Transbrachial Artery as Single or Combined Approach for Complex Interventions in Patients with Peripheral Artery Disease.

BACKGROUND: This study aimed to assess the safety and efficacy of the transbrachial approach as a single or combined procedure for complex interventions in peripheral artery disease (PAD). METHODS: Between March 2011 and April 2021, 169 patients with PAD underwent endovascular therapy via the transbrachial approach as a single or dual procedure. Univariate and multivariate analyses were performed to evaluate the predictors of adverse events at the brachial puncture site. All demographic, clinical, and perioperative data were acquired from electronic medical records and retrospectively analyzed. RESULTS: Brachial artery access was used alone and in combination in 87 and 82 patients, respectively. Patients in the combined-approach group underwent more intraoperative stent implantations and had more vascular closure devices (VCD). Multivariate logistic regression analysis revealed that hypertension was an independent factor for higher rates of brachial puncture site adverse events (odds ratio, 4.76; 95% confidence interval, 1.33-16.97; P = 0.016). Brachial artery access-site complications occurred in 26 patients, including 6 (23.1%) major and 20 (76.9%) minor entry-site complications. Entry-site complications were observed in 21 (16.8%) and 5 (11.4%) patients assigned to manual compression and VCD groups, respectively. There were no significant intergroup differences in the incidence of major or minor complications. Interestingly, patients assigned to the VCD group did not experience major entry-site complications. CONCLUSIONS: The transbrachial approach, as a single or combined procedure, is a safe alternative to complex interventions in patients with PAD. Complications of brachial access progressively decrease with improved blood pressure control.

A Novel Endovascular Robotic System for Treatment of Lower Extremity Peripheral Arterial Disease: First-in-Human Experience.

BACKGROUND: To assess the feasibility and first-in-human experience of a novel endovascular robotic system for treatment of lower extremity peripheral arterial disease (PAD). METHODS: Between November 2021 and January 2022, consecutive patients with obstructive lower extremity PAD and claudication (Rutherford 2-5) with >50% stenosis demonstrated on angiography were enrolled in this study. Lower extremity peripheral arterial intervention was performed using the endovascular robotic system, which consisted of a bedside unit and an interventional console. The primary endpoints were technical success, defined as the successful manipulation of the lower extremity peripheral arterial devices using the robotic system, and safety. The secondary endpoints were clinical success, defined as 50% residual stenosis at the completion of the robot-assisted procedure without major adverse cardiac events and radiation exposure. RESULTS: In total, 5 patients with PAD were enrolled in this study (69.2±6.0 years; 80% men). The novel endovascular robotic system successfully completed the entire procedure of endovascular treatment of lower extremity PAD. Conversion to manual operation, including advancement, retracement, rotation of the guidewires, catheters, sheaths, deployment, and release of the balloons and stent grafts, was not necessary. We achieved the criteria for clinical procedural and technical success in all patients. No deaths, myocardial infarctions, or ruptures occurred in the period up to 30 days after the procedure, and no device-related complications were observed. The robotic system operator had 97.6% less radiation exposure than that at the procedure table, with a mean of 1.40±0.49 µGy. CONCLUSIONS: This study demonstrated the safety and feasibility of the robotic system. The procedure reached technical and clinical performance metrics and resulted in significantly lower radiation exposure to the operators at the console compared with that at the procedure table. CLINICAL IMPACT: There were some reports about several robotic systems used in the peripheral arterial disease, but no robotic system was able to perform entire procedure of endovascular treatment of lower extremity peripheral arterial disease (PAD).To solve this problem, we designed a remote-control novel endovascular robotic system. It was the first robotic system that can perform entire procedure of endovascular treatment of PAD worldwide. A novelty retrieval report about this is provided in the supplementary materials.The robotic system is compatible with all commercial endovascular surgical devices currently available in the market, including guidewires, catheters and stent delivery systems. It can perform all types of motion, such as forward, backward, and rotation to meet the requirements of all types of endovascular procedures. During the operation, the robotic system can perform these operations in a fine-tuned manner, so it is easy to cross the lesions, which is the key factor influencing the success rate of the operation. In addition, the robotic system can effectively reduce the exposure time to radiation, thereby reducing the risk of occupational injury.

