Serious Adverse Events with Cyanoacrylate Closure of Varicose Veins: An Initial Report from a Large-Scale National Survey in Japan.

Objective: Cyanoacrylate closure (CAC) is a minimally invasive technique for the treatment of varicose veins. A recent paper reported serious adverse events (AEs) associated with this use. This triggered an urgent survey to determine the incidence of AEs in Japan. Methods: The CAC-AE survey was sent to all 1,030 institutions authorized for CAC treatments. Cases performed between January 2020 and October 2023 were surveyed. Data on serious AEs and mortality were collected. Results: There were 623 surveys returned. There were 16 cases of proximal deep vein thrombosis, 3 cases of pulmonary embolism (PE), and 0 cases of stroke. Deep vein occlusion due to cyanoacrylate extension was observed in 1 case. Vein resection due to infection was observed in 4 cases. There were 299 cases of localized phlebitis and/or allergic reactions requiring steroid administration. Systemic allergic reactions requiring steroid administration were observed in 66 cases. There was no anaphylaxis associated with cyanoacrylate. There was one postoperative death from PE. Conclusion: This report's intent is to provide real world data on serious AEs following CAC from Japan given current concern over these events. An extensive report investigation of individual complications with analysis including causality will be provided following a full investigation separately.

Clinical Results 5 Years after Great Saphenous Vein Stripping.

Background: As a standard treatment for the varicose vein of the great saphenous vein (GSV) type, endovenous ablation (EVA) is the main approach. However, as a background to this, in Europe and the United States, neovascularization (Neo) following high ligation (HL) of the saphenofemoral junction (SFJ) at the time of GSV stripping has been emphasized as one of the reasons for the high rate of recurrence. However, in Japan, almost no similar mid- or long-term results of GSV stripping have been reported. Patients and Methods: From September 2011 to March 2014 when EVA was not my surgical option, 413 consecutive legs of patients underwent GSV stripping by myself using the same procedure. The patients were contacted by phone 5 years later, and recurrent varices after surgery (REVAS) and reoperation (REDO) were investigated. A total of 270 legs of the 391 living cases (69%) underwent venous ultrasonography (VUS). HL of the SFJ was performed via central flash ligation with towing and pulling out of the peripheral side branches containing the accessory saphenous veins. In principle, GSV stripping was performed using the invagination method in the range of the entire reflux region from the HL cut section to the confluent section of the side branch causing branch varicose veins. The range of stripping was to the upper thigh in 3 legs, to the middle thigh in 3 legs, to the lower thigh in 7 legs, to the knee in 46 legs, to the upper calve in 83 legs, to the middle calve in 52 legs, and over the full length in 76 legs. Stab avulsion was performed as much as possible for the side-branch varices. On VUS, the SFJ's stump of GSV, the presence of side-branch remnants and their reflux, the presence or absence of Neo, and the recurrent lesions in other sites were evaluated. REVAS were classified as follows: Level 1, symptomatic recurrent lesion for which surgery is indicated; Level 2, asymptomatic recurrent lesion possibly requiring future surgery; and Level 3, asymptomatic recurrent lesion that is unlikely to require future surgery. Results: Of the 391 legs of patients who could be contacted, REDO was performed in 23 (6%), including 15 limbs, immediately after this investigation, and symptomatic REVAS were observed in 29 (7%). In 270 legs examined by VUS, REVAS were diagnosed as follows: 29 legs with Level 1 lesion, 40 legs with Level 2 lesion, and 27 legs with Level 3 lesion. Level 1 REVAS that occurred at the SFJ were observed only in 3 legs (1.1%), Level 1 REVAS due to incompetent perforating veins (IPVs) were observed in 14 legs (5%), and Level 1 solitary tributary varices were observed in 9 legs (3%). Conclusion: In this study, REVAS at the SFJ were significantly less than those in the past reports. It has been shown that REVAS due to IPVs or solitary tributary varices were more important than those at the SFJ. (This is a translation of Jpn J Phlebol 2019; 30(3): 259-265.).

