Yasushi Kanaoka

Pulmonary embolism in patients with isolated soleal vein thrombosis

This study investigated the features of calf deep vein thrombosis (DVT) as a pulmonary embolic source. Fifty-eight lower limbs in 29 patients who were suspected of having DVT distal to the popliteal vein were screened by ultrasonography. Then, ascending venog raphy was performed to confirm the diagnosis. Pulmonary embolism (PE) was diagnosed in suspected patients by use of pulmonary perfusion scanning or pulmonary angiography. Venography revealed calf DVT in 33 limbs in 28 patients. Of 28 patients, six had symp tomatic PE. Thrombosis was found in the muscle veins in 18 limbs, the trunk veins in 11, and both veins in four. Isolated single vein thrombosis was found in the soleal vein in 14 limbs (42%), the posterior tibial vein in eight, the peroneal vein in two, and the gastroc nemius vein in two. The overall percentage of soleal vein thrombi was 61%. All six patients with symptomatic PE had isolated soleal vein thromboses. Calf DVT was a pulmonary embolic source when isolated thrombosis of the large soleal vein was more than 7 mm in diameter. Soleal veins were the most frequent and important location of calf DVT, suggesting that these were an occasional embolic source of critical PE.

Objective Evaluation of Compression Therapy for Deep Vein Thrombosis by Ambulatory Strain-Gauge Plethysmography

Objective: To evaluate objectively the effect of compression therapy in patients with different degrees of calf muscle pump impairment following deep vein thrombosis. Design: Prospective study. Setting: Second Department of Surgery, Tottori University School of Medicine, Yonago, Japan. Patients: Twenty-one lower extremities in 16 patients and 23 lower extremities in 13 healthy control subjects. Intervention: Application of standard compression elastic stockings (30–40 mmHg compression at the ankle) and high compression elastic stockings (40–50 mmHg at the ankle) (Sigvaris, Sweden). Main outcome measures: Comparison of expelled volume measured by ambulatory strain-gauge plethysmography. Results: Calf pump function after deep vein thrombosis was classified into three grades (normal, compensated and failed) by the expelled volume. The expelled volume increased from 0.4 ml/dl (SD 0.2) to 0.9 ml/dl (SD 0.5) following the application of strong compression. Conclusion: Compression therapy is haemodynamically effective only when using strong compression (40–50 mmHg) in patients with post-thrombotic syndrome.

Mycotic abdominal aortic pseudoaneurysm caused by a penetrating atherosclerotic ulcer: report of a case.

We report a case of mycotic abdominal aortic pseudoaneurysm caused by a penetrating atherosclerotic ulcer (PAU). An 81-year-old woman was admitted to a local hospital with fever and abdominal pain, and when her symptoms were not improved by antibiotics, she was referred to our department. Computed tomography (CT) and angiography showed a saccular aneurysm below the renal arteries, and an emergency laparotomy was performed because we suspected a mycotic abdominal aortic pseudoaneurysm. An abscess was found on the proximal side of the jejunum, caused by an aneurysm penetrating the serosa. We diagnosed a mycotic pseudoaneurysm after finding the anterior wall of the aorta penetrated by intense calcification. The pseudoaneurysm was resected with the abscess and the area was covered with a pedicled omental flap to prevent infection. An axillofemoral bypass was also done. The patient recovered well.

Deep Vein Thrombosis in Patients with Severe Motor and Intellectual Disabilities, Especially Diagnosis and Prevention of Recurrence for Chronic Thrombosis-Serial Changes of Sonography and D-Dimer.