Consensus on the application of negative pressure wound therapy of diabetic foot wounds.

Because China is becoming an aging society, the incidence of diabetes and diabetic foot have been increasing. Diabetic foot has become one of the main health-related killers due to its high disability and mortality rates. Negative pressure wound therapy (NPWT) is one of the most effective techniques for the treatment of diabetic foot wounds and great progress, both in terms of research and its clinical application, has been made in the last 20 years of its development. However, due to the complex pathogenesis and management of diabetic foot, irregular application of NPWT often leads to complications, such as infection, bleeding and necrosis, that seriously affect its treatment outcomes. In 2020, under the leadership of Burns, Trauma and Tissue Repair Committee of the Cross-Straits Medicine Exchange Association, the writing group for 'Consensus on the application of negative pressure wound therapy of diabetic foot wounds' was established with the participation of scholars from the specialized areas of burns, endocrinology, vascular surgery, orthopedics and wound repair. Drawing on evidence-based practice suggested by the latest clinical research, this consensus proposes the best clinical practice guidelines for the application and prognostic evaluation of NPWT for diabetic foot. The consensus aims to support the formation of standardized treatment schemes that clinicians can refer to when treating cases of diabetic foot.

Endovascular Repair of Aortic Dissection Involving the Left Subclavian Artery by Castor Stent Graft: A Multicentre Prospective Trial.

OBJECTIVE: The left subclavian artery (LSA) origin can be intentionally covered by stent grafts, to provide adequate proximal landing zones during thoracic endovascular repair for Stanford type B aortic dissections (TBADs). To preserve the LSA, a novel single branched stent graft, named "Castor" was designed and a clinical trial conducted to investigate its suitability. METHODS: From April 2013 to March 2015, 73 patients with TBAD were treated by Castor stent grafts at 11 Chinese tertiary hospitals as part of a single arm prospective clinical trial. There were 50 acute (<2 weeks [68.5%]) and 23 chronic aortic dissections (>2 weeks [31.5%]). RESULTS: The technical success rate was 97% (n = 71/73). The two failures were caused by occlusion of the branch section of the stent graft. There were four intra-operative endoleaks (two type Ia, two type B from the LSA). The endoleak rate was 5% (n = 4/73). There was one in hospital death and no major complications. The median follow up time was 61 months (range 48-72 months). The mortality was 5% (n = 4/73) within one year and 7% within six years (n = 5/73). Two deaths were of unknown cause and three were not related to the aorta. Two new entry tears were found on the proximal or distal edge of the stent graft and were retreated endovascularly. Six occlusions of the branch section of the Castor stent graft were found, and the follow up patency rate of the branch section was 93% (n = 63/68). Two intra-operative endoleaks were left during follow up and eventually disappeared according to the latest computed tomography angiograms. CONCLUSION: For patients with TBADs needing anchoring proximal to the origin of LSA, the Castor single branched stent graft may provide an easily manipulated, safe, and effective endovascular treatment.

Six-month results of stenting of the femoropopliteal artery and predictive value of interleukin-6: Comparison with high-sensitivity C-reactive protein.

OBJECTIVES: To determine the association of pre- and postinterventional serum levels of interleukin-6 and high-sensitivity C-reactive protein at the six-month evaluation of restenosis after stenting of the femoropopliteal artery. METHODS: Sixty-eight consecutive patients with steno-occlusive femoropopliteal artery disease of Rutherford category III or IV who underwent stent implantation were included. Six-month patency was evaluated with color-coded duplex ultrasound. The association of in-stent restenosis with interleukin-6 and high-sensitivity C-reactive protein levels at baseline, and 24-h postintervention was assessed with a multivariate logistic regression analysis. RESULTS: In-stent restenosis was found in 15 patients (22.1%) within six months. Interleukin-6 and high-sensitivity C-reactive protein levels were significantly increased at 24-h postintervention compared to their preintervention values (p < 0.001 and p = 0.002, respectively). Interleukin-6 values at baseline (odds ratio, 1.11; 95% confidence interval: 1.00, 1.23; p = 0.044) and 24-h postintervention (odds ratio, 1.04; 95% confidence interval: 1.02, 1.06; p < 0.001) were independently associated with six-month in-stent restenosis. Twenty-four-hour postinterventional high-sensitivity C-reactive protein levels were also found to be related to restenosis (odds ratio, 1.15; 95% confidence interval: 1.04, 1.26; p = 0.006), but high-sensitivity C-reactive protein levels at baseline did not show an independent association with in-stent restenosis (odds ratio, 0.57; 95% confidence interval: 0.35, 1.80; p = 0.667). Smoking, diabetes mellitus, and cumulative stent length were other parameters associated with an increased risk for in-stent restenosis. CONCLUSIONS: Femoropopliteal artery angioplasty with stent placement induces an inflammatory response. Interleukin-6 is a powerful independent predictor of intermediate-term outcomes for stenting of the femoropopliteal artery, suggesting that its predictive value may be superior to that of high-sensitivity C-reactive protein.