Surgery for Varicose Veins Caused by Atypical Incompetent Perforating Veins.

Objective: To clarify the localization of and surgery for atypical incompetent perforating veins (IPVs) other than Dodd, Boyd, Cockett perforators, which have not been previously discussed. Methods: Forty-three atypical IPVs, diagnosed by venous ultrasonography and treated surgically from January 2014 to June 2018, were analyzed from the viewpoint of localization and surgical treatment. Results: All atypical IPVs passed through the fascia in the area between the muscle compartments in the same way as the typical IPV. The IPVs were most commonly located in the posterolateral part of the lower thigh (16), around the popliteal fossa (9), and in the posterolateral part in the lower calf (7). For 42 IPVs, surgery consisted of direct ligation and resection at the fascia level, and foam sclerotherapy was performed for 1 IPV. The blood flow of the perforating vein was blocked under the fascia in 40 IPVs, but to and fro flow at the fascia level remained in 3 IPVs. Conclusion: Atypical IPVs causing varicose veins were most common in the posterolateral part of the lower thigh. For treatment, it is important to ligate and cut them without leaving stumps with related branches outside the fascia under precise ultrasonic observation. (This is a translation of Jpn J Vasc Surg 2018; 27: 461-466.).

Surgical methods and clinical results of subfascial endoscopic perforator surgery in Japan.

OBJECTIVES: To clarify the surgical methods and the clinical results of subfascial endoscopic perforator surgery in Japan. METHODS: This study included 1287 limbs of 1091 patients who underwent subfascial endoscopic perforator surgery in 14 hospitals. Simultaneous saphenous vein treatment was performed in 1079 limbs (83.8%), and 118 limbs (9.2%) had deep venous lesions. The venous clinical severity score was calculated before and 6 to 12 months after surgery. The ulcer healing rate and ulcer recurrence rate were calculated cumulatively. RESULTS: Preoperative venous clinical severity score was significantly decreased from 10.0 ± 6.6 to 3.1 ± 3.4 ( P < .0001) postoperatively. The primary ulcer healing rate was 96.2% (332/345 C6 limbs) at an average follow-up of 47.7 months, and the ulcer recurrence rate was 12.0% (49/393 C5, C6 limbs) at the average follow-up of 46.0 months after the ulcer healed. CONCLUSION: These results indicate that subfascial endoscopic perforator surgery is an alternative to improve the long-lasting disease severity and/or clinical outcome.

[Effectiveness of perioperative administration of eltrombopag in a patient with idiopathic thrombocytopenic purpura undergoing cardiovascular surgery].

We report a case of chronic aortic dissection and angina pectoris with idiopathic thrombocytopenic purpura treated perioperatively with eltrombopag. A 72-year-old man was admitted to our hospital because of significant enlargement of an ulcer-like projection in the thoracic aorta revealed by chest computed tomography after acute aortic dissection. Laboratory data showed thrombocytopenia with idiopathic thrombocytopenic purpura. Eltrombopag was administered 12.5 mg daily and increased by 12.5 mg every 2 weeks until 37.5 mg/day to control idiopathic thrombocytopenic purpura(ITP). After 7 weeks' eltrombopag therapy, thrombocyte increased, and the patient underwent total arch replacement. Nine months later, coronary angiography revealed progression of coronary artery stenosis at the left main trunk. The patient underwent off-pump coronary artery bypass grafting 10 days after initiation of eltrombopag therapy. His postoperative course was uneventful. Eltrombopag was suggested to be effective in perioperative management in a patient with idiopathic thrombocytopenic purpura undergoing cardiovascular surgery.

Subfascial endoscopic perforator surgery for posterolateral perforators performed in the prone position.

OBJECTIVES: Subfascial endoscopic perforator surgery (SEPS) is usually performed for posteromedial perforators in the supine position, but subfascial endoscopic perforator surgery for posterolateral perforators in the prone position has not been reported. METHODS: A 51-year-old male suffered from a venous stasis ulcer around his lateral malleolus because of reflux in the small saphenous vein and incompetent perforating veins around the ulcer. RESULTS: Stripping of the small saphenous vein and subfascial endoscopic perforator surgery utilizing screw-type ports was successfully conducted in the prone position. CONCLUSIONS: The prone position enables interruption of the posterolateral perforators, because gravity-dependent flattening of the muscles enables creation of sufficient subfascial space.

