Motohiro Nozaki

High peak reflux velocity in the proximal deep veins is a strong predictor of advanced post-thrombotic sequelae.

Summary.  Background: The presence of reflux in the femoral vein (FV) and popliteal vein (POPV) after acute deep vein thrombosis (DVT) is considered to contribute to the development of advanced post‐thrombotic syndrome (PTS). However, a quantification of reflux has yet to be determined. The purpose of study was to determine the indicative parameters reflecting the progression of PTS. Methods: Venous abnormalities were evaluated in 131 limbs out of 130 patients who completed a six‐year follow‐up after an acute DVT. Clinical manifestations were categorized according to the clinical, etiologic, anatomic, and pathophysiologic (CEAP) classification, and the patients were divided into two groups at a six‐year follow‐up point: group I, C0–3Es,As,d,p,Pr,o, early chronic venous insufficiency (CVI); group II, C4–6Es,As,d,p,Pr,o, advanced CVI. Venous segments were examined whether they were occluded or recanalized. The reflux parameters assessed were the diameter (cm), the reflux time (RT; s), the peak reflux velocity (PRV; cm s−1), and total refluxed volume, and these parameters were assessed especially in the FV and POPV at the two‐year (early phase) and subsequent six‐year (late phase) follow‐up points after DVT. Results: There were 98 limbs in group I and 33 in group II. The frequency of venous reflux was significantly higher in group II (<0.0001). In contrast, the proportion of occlusion did not differ between the groups (P = 0.138). The proportions of FV and POPV incompetence were significantly higher in group II (P < 0.0001 and P < 0.0001, respectively). In these veins, the RT did not improve the discrimination power between the two groups. In contrast, the PRV had significant discrimination power in these veins at both the two‐ and six‐year follow‐up points. In the superficial venous system, there were no significant differences in any of the determined parameters between the groups. In group II, 19 patients (58%), who had early symptoms of CVI at the two‐year follow‐up point, subsequently developed advanced symptoms of PTS. After calculating a suitable cutoff point using receiver operating characteristic curves analysis at the two‐year follow‐up point, multivariable analysis showed that a PRV of >25.4 cm s−1 in the POPV was the strongest independent predictor of advanced CVI [odds ratio (OR) 60.32; 95% confidence interval (95CI) 43.1–1238.97, P < 0.0001]. Similarly, in the FV, a PRV of >24.5 cm s−1 was found to be a strong predictor of advanced CVI (OR 25.77, 95CI 10.56–331.12, P < 0.0001). Conclusions: These findings suggest that the presence of a high PRV in the proximal deep veins is an independent predictor of advanced symptoms of PTS.

Monitoring the changes in intraparenchymatous venous pressure to ascertain flap viability.

Background: Disruption of venous outflow can lead to tissue necrosis. Thrombosis of a venous channel at the coaptation site in instances of free tissue transfer could cause death of the transplanted tissues. Although various techniques have been used to monitor the viability of transferred tissues, there has been no technique designed specifically to check the flow within and the patency of the venous channel. The authors have devised an approach with which to monitor the changes in venous pressure in a composite tissue transferred by means of microsurgical technique for bodily reconstruction. Methods: The status of the venous system in various composite tissue grafts was monitored at the time of surgery or for 3 days after the completion of surgery by placing a small-caliber catheter in the vein within the transferred tissue. A total of 52 patients participated in the study. Results: The venous pressure noted in grafts with a patent venous channel remained constant within a range between 0 and 35 mmHg. Venous insufficiency was detected in three of the 52 cases, with unmistakable findings of an elevated venous pressure of over 50 mmHg. Conclusions: The technique of measuring the venous pressure by means of an indwelling venous catheter to monitor changes was found to accurately assess the patency of the venous channel and, by inference, the viability of the transferred tissue. No morbidity was associated with the technique.

Evaluation of fluence and pulse-duration on purpuric threshold using an extended pulse pulsed-dye laser in the treatment of port wine stains

Laser therapy of port‐wine stains (PWS) using the extended pulse pulsed‐dye laser (EPPDL) is accepted as the optimal approach because the thermal relaxation time for the vessels in PWS is actually 1–10 msec. The purpose of this study is to elucidate the purpuric threshold using the EPPDL for treatment of PWS. One hundred and seventy‐seven Japanese patients with PWS were recruited for this study. All the patients were dark‐skinned with skin phototype III (n = 103) and IV (n = 74). PWS were treated with the EPPDL with a pulse duration ranging 1.5–10 msec, fluence ranging 9–15 J/cm2, and a spot size of 7 mm. Cryogen spray cooling (CSC) was fixed to 30 msec of delay and 30 msec of spray duration. Patients returned to our clinic within 1 week after their initial laser therapy and the treatment sites were examined for the evidence of purpura formation. Of the 177 patients, 108 developed purpura. The lowest fluences that caused purpura and were seen in more than 50% of patients were 10 J/cm2 with a pulse duration of 1.5 msec, 12 J/cm2 with a pulse duration of 3 msec, 13 J/cm2 with a pulse duration of 6 msec, and 13 J/cm2 with a pulse duration of 10 msec. The fluence and pulse duration thresholds were 12.5 J/cm2 and 1.65 msec, respectively. Because purpura is one of the treatment endpoints when using a pulsed‐dye laser for PWS, higher fluences are necessary when using a long pulse duration.

