Clinical Characteristics, Treatment, and Prognosis of Diabetic Foot Disease in Macao and Beijing: A Retrospective Study.

INTRODUCTION: There has been no epidemiological study of diabetes mellitus (DM) in Macao. Also, multidisciplinary treatment is yet to be popularized and complications of DM cannot be managed promptly in this region. Therefore, this study was performed to compare the clinical characteristics, treatment, and prognosis of diabetic foot disease between patients in Macao and Beijing. METHODS: A total of 243 patients with diabetic foot disease were enrolled: 124 from a tertiary hospital in Beijing and 119 from a tertiary hospital in Macao. The clinical profiles were collected and analyzed. RESULTS: The surgical treatment rate in the Beijing group (96.0%) was significantly higher than that in the Macao group (21.0%) (P < 0.05). The overall mortality rate was 14.8%, and cardiac failure was the most common cause (72.2%). Monthly household income and smoking were independent factors affecting the age of onset. Age of diabetes onset was a risk factor for the occurrence of diabetic foot disease; age, duration of diabetic foot disease, and length of smoking history were independent factors affecting the severity of diabetic foot disease. Renal dysfunction and activated partial thromboplastin time were independent factors affecting the survival time of patients with diabetic foot disease. CONCLUSIONS: Smoking may be a risk factor for the occurrence and development of diabetic foot; it can significantly reduce the onset age and aggravate the severity of this disease. The onset age of diabetic foot was lower in high-income patients, and prevention should be encouraged in this population. Elderly age may be associated with a rapidly developing and severe diabetic foot. The clinical course was also associated with the severity of diabetic foot. Renal and coagulation function should be closely monitored during the treatment of diabetic foot.

A national survey on management of varicose veins in China.

OBJECTIVE: This study aimed to investigate the current clinical practice and management strategies for varicose veins among Chinese physicians in general and in specific case vignettes. METHODS: A questionnaire survey was conducted among 726 Chinese physicians who were attending the vascular surgery academic conferences during August 2016 to May 2017 in China. Physicians were eligible if they were familiar with several currently used treatment techniques for varicose veins. RESULTS: A total of 681 physicians from 527 hospitals in 29 provinces across China completed the questionnaire. Of them, 80.0% were vascular surgeons, 13.1% were general surgeons, and 6.9% were interventional radiologists. More than half (67.0%) of them had >5 years of experience in management of varicose veins. A third of the participants performed routine venography for patients with suspected varicose veins. Moreover, 87.5% believed that the patient's medical insurance would influence their choice of treatment modalities. Only 38.5% of the participants' departments could perform day surgery for varicose veins. The most common average hospitalization time was 4 to 7 days, with an average cost of 4000 to 8000 yuan per leg. In the basic case (Clinical, Etiology, Anatomy, and Pathophysiology classification C2,SEpAsPr2,3), 63.8% preferred traditional surgery for great saphenous vein reflux, followed by endovenous laser ablation (24.3%), radiofrequency ablation (5.6%), and ultrasound-guided foam sclerotherapy (3.1%). Physicians in coastal China were more likely to choose endovenous thermal ablation than those from western China (P < .05). In modified case vignettes complicated with hyperpigmentation and lipodermatosclerosis or ulceration, more participants chose traditional surgery for great saphenous vein (73.2% vs 63.8% [P < .001]; 75.9% vs 63.8% [P < .001]) compared with the basic case. Moreover, 31.9% preferred continuation of compression therapy for patients with varicose veins and deep venous reflux, and 65.4% preferred correction of iliac vein compression before treatment of varicose veins. Distributions of management strategies were significantly different between the basic and modified case vignettes (all P < .01). CONCLUSIONS: Both traditional surgery and minimally invasive techniques are used for patients with varicose veins in China, but traditional surgery is the mainstay of treatment for varying degrees of varicose veins. Related clinical factors, duplex ultrasound scan findings, medical insurance, and economy may have influenced the physicians' choice of treatment modality for varicose veins.