Impact of high blood pressure variability on the occurrence of acute type B aortic dissection.

BACKGROUND: Acute type B aortic dissection is a life-threatening medical emergency, and hypertension is believed to be an important predictor of aortic dissection; the impact of blood pressure variability on the onset and development of aortic dissection has attracted increasing attention. METHODS: A total of 120 acute type B aortic dissection patients and 57 hypertensive patients without aortic dissection were consecutively enrolled and retrospectively reviewed between January 2013 and November 2015. There were 60 acute type B aortic dissection patients in both high and low blood pressure variability groups. RESULTS: Blood pressure variability showed higher diagnostic value than hypertension in aortic dissection, and the best threshold of blood pressure variability is 5.71 mmHg. By performing multivariable logistic regression, we found that the history of hypertension was likely to be a risk factor of blood pressure variability (95% CI: 1.155-6.422, P = 0.022). Nine patients from high blood pressure variability group and two from low blood pressure variability group (χ2 = 4.90, P = 0.027) received emergency surgery within 24 hours after admission. The presence of multiple tears (>2, 55.0% vs. 45.0%, P = 0.001), configuration of the false lumen (spiral false lumen) (50.0% vs. 21.7%, P = 0.001), the diameter of the false lumen (49.6 ± 15.0 mm vs. 37.6 ± 10.8 mm, P < 0.001), the false/true lumen ratio (1.53 ± 1.02 vs. 0.929 ± 0.733, P < 0.001), and the number of visceral arteries involved (1.75 ± 0.942 vs. 0.800 ± 0.927, P < 0.001) showed significant differences between high and low blood pressure variability groups. Nine (30%) patients from the high blood pressure variability group showed a maximum diameter of false lumen over 60 mm, while none was found in the low blood pressure variability group. CONCLUSIONS: High blood pressure variability, the presence of multiple tears (>2), the configuration of false lumen, the diameter of the false lumen, false/true lumen ratio, and the number of visceral arteries involved were independent risk factors for acute type B aortic dissection.

Systematic review of endovascular repair of ascending aortic dissection.

BACKGROUND: Endovascular repair has been used in selected ascending aortic dissection patients judged unfit for direct open surgery. However, the selective criteria and the results of endovascular repair of ascending aortic dissection, and the potential risk factors of adverse events were still obscure. The aim of this study was to summarize the published data linking endovascular therapy for ascending aortic dissection. METHODS: Studies reporting endovascular repair of ascending aortic dissections were identified by searching PubMed and Embase databases in accordance with preferred reporting items for systematic reviews and meta-analyses guidelines, and by reviewing the reference lists of retrieved articles. All available data were pooled and the subgroup analyses were conducted. RESULTS: A total of nine studies were identified according to the inclusion criteria. The overall technical success was 91.7%. The mean period of follow-up was 34.7 months. The early mortality within 30 days and late mortality during the follow-up were 10.3% and 19.0%, respectively. The incidence of endoleak was 14.3%. In the subgroup analysis, we found that female and oversizing >10% were risk factors of adverse events. CONCLUSIONS: The pooled results suggested that endovascular repair of ascending aortic dissection was feasible, promising, and inspiring. The selection of endovascular therapy should be cautious based on preoperative evaluation. Application of different strategies for different ascending lesions should be considered. The dedicated endograft for ascending aorta is desperately needed before broader application of endovascular repair for ascending aortic pathologies can be achieved.

Endovascular Treatment for Iliofemoral Vein Thrombosis with Composite Stents.