[Successful resection of lung cancer with idiopathic pulmonary fibrosis treated by pirfenidone during perioperative period].

We report a case of lung cancer treated with pirfenidone as preoperative therapy before subsequent successful surgical resection. A 76-year-old man was admitted to our hospital because of abnormal shadows and diffuse reticular shadow in bilateral lung on chest computed tomography(CT). CT-guided percutaneous lung biopsy confirmed suquamous cell carcinoma for both lung. Pulmonary reticular shadow was diagnosed as idiopathic pulmonary fibrosis (IPF) clinically and the pirfenidone was administered 600 mg daily and increased by 600 mg for every week until 1,800 mg/day to control IPF. After 3 weeks pirfenidone therapy, Krebs von den Lungen( KL)-6, pulmonary surfactant( SP)-D and lactate dehydrogenase (LDH) decreased, and the patient underwent wedge resection. His postoperative course was uneventful.

[Lung cancer occurring in a left upper division which is mirror imaged to a right upper lobe].

A 55-year-old man was admitted to our hospital because of an abnormal shadow in the left upper division on chest computed tomography(CT). Virtual bronchoscopy revealed a displaced anomalous bronchus. Thin sliced CT revealed complete lobulation between the upper division and the lingula. Three dimensional (3D)-CT revealed abnormal distribution of the left pulmonary artery which descended without passing over the left main bronchus. The left upper division was evaluated to be mirror imaged to a right upper lobe. Video assisted thoracoscopic left upper divisionectomy was performed. The tumor was diagnosed as adenocarcinoma( pT1aN0M0:p-stage I A).

Subfascial endoscopic perforator surgery using screw-type ports is a very useful component of a comprehensive treatment program for chronic venous insufficiency.

BACKGROUND: Subfascial endoscopic perforator surgery (SEPS) with a two-port system utilizing screw-type ports, CO2 insufflation and an ultrasonic coagulation system, is a useful procedure that does not require burdensome apparatus and techniques. SEPS was accepted as a national advanced medical system by the Japanese Ministry of Health, Labor and Welfare in May 2009. PATIENTS AND METHODS: Forty-one limbs of 35 patients with 10 active ulcers (C6) and 2 healed ulcers (C5) were treated by SEPS between February 2010 and December 2011. Thirty-three limbs had concomitant superficial vein surgery. SEPS alone was performed on 8 limbs, in 6 of which the superficial veins had already been ablated. In 2 limbs, incompetent perforating veins (IPVs) existed under the affected skin, around the scars of past surgery. RESULTS: All stasis ulcers of the 10 C6 limbs healed between 1 week and 14 months after SEPS (mean 2.9 months), with no ulcer recurrence during the follow-up period (2 to 24 months). IPVs under the scars were easily and safely interrupted by SEPS. CONCLUSION: SEPS is a very useful component of a comprehensive treatment program for chronic venous insufficiency, especially in patients with venous stasis ulcers and IPVs under the scars of past surgery.

Bronchopulmonary foregut malformation.

Bronchopulmonary foregut malformation (BPFM) is a rare anomaly of accessory pulmonary tissue that usually arises from esophagus or stomach. We present a case of extralobar pulmonary sequestration (ELS) connecting with the esophagus by a cyst, the inner wall of which is lined with squamous epithelium or respiratory epithelium. BPFM is sometimes used to group a number of ventral anomalies of accessory pulmonary tissue. The term currently refers specifically to those lesions composed of sequestrations that retain communication with the gastrointestinal tract. Usually the communication is a well-formed muscular tube lined with stratified squamous or columnar epithelium. The presence of both epithelia in a communication that is a component of the BPFM suggests embryogenesis. We describe an adult with BPFM composed of ELS and a connecting stalk to the esophagus by a foregut cyst that contains both squamous epithelium and respiratory epithelium.