Development and evaluation of a new biodegradable vena cava filter in a canine model.

PURPOSE: Preliminary testing of a new biodegradable inferior vena cava filter in a canine model. METHODS: The biodegradable filter consisted of two parts, a filter cone and a stent. The filter cone was constructed of six polyglycolic acid polymer strands anchored to a handmade absorbable stent. Central inferior vena cava fixation was accomplished by the absorbable stent, which was made of polycaprolactone. Device insertion was performed through a 9F sheath under ultrasound guidance on 10 adult beagles. The filters were operatively retrieved at 6 weeks after implantation. The inferior venae cavae were subsequently analyzed grossly and using light microscopy. RESULTS: None of the 10 beagles had abnormal vital signs. All of the 10 filters migrated cephalad approximately <2 cm and remained below the renal vein ostia. One specimen had evidence of incorporated residual strands within the caval wall on gross examination. The caval wall became thickened at the level of filter placement without significant lumen narrowing. There was no evidence of pulmonary embolism caused by degradation products of the absorbable strands. CONCLUSION: Biodegradable inferior vena cava filters are feasible and potentially could be used in specific patients who are at temporary high risk of venous thromboembolism.

Routine Use of Surgical Retrograde Transtibial Endovascular Approach for Failed Attempts at Antegrade Recanalization of Chronic Peripheral Artery Total Occlusions.

PURPOSE: Our aim was to describe the technical aspects and clinical outcomes of an open surgical approach to retrograde transtibial endovascular therapy for recanalization of chronic total occlusions (CTOs) of peripheral arteries because of inability to acquire antegrade intravascular access across the occlusion. MATERIALS AND METHODS: Between January 2011 and May 2014, conventional antegrade revascularization failed in 15 limbs of 15 patients (11 males, 4 females) with complex CTOs. The mean age of the patients was 74 years (range 48-83 years). Five patients had severe claudication (Rutherford Category 3), and 10 patients had critical limb-threatening ischemia (Rutherford Categories 4-5). For each of these cases of antegrade failure, an open surgical exposure of the tibial or dorsalis pedis artery was used to allow a safe retrograde transtibial endovascular approach to recanalize the CTO. RESULTS: Surgical retrograde access from the tibial artery was achieved successfully in 14 of the 15 patients. In the 14 successful retrograde endovascular approaches, surgical retrograde transtibial access was achieved from the dorsalis pedis artery in 8 patients and from the posterior tibial artery in 6. The average time to obtain retrograde access was 5 min (range 2-11 min). No stenosis or occlusion occurred in the tibial or dorsalis pedis arteries used for the retrograde access sites during follow-up. CONCLUSIONS: Routine surgical exposure can be a safe and an effective method for retrograde transtibial access to the more proximal occluded arterial segments in selected patients with CTO.

Preparation and experimental research into retrievable rapamycin- and heparin-coated vena cava filters: a pilot study.

