We report a very rare case of placement of a superior vena caval (SVC) filter for upper extremity deep venous thrombosis. A 67-year-old woman with left axillary pain was admitted. Lower extremity deep venous thrombosis was diagnosed. CT scan and venography revealed acute thrombosis of the left brachial, axillary, subclavian, common jugular and innominate veins. We performed thrombolytic therapy and placement of a temporary filter within the SVC, because CT scan and a ventilation-perfusion scan revealed pulmonary embolism. After one week, due to lack of improvement, we placed a Greenfield filter within the SVC. It is necessary to place a SVC filter in high risk patients if anticoagulation therapy fails or if there is recurrence, proximal/wide range thrombosis, or pulmonary embolism.

Two cases of blue toe syndrome were effectively treated by PGE1. Case 1 was an 80-year-old man who had an ulcer lesion of the 5th toe. Angiography indicated the symptoms were caused by microemboli from an extended lesion of the aorta and iliac artery. The wound was healed by lipo PGE1 (10μg×30 days). Case 2 was a 54-year-old man who had dull pain and skin color change of the 3rd and 4th fingers. A thrombus could not be detected by transthoracic echocardiography, but was found by transesophageal echocardiography. The symptoms improved by PGE1 (60μg×20days). Blue toe syndrome is induced by a microembolism in the peripheral arteries, and thus the conventional treatment has been the administration of fibrinolysins and anticoagulants. PGE1 was used in this study for the first time in consideration of its vasodilating effect on the collateral circulation and to prevent a secondary thrombus by inhibiting platelet aggregation.

Between 1988 and 1992, we experienced 4 cases of removal of renal or hepatic cell carcinoma tumor thrombi extending into the inferior vena cava and the right atrium, under cardiopulmonary bypass. We operated on 3 cases using profound hypothermia and circulatory arrest, and 1 case using moderate hypothermia and the Pringle maneuver. One case developed acute massive pulmonary embolism followed by cardiac arrest during the procedure of freeing the inferior vena cava and died on the second postoperative day due to low output syndrome. The postoperative courses of the other 3 cases were uneventful, and there was no major complication due to surgery. They were discharged and enjoyed normal daily lives. Two cases died due to recurrence of the tumor, 6 and 7 months after the operation, respectively. The merits and demerits of these two surgical methods were discussed. Appropriate selection of these methods and subjects allows safe and complete excision of tumor thrombi with satisfactory operative results.

Twelve cases of ruptured abdominal aortic aneurysm (RAAA) were treated during 5 years. Nine showed severe hypotension (systolic pressure below 70mmHg) and three required cardiac massage prior to operation. At the beginning of this study, direct laparotomy was conducted on 4 cases but mortality was high mortality (75%). Left thoracotomy with antero-lateral incision through the 7th intercostal space was carried out to access the thoracic aorta for clamping before laparotomy, since the major mortality of this disease is due to abrupt bleeding following anesthesia and operation. Left thoracotomy before laparotomy was conducted on 8 cases, half of whom required aortic clamping during operation (clamping time 21min). Operative mortality following thoracotomy decreased (12.5%). The aneurysm size and the time of operation for the groups with or without thoracotomy were the same, though the degree of bleeding significantly differed (3, 925ml in the group with thoracotomy, 7, 193ml in the group without thoracotomy). Left thoracotomy befor laparotomy obtained good results in case of RAAA.

Patients who underwent the bypass operation during 5 years from 1987 to 1992 in the 1st Department of Surgery, Hiroshima University School of Medicine, were divided into 2 groups; AIOD group (51 cases) had lesions in the aorta and iliac artery, and FPOD group (46 cases) had lesions in the femoral artery and popliteal artery. A comparative study of these two groups was made. There was no significant difference in age, sex, symptom severity, smoking history, serum cholesterol level, serum triglyceride level. The complication rate of peripheral lesions of the AIOD group was 24% and of the FPOD group was 57%. The cumulative patency rate for 5 years of the AIDO group was 100% and of the FPOD group was 61%. The AIOD group exhibited better patency. In addition to the lower complication rate of peripheral lesions, all the AIOD group had underwent reconstruction operation for peripheral lesions simultaneously. The run-off state of the peripheral region may thus possibly be related to patency.

Fifty-one cases which underwent surgery for arteriosclerosis obliterans in the aorta and iliac artery at the First Department of Surgery, Hiroshima University School of Medicine were divided into two groups. The EAB group (18 cases) underwent extra-anatomic bypass operation, and the AB group (33 cases) underwent anatomic bypass operation. A comparative study showed the mean age of the EAB group to be 10 years higher than that of the AB group, and the former group exhibited severer symptoms. Renal and pulmonary function declined in the EAB group, and the occurrence rate of complications such as cerebral infarction was also higher At operation, the following approaches were employed; long-term administration of PGE-1 before and after operation, operation with a better visual field under light general anesthesia, simultaneous reconstructive operation in peripheral lesions, artificial vessels of externally supported velour knitted Dacron. There was no case of obstruction in the past 5 years. Extra-anatomic bypass operation therefore provides as good postoperative patency as anatomic operation.

A 74-year-old man presented with swelling in both lower limbs and fatigue. Venography indicated nozzle-like stenosis of the inferior vena cava that appeared during the inspiratory phase but disappeared during the expiratory phase. A large pressure gradient between the upper and lower portion of the stenosis was observed during the expiratory phase. Stenosis during the inspiratory phase was relieved by percutaneous transluminal angioplasty, and symptoms and signs disappeared. Although stenosis occurred only during the inspiratory phase, our patient exhibited symptoms characteristic of Budd-Chiari syndrome. We believe that this patient originally had stenosis of the diaphragmatic portion of the inferior vena cava, and that his symptoms derived from the formation of a parietal thrombus.