Most patients with severe motor and intellectual disabilities (SMID) have restricted mobility capability and have been bedridden for long periods because of paralysis of the extremities caused by abnormal muscular tonicity due to cerebral palsy and developmental disabilities. Such patients are associated with a high risk of complications like deep vein thrombosis (DVT). Here, we report twelve patients (42.9%) with DVT among 28 patients with SMID during prolonged bed rest. However, we did not detect thrombosis in the soleal veins, finding it mostly in the femoral and common femoral veins. We applied anticoagulant therapy (warfarin), and carefully followed up the cases with DVT, regulating the warfarin dosage at prothrombin time-international normalized ratio (PT-INR) values around two to prevent recurrence of chronic thrombosis. Regarding laboratory data for the coagulation system, there were no cases above 5 µg/ml for the D-dimer and there were significant differences between the DVT and non-DVT groups in the D-dimer levels. The plasma levels of D-dimer in patients with DVT diminished to less than 1.0 µg/ml after warfarin treatment. Concerning sudden death (4.2%) in patients with SMID, we have to be very careful of the possibility of pulmonary thromboembolism due to DVT. Therefore, we should consider the particularity of the underdeveloped vascular system from underlying diseases for the evaluation of DVT. A detailed study of DVT as a vascular complication is very important for the smooth medical care of SMID, and serial assessment of compression Doppler ultrasonography of the lower extremities, as a noninvasive examination and measurement of D-dimer, is very helpful. (This article is a translation of Jpn J Phlebol 2014; 25: 34-42.).

Quantitative Evaluation of Abdominal Aortic Aneurysm

Rupture of an abdominal aortic aneurysm (AAA) is usually predicted on the basis of measuring the maximum diameter. However, since the size of a normal aorta varies depending on each individual, this indicator does not seem to be ideal. The authors propose a new indicator for the enlargement of aorta and have started clinical application of this technique. The abdominal aortic diameter was measured by using two-dimensional ultrasonography in 261 adults (aged 20 and over). The control group consisted of subjects with no evident aortic dilatation. Patients with AAA were divided into the nonruptured group and the ruptured group. Analysis of the data from the control group revealed that the abdominal aortic diameter could be defined by the following equation: Diameter (mm) = 0.147 x age (years) + 0.169 x height (cm) - 15.9. The baseline diameters of the abdominal aorta were calculated by applying the age and height of individual subjects in this equation. The measured diameter was divided by the baseline diameter to obtain the aortic expansion index (AEI). If a cut-off value of the aneurysm diameter and the AEI (calculated by using age 20) for the prediction of significant risk of rupture is set at 44.2 mm (= mean - 2SD of the aneurysm diameter in the ruptured group) and at 2.7 (= mean - 2SD of the AEI in the ruptured group), the risk of rupture based on the diameter in the nonruptured group is underestimated in 11% of cases. However, when the risk of rupture is based on the AEI, the risk is not underestimated in any case in the nonruptured group. The authors conclude that the AEI is a useful indicator for quantitatively evaluating the risk of rupture of an AAA.

Age-Related Changes in the Abdominal Aortic Diameter

As yet no clear criteria are available for differentiation of normal from abnormal abdominal aortic diameter in relation to the development of aortic aneurysm. The purpose of this study was to elucidate the age-related changes in the abdominal aortic diameter. A total of 194 individuals (97 men and 97 women) aged twenty years or more with no abnormalities in the abdominal aorta on physical examination were measured by B-mode two-dimensional ultrasonography for the maximum anteroposterior diameter of the abdominal aorta. Results were as follows: 1. A multiple regression analysis demonstrated that the age, height, and body weight were factors influencing the aortic diameter. The most significant factor among them was the age (the partial correlation coefficient was +0.811, P<0.01), and the next was the height (the partial correlation coefficient was +0.453, P < 0.01) . 2. The relationship between the diameter and the height was evaluated by stratification of the subjects at ten-year intervals. The correlation coefficients showed significant positive correlations observed in all age groups (P< 0.001) . 3. The relationship between the diameter and the age was studied according to the height by dividing the subjects into five height groups. The correlation coefficients showed significant positive correlations observed in all height groups (P < 0.001 ) .