The use of retrievable vena cava filters (RVCFs) was once commonplace, but filter retrieval was often very difficult. Most unsuccessful retrieval was due to intimal hyperplasia of the inferior vena cava and in-filter thrombosis. This pilot study aimed to design a drug-eluting RVCF. The hypothesis was that coated drugs could be released continuously to inhibit vena intimal hyperplasia and thrombosis, and thus improve the retrieval rates of RVCFs. Various concentrations of polycaprolactone (PCL)/chloroform solution were made from a mixture of Rapamycin and Heparin according to the quality of PCL. The drug was coated onto the surface of the filters by a process of dipping. In vitro tests were performed to check stability and in vitro drug release. Animals receiving filter implantation were divided into 4 groups, the experimental intervention group (EI), experimental laparotomy group (EL), control intervention group (CI), and control laparotomy group (CL). Filters were retrieved by laparotomy in the EL and CL groups, and by interventional operation in the EI and CI groups at 10, 20 and 30 days after implantation. Pathological endothelia biopsies were performed with wood grain-eosin (HE) staining and immunohistochemical examination, with the proliferating cell nuclear antigen (PCNA) index, and the results were compared between the experimental and control groups. The weight of thrombus within the filters was also measured by scale and compared. The coating concentration that succeeded in completely covering the surface was 0.2 g/ml. There was better coverage by SEM at this concentration, and the coated drugs had no obvious loss after filter release. The drug release curves showed that the amount of Heparin released was more than 50 % at day 1; Rapamycin released little in the first few days, beginning in earnest at 20 to 30 days. The filters were easy to retrieve at 10 days for both groups, while neither could be retrieved at 30 days. However, at 20 days the filter in the EI group could be retrieved with some difficulty, but the filter in the CI group couldn't be removed at all. The pathological examination and immunohistochemical PCNA examination results showed that the use of drug-eluting filters could effectively inhibit endothelial hyperplasia at 10 and 20 days, but was less effective at 30 days. There was no apparent difference in the total weight of blood clots between the experimental and control groups. We successfully conducted a pilot study into preparing Rapamycin- and Heparin-coated RVCFs. In vitro and in vivo tests further proved the possibility of improving the retrieval rates of RVCFs by effectively inhibiting vein endothelial proliferation, but the anticoagulation and antithrombosis effects of Heparin were unsatisfactory.

[Risk factors associated with the severity of pulmonary embolism in patients with acute deep venous thrombosis of lower extremities].

OBJECTIVE: To identify the risk factors associated with the severity of pulmonary embolism among patients with deep venous thrombosis of lower extremities. METHODS: This prospective study enrolled 208 patients with acute deep venous thrombosis to screen for pulmonary embolism between July 2010 and July 2012 in Beijing Shijitan Hospital. There were 101 male and 107 female patients, with a mean age of (59 ± 16) years. Gender, age, extension, side of lower extremities of deep venous thrombosis was analyzed by χ² test. Ordinal Logistic regression was used to determine risk factors associated with severity of pulmonary embolism. RESULTS: There were 83 patients with iliofemoral deep venous thrombosis, 102 patients with femoropopliteal and 23 patients with calf deep venous thrombosis. Pulmonary embolism was detected in 70 patients with the incidence of 33.7%. Pulmonary embolism was significantly correlated with extension (χ² = 17.286, P = 0.004) and sides (χ² = 15.602, P = 0.008) of deep venous thrombosis, not with age (χ² = 7.099, P = 0.260), gender (χ² = 7.014, P = 0.067), thrombotic risk factors (χ² = 3.335, P = 0.345) in univariate analysis. Results of multivariate ordinal logistic regression showed that iliofemoral vein thrombosis (OR = 6.172, 95% CI: 1.590 to 23.975, P = 0.009) and bilateral venous thrombosis (OR = 7.140, 95% CI: 2.406 to 24.730, P = 0.001) are associated with more serious pulmonary embolism. CONCLUSIONS: Incidence of pulmonary embolism is still high in patients with deep venous thrombosis. Extensive iliofemoral and bilateral vein thrombosis may increase risk of severity of pulmonary embolism. Clinicians should pay more attention to these high-risk patients.

[Recent progress in application of local drug delivery for preventing restenosis after peripheral arterial revascularization].