The utility of quantitative calf muscle near‐infrared spectroscopy in the follow‐up of acute deep vein thrombosis

Summary.  Background: To investigate patterns of venous insufficiency and changes in calf muscle deoxygenated hemoglobin (HHb) levels after an acute deep vein thrombosis (DVT). Methods: A total of 78 limbs with an acute DVT involving 156 anatomic segments were evaluated with duplex scanning and near‐infrared spectroscopy (NIRS) at 1, 3, 6 and 12 months. Venous segments were examined whether they were occluded, partially recanalized, and totally recanalized, and the development of venous reflux was noted. The NIRS was used to measure calf muscle HHb levels. Calf venous blood filling index (HHbFI) was calculated on standing, then the calf venous ejection index (HHbEI), and the venous retention index (HHbRI) were obtained after exercise. Results: The segments investigated were the common femoral vein (CFV; 38 segments), femoral vein (FV; 37), popliteal vein (POPV; 44), and calf veins (CV; 37). At 1 year, thrombi had fully resolved in 67% of the segments, 27% remained partially recanalized, 6% were occluded. The venous occlusion was predominant in the FV (24%) at 1 year. On the contrary, rapid recanalization was obtained in CV than proximal veins at each examination (P < 0.01). Venous reflux was predominant in POPV (55%), followed by FV (19%), and no reflux was found in CV. At 1 year, the HHbFI in POPV reflux patients was significantly higher than those with resolution (0.19 ± 0.14, 0.11 ± 0.05 μm s, P = 0.009, respectively). Similarly, there was a significant difference in the HHbRI between the two groups (3.08 ± 1.91, 1.42 ± 1.56, P = 0.002, respectively). In patients with FV occlusion, the value of HHbRI was significantly higher than those with complete resolution (2.59 ± 1.50, 1.42 ± 1.56, P = 0.011, respectively). Conclusions: The lower extremity venous segments show different proportions of occlusion, partial recanalization, and total recanalization. The CV shows more rapid recanalization than proximal veins. The NIRS‐derived HHbFI and HHbRI could be promising parameters as the overall venous function in the follow‐up of acute DVT. These findings might be very helpful for physician in detecting patients who require much longer follow‐up studies.

Intraoperative application of three-dimensional imaging for breast surgery

The planning of an operation based on three-dimensional imaging has been used mainly in orthognathic surgery. It is a useful way to plan the preoperative treatment as well as to make the postoperative evaluation. We used this technique in breast reconstruction. For the evaluation of breast volume and contour, we used three-dimensional photography by laser scanner, and these were analysed intraoperatively. Three-dimensional data obtained during the operation gave us precise information about the volume and contour of the breast.

Treatment of facial angiofibroma of tuberous sclerosis using cultured epithelial autografts

Treatment of facial angiofibroma of tuberous sclerosis is problematic, because the skin lesions involve entire dermis. Five patients aged from 14 to 33 (mean: 23.6) years old with angiofibroma of tuberous sclerosis were treated with cultured epithelial autografts between 1995 and 2004. The entire area of the facial lesions was excised using a razor to remove large nodules, and then the remaining lesions were further abraded to a rather deep layer of the dermis to smooth the skin and remove small nodules. Then a cultured autologous epithelium was grafted onto the wound. In all patients, epithelization was complete within 10 (mean: 9) days after the surgery. All patients were followed up for more than 6 months and showed neither depigmentation due to scar formation nor hypertrophic scars. In some patients, some pebbly regrowth had occurred at 5 years postoperatively, but the appearance was quite acceptable.

Mongolian spots with involvement of mandibular area

A 1‐year‐old boy had grayish pigmentation on the left side of his face over the area supplied by the mandibular branch of the trigeminal nerve. Upon further examination, the lesion was also found on the left side of the neck, shoulder, upper arm, right lower back and buttock. The pigmentation was uniform in intensity. This case report demonstrates that Mongolian spots can occur on the face in the area supplied by the mandibular branch of the trigeminal nerve. These spots should not be misdiagnosed as nevus of Ota.

Reconstruction of the pharyngoesophagus with voice restoration

Vocal rehabilitation is of great importancefor patients to maintain life quality following surgical treatment of head and neck tumors. Although the tracheo-neoesophageal shunt is a possible solution for voice restoration after pharyngolaryngoesophagectomy, regurgitation through the reconstructed shunt easily leads to aspiration pneumonia. Therefore, prevention of reflux to the airway is essential in all reconstructive proceduresfor tracheo-neoesophageal shunt. This article reviewsprevious methods restoring speech function following pharyngolaryngoesophagectomy.