Comparison of Three Exercises for Evaluation of the Calf Muscle Pump

Objective: To evaluate accurately the calf muscle pump in patients with venous insufficiency using foot vein pressure measurements during three different exercises. Design: Prospective study in three groups, comparing patients with venous disease with controls. Setting: Second Department of Surgery, Tottori University Faculty of Medicine. Patients: Twenty normal legs, 29 legs previously affected by deep vein thrombosis and 36 legs with primary varicose veins. Main outcome measures: The foot vein pressure was measured during ankle dorsiflexions, knee-bending and walking on the spot at 40 paces per minute during which minimum ambulatory venous pressure (AVP) and venous refilling time (VRT) were assessed. Results: The three groups differed significantly from each other in AVP and VRT after dorsiflexion and in AVP during walking on the spot, but not after knee-bending. Conclusion: Dorsiflexion is the most useful exercise distinguishing various severities of venous insufficiency, but walking on the spot is more useful for accurately evaluating the calf muscle pump.

Exploration of Pulmonary Embolic Sources in the Lower Limbs by Ultrasonography

We demonstrate our method for detecting deep vein thrombosis in the lower limbs, the most frequent source of thrombosis, and we investigate the pathogenesis of critical pulmonary embolic sources. The subjects were 157 patients who underwent either pulmonary perfusion scanning or pulmonary angiography from 1987 to 1998. Unilateral thrombosis was found in 128 cases and bilateral thrombosis in 29. Among them, 42 patients exhibited symptomatic pulmonary embolism: 31 acute and 11 chronic. For exploration of deep vein thrombosis, the duplex with color Doppler was mainly used. Both sitting position and compression technique were necessary to diagnose calf vein thrombosis. Compared with the proximal occlusive levels and the incidence of symptomatic pulmonary embolism, the frequency of symptomatic pulmonary embolism was higher in the femoral vein or soleal vein than in other areas. In particular, most patients with chronic pulmonary embolism had bilateral soleal vein thrombosis. The frequency was significantly higher in bilateral thrombosis than in unilateral thrombosis. The duplex with color Doppler is the first choice of noninvasive testing methods to explore pulmonary embolic sources in the lower limbs. Both femoral vein thrombosis and soleal vein thrombosis are critical pulmonary embolic sources, and bilateral soleal vein thromboses may be a specific embolic source for chronic pulmonary embolism.

Prevalence and Characteristic Features of Deep Venous Thrombosis in Patients with Severe Motor and Intellectual Disabilities

Sudden death associated with patients with severe motor and intellectual disabilities (SMID) have been thought to be caused in part by venous thromboembolism (VTE), but actual situation of VTE in SMID is not clear. We examined the prevalence and location of deep venous thrombosis (DVT), and the relation of the development of crural veins in 16 patients with SMID, using ultrasonography. The maximum diameter of soleal vein was 1.6±0.5 mm. In most cases, DVT was found in the femoral veins. We could not detect thrombus in the soleal veins. In the present study, the detection ratio of DVT was high in patients with SMID who had restricted mobility capability and were bedridden, and we found the veins centrally from popliteal veins in DVT in SMID, not soleal veins, as the initial sites of the DVT. In the literature, the mean diameter of soleal veins, in healthy adults is 6.7±1.8 mm, that in contrast in SMID being smaller. Underdevelopment of intramuscular veins is possibly related to the mechanism of DVT in SMID. In the current guidelines for the management of VTE, there is limited in scope of ambulatory adults and no application cases who exhibit to SMID restricted mobility of the lower extremities and are bedridden associated with cerebral palsy and developmental motor disabilities, and such patients have associated high risk of the complications of DVT. According to our present study, it is necessary to provide appropriate guidelines for DVT in SMID considering characteristic features. (This is a translation of Jpn J Phlebol 2017; 28: 29–34.)

Resection of a cardiac tumor extending into the inferior vena cava presenting as Budd-Chiari syndrome

This report describes the successful treatment of a case of cardiac adenocarcinoma with the clinical presentation as Budd-Chiari syndrome. Complete surgical excision of the atriocaval mass was successfully achieved under deep hypothermic circulatory arrest. Histopathological diagnosis of this tumor was tubular adenocarcinoma with positive immunostaining by carcinoembrionic antigen. Subsequent systemic search could not detect any evidence of extra-cardiac primary site and distant metastatic lesion. A 2-year follow-up without any adjuvant therapy revealed no sign of recurrence.