Restenosis following vascular revascularization remains an important clinical problem. Local drug delivery which can provide enough drug concentration in the lesion location without causing adverse systemic effect is an excellent solution for this question. We conducted a systematic literatory search on PubMed and CKNI through May 2014. After reviewing all related papers, we provided a comprehensive overview of the available drugs and techniques for local drug delivery that have been developed to prevent restenosis after peripheral vascular interventions, including innovations that have been tested only in animals as well as those already approved for clinical use. In brief, anti-proliferative drugs such as paclitaxel and sirolimus are the most used and suitable drugs for local delivery system. Additionally, some promising drugs including anti-inflammatory drugs, antioxidant drugs and drugs inhibiting cell proliferation and migration are already being tested in pre-clinical trials or animal models. At the same time, intraluminal and extraluminal delivery devices have also got a rapid development during the past decades. The efficacy of drug-eluting stent, drug-eluting balloon, porous and microporous balloon and the most recent drug-eluting bioresobable scaffold for preventing of restenosis in peripheral vessels have been demonstrated in humans or in animals, some of them even have received the CE mark in Europe. Endovascular microinfusion catheter and drug-loaded perivascular wraps have only been tested in animal models, more researches are needed. With the development of pharmacology and bioengineering, great strides will be made in the prevention of restenosis in the near future.

[Exercise versus immobilization in the treatment of acute deep vein thrombosis during different clot-organized stage: an animal experiment].

OBJECTIVE: To evaluate the corresponding influence on pulmonary embolism incidence between immobilization and exercise in different stage of thrombus after acute deep vein thrombosis in rabbits. METHODS: Forty-eight New Zealand rabbits were randomly divided into three groups depending on the different organized stage of thrombus: the early, medium and later stage group.Each group was subdivided into two sub groups: the immobile and mobile subgroup. Rabbit modeling of deep vein thrombosis was made by ligating the right femoral vein. Among the early-stage group, rabbits of the immobile subgroup were fixed for 3 days, while that of the mobile subgroup were free to move for 3 days, then each was euthanized to extract the lungs for pathological examination. Among the medium-stage group, each of the immobile subgroup were fixed for 7 days, while the mobile subgroup ones were fixed for 3 days, then released free-moving for 4 days following the pathological extraction. Among the later-stage group, animals in the immobile subgroup were fixed for 14 days comparing the mobile subgroup fixed for 7 days and next free-moving for 7 days, then each was euthanized. RESULTS: Among the early-stage group, pulmonary embolism incidence (PEI) of the immobile and mobile subgroup was 4/8 vs.3/8, the pulmonary lobe embolism incidence (PLEI) was 17.5% (7/40) vs. 15.0% (6/40). Among the medium-stage group, PEI of the immobile and mobile subgroup was 3/8 vs. 2/8, PLEI was 37.5% (7/40) vs. 25.0% (10/40). Among the later-stage group, PEI of the immobile and mobile subgroup was 3/8 vs. 3/8, PLEI was 12.5% (5/40) vs. 15.0% (6/40). There was no statistical difference between immobilization subgroup and mobilization subgroup among different stage group. CONCLUSION: On the premise of given anticoagulation treatment, early ambulation do not significantly increase pulmonary embolism incidence after acute deep vein thrombosis of lower extremity in rabbits.

Catheter-directed thrombolysis-assisted angioplasty for chronic lower limb ischemia.

BACKGROUND: Thrombolysis is an appropriate treatment for acute arterial occlusion. There remains controversy as to whether thrombolysis before angioplasty helps to identify the underlying lesion and improve results for chronic ischemia of the lower extremity. We sought to investigate the feasibility of catheter-directed thrombolysis-assisted angioplasty for chronic lower limb ischemia. METHODS: Between July 2008 and December 2009, the data of patients with chronic lower limb ischemia undergoing catheter-directed thrombolysis-assisted angioplasty were retrospectively analyzed. RESULTS: Twenty consecutive patients (18 men with a mean age of 56.35 ± 8.5 years) underwent thrombolysis-assisted angioplasty for occlusion of a native artery (n = 18) or bypass graft (n = 2). The median duration of symptoms was 19 months (range: 3-48 months). Symptoms included disabling claudication in 12 patients, rest pain in 5 patients, and gangrene of the toes in 3 patients. Urokinase or recombinant tissue plasminogen activator as a thrombolytic agent was used before angioplasty. The mean length of occlusive lesions decreased significantly from 150 mm to 30 mm after thrombolysis (P < 0.01). Four patients had no change in their lesions. Improvement of Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II) classification was achieved in 16 patients, with 14 TASC IIA lesions and 2 TASC IIB lesions after thrombolysis. Subsequent stenting was successfully performed in all patients. The ankle-brachial index increased significantly from 0.33 to 0.63 (P < 0.01). No perioperative deaths occurred. Morbidity included access site bleeding in 1 patient and distal embolization in 2 patients without further intervention. The primary patency rate at 1 year was 95%, with a median follow-up time of 19 months. CONCLUSIONS: Catheter-directed thrombolysis-assisted angioplasty is a safe and effective treatment in some patients with chronic lower limb ischemia. It may reduce the magnitude of the lesion and simplify the expected intervention procedures.