[Cavernous hemangioma of the superior mediastinum; report of a case].

A 44-year-old female was admitted with an abnormal left mediastinal shadow on chest roentgenography. Computed tomography (CT) revealed a mass lesion in the left superior mediastinum, which was not enhanced with contrast medium. Magnetic resonance imaging demonstrated equal signal intensity to that of the muscle on T1 weighted images, and higher signal intensity on T2 weighted images. As a cystic mediastinal tumor was suspected preoperatively, thoracoscopic excision was performed. The tumor was diagnosed as a cavernous hemangioma by pathology. A preoperative diagnosis is difficult because of a variable feature of image study. When the diagnosis of the cystic tumor of mediastinum is made, the diagnosis of mediastinal hemangioma should be kept in mind.

Successful surgical treatment of Takayasu's arteritis associated with pyoderma gangrenosum.

Pyoderma gangrenosum is rarely associated with Takayasu's arteritis. We report the successful surgical treatment of a 34-year-old woman who was diagnosed with pyoderma gangrenosum associated with thoracic aortic aneurysm and dissection due to Takayasu's arteritis. She underwent graft replacement of the thoracic aortic aneurysm under cardiopulmonary bypass, with perioperative management using prednisolone and cyclosporine A. She has had no evidence of the development of skin lesions or the progression of Takayasu's arteritis.

Changes in false lumen after transluminal stent-graft placement in aortic dissections: six years' experience.

BACKGROUND: Transluminal stent-graft placements (TSGPs) are a new, less invasive procedure now recognized as the choice for aortic disease repair. Treatment of aortic dissections with TSGPs has resulted in good early results, but the long-term results and changes in the false lumen have not been elucidated in detail. METHODS AND RESULTS: TSGPs were performed in 49 patients with primary tears in their descending aortas, and the follow-up period ranged from 4 months to 6 years. The patients were divided into 32 acute-onset and 17 chronic dissections; of the acute-onset cases, there were 15 Stanford type A retrograde dissections. Periodic enhanced spiral CT was conducted after TSGP. The false lumen in the ascending aorta in 14 (93%) of the Stanford type A cases was obliterated completely within 3 months. The CT study was continued for >2 years for 17 acute-onset dissection and 11 chronic dissection patients. The average false lumen diameters of the proximal, middle, and distal descending aorta before treatment were 15.9, 16.2, and 15.6 mm in the acute-onset dissection group and 28.1, 25.2, and 21.0 mm in the chronic dissection group, respectively. The false lumen diameters 2 years after treatment were 3.0, 3.7, and 3.1 mm in the acute-onset dissection group and 10.6, 10.5, and 11.9 mm in the chronic dissection group, respectively. Two years after TSGPs, the false lumen of the thoracic aorta totally disappeared in 76% of the acute-onset dissection group and 36% of the chronic dissection group. No cases showed rupture after TSGP. CONCLUSIONS: Complete obliteration of the false lumen is more likely in acute-onset cases than in chronic cases.

Surgical repair of a pseudoaneurysm derived from a nine-year-old saphenous vein graft after coronary artery bypass.

A 57-year-old male presented intermittent pain between the left shoulder and neck. He had undergone coronary artery bypass twice and all grafts had been confirmed to be angiographically intact at three and a half years prior. Coronary angiography revealed that a pseudoaneurysm derived from around the proximal ascending aortic anastomosis of the saphenous vein graft that connected to the left anterior descending branch and #4-atrioventricular branch sequentially. The pseudoaneurysm compressed the saphenous vein graft itself. He underwent repair of the pseudoaneurysm through median sternotomy after left subclavian artery-saphenous vein graft bypass utilizing a free left radial artery without cardiopulmonary bypass through left anterolateral thoracotomy. A 7 mm length longitudinal tear in the saphenous vein graft near the proximal anastomosis had caused the pseudoaneurysm. This tear had likely been caused by perforation by a catheter during coronary arteriography three and a half years ago.