women; mean age 27.6 years; 14 limbs) underwent surgery for PVE causing calf ache, swelling, and tenderness of the popliteal fossa. Preoperative evidence of PVE included positive results on a passive dorsi-flexion test, compression of the popliteal vein on ascending venography, hypertrophied or aberrant muscle in the popliteal fossa on CT scanning and elevated below-knee venous pressure. The medial or third head of the gastrocnemius muscle was partly or totally resected under the guidance of intraoperative venous pressure measurement and venography. Results: No operative complications occurred. During 3-10 years of follow-up, 57% of limbs were symptom-free, 21% were improved and 21% were unchanged. Conclusion: Treatment of PVE by resection of muscle fibres under the guidance of objective intraoperative assessments was effective in most patients.

Detection of Peripheral Microemboli Through Collateral Circulation by Doppler Ultrasound Monitoring Report of 2 Cases

It is possible for a proximal arterial source to lead to distal atheroembolism even in the presence of chronic occlusive disease. However, no monitoring technique has been established regarding detection of peripheral emboli through the collateral circulation in the lower limbs. We report a 60-year-old woman and a 73-year-old man with iliac stenosis and complete occlusion of the ipsilateral superficial femoral artery in whom Doppler ultrasound successfully detected microembolic signals (MES) at the tibioperoneal trunk during percutaneous transluminal angioplasty (PTA) and stent placement. By means of continuous Doppler ultrasound monitoring, 29 MES were successfully detected immediately after PTA or stent placement (MESp) and 64 MES were detected immediately after the contrast medium administration (MESc). MESc generated significantly higher intensities (median 28, range 7 to 38) as opposed to MESp (median 21, range 5 to 35, p= 0.017). In addition, the intensity of MES after prestent PTA (n=8, 25 dB, 12–35 dB) and stenting (n=18, 22 dB, 9–35 dB) was significantly higher than that of MES after poststent PTA (n=3, 13 dB, range; 5–16 dB), respectively (p=0.041, p=0.034). Iliac PTA and stent placement were successful. Ankle/brachial pressure index and the symptoms improved in both patients, who showed no embolic symptoms after the procedure. This study suggested that it was possible to detect peripheral microemboli through the collateral circulation by Doppler ultrasound monitoring and that this technique would be helpful to investigate the mechanism of embolization in patients with PTA and stent placement.

Vascular closure system type of nonpenetrating arcuate-legged titanium clips for graft-artery and graft-graft anastomoses: review of our clinical experience.

PurposeTo assess the durability of Vascular Closure System (VCS) clips for graft-artery and graft-graft anastomoses.MethodsThe subjects were 100 consecutive patients, who had undergone vascular procedures in which VCS clip application was attempted for anastomoses. The operative indications were arteriosclerosis obliterans in 69 patients, aortic aneurysm in 26, and other disorders in 5. Large clips were used for both graft-artery and graft-graft anastomoses, and medium-sized clips were used for the smaller caliber femoral or popliteal arteries.ResultsVascular Closure System clips could not be applied to anastomose the graft to the artery in 13 patients because the arterial wall was too thick or stiff. Anastomosis was accomplished without any problems in 80 patients, although suture-line bleeding occurred in 7 patients. This was ameliorated by an additional clip in four patients, but interrupted sutures were needed to seal the anastomosis in the other three patients. The 1-, 3-, and 5-year cumulative primary patency rates were 98.7%, 97.4%, and 87.7%, respectively. There were two graft failures and two anastomotic aneurysms.ConclusionVascular Closure System clips were useful to coapt a prosthetic graft to an artery unless the arterial wall was thicker than 2 mm or calcified. Thus, VCS clips could be durable enough for graft-artery anastomoses in the iliac or popliteal region.

Subfascial endoscopic perforator surgery using a soft trocar for varicose veins in the lower leg

Objective: To describe the use of a novel soft trocar to perform subfascial endoscopic perforator surgery (SEPS) in patients with varicose veins in the lower leg. Procedures: From January 1999 through March 2001, SEPS was performed in 14 patients (17 legs) with primary varicose veins (clinical classes 3-6) by using a soft trocar. The soft trocar is a Y-shaped polyvinyl chloride bag with two ports at one end and a flexible, sealing ring at the opposite end. The subfascial space was dissected with an endoscopic dissection cannula and expanded with a balloon. Carbon dioxide gas insufflation was applied, and the perforating veins were divided by using UltraShears inserted simultaneously with an endoscope through the second port of the trocar. Results: A mean of 4.7 ± 2.9 perforating veins per leg were divided. No wound complications occurred. Conclusion: Use of the soft trocar facilitates both visualization and manipulation during SEPS.