A prospective randomized controlled clinical trial on clopidogrel combined with warfarin versus clopidogrel alone in the prevention of restenosis after endovascular treatment of the femoropopliteal artery.

BACKGROUND: We sought to compare the effects of clopidogrel combined with warfarin with clopidogrel alone in the prevention of restenosis after endovascular treatment (EVT) of the femoropopliteal artery. METHODS: Between June 2008 and May 2009, 88 consecutive patients referred for EVT were randomly divided into a clopidogrel group (42 cases) and a clopidogrel combined with warfarin group (46 cases) before the procedure. Examinations including staging of peripheral arterial disease by Rutherford, ankle-brachial index, and color duplex ultrasonography were performed at baseline, 1 week, 3 months, 6 months, and 12 months after procedure. At the same time, bleeding complications were observed. RESULTS: Fifty patients (63 limbs) were included after 12 months of follow-up, in which 25 patients (30 limbs) were from the clopidogrel group and 25 patients (33 limbs) were from the combination group. At 3 months, the rates of restenosis on duplex ultrasonography were 17% in the clopidogrel group and 18% in the combination group (P = 1.0). At 6 months, the accumulated restenosis rates were 37% and 36% (P = 0.98), respectively. At 12 months, the accumulated restenosis rates were 53% and 42% (P = 0.523), respectively. The rate of clinical bleeding events was 21% (6/29) in the combination group compared with 7% (2/27) in the clopidogrel group, and there was no statistical difference (P = 0.3). CONCLUSIONS: The combination of clopidogrel with warfarin was not more effective than clopidogrel alone in restenosis prevention for patients who underwent EVT. Instead, the combination of antiplatelet and anticoagulation therapy was inclined to increase the clinical bleeding events.

Endovascular repair of an infected ruptured isolated iliac artery aneurysm combined with congenital lymphedema: report of a case.

PURPOSE: A novel technique using the reversed iliac leg of a Zenith device has been reported. This study reports a complicated isolated iliac artery aneurysm (IIAA) using this novel technique and reviews the relative literature to discuss current treatment modalities. CASE REPORT: A 46-year-old man presented with a mass in the left lower quadrant accompanied by abdominal pain for 60 days. Computer tomography angiography (CTA) revealed a complicated IIAA and a massive retroperitoneal hematoma. Percutaneous puncture and drainage at the hematoma was done. Enterococcus faecium was isolated from the hematoma. The infection was controlled after 2 weeks of drainage and anti-infection treatment. The IIAAs were successfully excluded using the novel technique. The 12-month CTA follow-up was unremarkable. CONCLUSION: Using inverted Zenith device legs is safe and effective even in complicated IIAAs. Further studies are warranted before it can become a widely acceptable definitive treatment option.

[A prospective randomized control clinical trial about clopidogrel combined with warfarin versus clopidogrel alone in the prevention of restenosis after femoral-popliteal artery angioplasty].

OBJECTIVE: Using two antithrombotic treatment (clopidogrel vs. clopidogrel combined warfarin) strategies after femoral-popliteal artery angioplasty prospectively, to evaluate which strategy is more effective for the restenosis prevention. METHODS: Totally 50 patients referred for endovascular treatment (including the percutaneous transluminal angioplasty (PTA) and stent implantation) of the superficial femoral artery and popliteal artery from January 2008 to May 2009 were randomly divided into clopidogrel group (group A, 25 cases, 30 limbs) and clopidogrel plus warfarin group (group B, 25 cases, 33 limbs) before operation. Clinical outcomes and restenosis rate of the target lesions were evaluated at 3, 6 and 12 months after operation. RESULTS: Totally 88 patients were screened for participation in the study, 56 patients were included after the follow-up of 12 months. At 3 months, the rates of restenosis were 16.7% in group A and 18.2% in group B (χ² = 0.025, P = 0.874). At 6 months, the accumulated restenosis rates were 36.7% in group A and 36.4% in group B (χ² = 0.001, P = 0.98). At 12 months, the accumulated restenosis rates were 53.3% in group A and 42.4% in group B (χ² = 0.75, P = 0.387). Analysis for the critical limb ischemia sub-group showed that follow-up of 12 months, the accumulated restenosis rate was 8/10 in group A and 6/12 in group B (χ² = 1.023, P = 0.312). CONCLUSION: The clopidogrel alone treatment for PTA or PTA plus stent implantation of femoral popliteal artery has no statistically significant difference in comparison with the clopidogrel combined warfarin treatment in terms of the cumulative vascular restenosis rate at 3, 6, 12 months postoperatively.

Effect of hydrogen sulfide on restenosis of peripheral arteries after angioplasty.

Peripheral artery disease (PAD) may lead to a poor quality of life. Although percutaneous transluminal angioplasty (PTA) is widely used for the treatment of PAD, restenosis remains a major drawback. Hydrogen sulfide (H2S) plays potential roles in many physiological processes, such as vasodilatation and inhibition of smooth muscle cell proliferation. However, little is known regarding its role in arterial restenosis. In this study, we induced atherosclerotic-like lesions in rabbits, and we treated the rabbits with balloon angioplasty (BA) in a similar manner as PTA performed in the clinic. The rabbits were treated with sodium hydrosulfide (NaHS, a donor of H2S) or DL-propargylglycine (PPG, an inhibitor of H2S synthase). Treatment with NaHS significantly inhibited arterial restenosis following BA by reducing the intimal area and the intima/media ratio, while PPG treatment had a tendency to result in more severe restenosis. NaHS treatment significantly reduced smooth muscle cell (SMC) proliferation and elevated SMC apoptosis in the neointima. In contrast, PPG induced a significant increase in SMC proliferation. In conclusion, H2S attenuates the progression of neointimal hyperplasia and inhibits restenosis after BA. This discovery may lead to potential novel therapies, which can improve the prognosis of PAD patients.

Analysis of serum enzyme levels in a rabbit model of acute mesenteric ischemia.

Early diagnosis of acute mesenteric ischemia (AMI) remains very difficult, partly due to the fact that useful markers of early small bowel ischemia have not yet been identified. Thus, in this study, we aimed to evaluate the levels of serum intracellular enzymes in the tissues and organs in a controlled animal model of mesenteric intestinal ischemia. Forty-eight New Zealand rabbits were divided into 4 groups including the control, artery ligation, vein ligation, and both artery and vein ligation groups. Plasma samples were obtained at 0-, 1-, 3-, 6- and 9-h time-points and enzyme levels were determined. The bowel color and vitality were observed at the same time. The bowel showed an appearance of infarction after a period of ischemia in the animals. Six and 9 h after superior mesenteric artery ischemia, alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels increased significantly. However, after 3 h of superior mesenteric venous (SMV) ligation, γ-glutamyl transpeptidase levels in the blood were considerably higher compared to the control group. Six hours after SMV ischemia, ALT, AST, alkaline phosphatase and lactate dehydrogenase levels were significantly elevated compared to those pre-ligation. Serum enzyme levels during intestinal ischemia are not able to provide sufficient information as regards the extent and reversibility of intestinal ischemia, although, they may be able to reflect the presence of injury.