BACKGROUND: To evaluate the applicability of endovascular treatment for iliofemoral vein thrombosis with composite stents. METHODS: Between September 2013 and August 2016, 29 consecutive patients underwent endovascular therapy with composite stents for iliofemoral vein thrombosis and were followed up at our institution. All the patients with acute or chronic iliofemoral vein thrombosis enrolled in this study were evaluated by color Doppler ultrasonography and diagnosed by venography. Treatment measures and related complications were recorded, and cumulative stent patency was assessed with Kaplan-Meier curves. RESULTS: Patients with acute iliofemoral vein thrombosis (n = 7) were successfully treated with catheter-directed thrombolysis treatment, balloon angioplasty, and stents, whereas patients (n =  = 22) with chronic deep vein thrombosis were treated successfully by balloon angioplasty and stent only. Among all patients, 2 stents were inserted in 25 patients, whereas 3 stents were deployed in 4 patients. Endovascular treatment for iliofemoral vein thrombosis with laser-cut stents combined with Wallstents showed primary patency of treated limbs at 6, 12, and 24 months was 96.6%, 93.1% and 93.1%, respectively. Mean duration of follow-up was 23 months, and there was no occurrence of contralateral vein thrombosis during follow-up by ultrasound. CONCLUSIONS: Iliofemoral vein thrombosis was successfully recanalized by endovascular therapy with composite stents, and there was no occurrence of contralateral vein thrombosis by ultrasound during follow-up.

Recanalization of native superficial femoral artery chronic total occlusion after failed femoropopliteal bypass in patients with critical limb ischemia.

OBJECTIVES: This study aimed to examine the outcomes of endovascular recanalization for native superficial femoral artery (SFA) chronic total occlusion (CTO) in patients with critical limb ischemia (CLI) after femoropopliteal bypass failure with limited surgical revascularization options. BACKGROUND: Endovascular recanalization of native artery occlusions has been recently used as a new alternative for threatened limbs after bypass graft occlusion. The feasibility and efficacy has not been widely reported. METHODS: We retrospectively analyzed 45 consecutive patients (45 limbs) undergoing endovascular recanalization of native SFA occlusion following failed femoropopliteal bypass between June 2010 and December 2016. RESULTS: All limbs had Transatlantic Inter-Society Consensus class C (26.7%, 12/45) or D (73.3%, 33/45) lesions with a mean lesion length of 29.8 cm. The technical success rate was 95.6% (43/45 limbs). The ABI showed a significant increase from 0.3 ± 0.1 pre-procedure to 0.7 ± 0.1 post-procedure (P < 0.01). Two early (<30 days) below-knee amputations due to acute thrombotic ischemia occurred during perioperative period and resulted in one death due to myocardial infarction. The mean follow-up was 42.7 months (1-62 months). Two patients were lost to follow up. The primary patency rates at 12 and 36 months were 54% and 51%, respectively. Secondary patency rates at 12 and 36 months were 78% and 61%, respectively. Limb salvage rate was 95% and amputation-free survival rate was 88% at both 12 and 36 months. CONCLUSION: Recanalization of native SFA CTO due to failed femoropopliteal bypass offers a feasible and safe alternative to surgical reconstruction with acceptable limb salvage.

Circulating microRNAs: a novel potential biomarker for diagnosing acute aortic dissection.

Acute aortic dissection (AAD) is a catastrophic emergency with high mortality and misdiagnosis rate. We aimed to determine whether circulating microRNAs allow to distinguish AAD from healthy controls and chest pain patients without AAD (CP). Plasma microRNAs expression were determined in 103 participants, including 37 AAD patients, 26 chronic aortic dissection patients, 17 healthy volunteers, 23 patients without AAD. We selected 16 microRNAs from microarray screening as candidates for further testing via qRT-PCR. The results showed that plasma miR-15a in patients with AAD (n = 37) had significantly higher expression levels than it from control group (n = 40; P = 0.008). By receiver operating characteristic curve analysis, the sensitivity was 75.7%; the specificity was 82.5%; and the AUC was 0.761 for detection of AAD. Furthermore, 37 patients with AAD had significantly higher plasma expression levels of let-7b, miR-15a, miR-23a and hcmv-miR-US33-5p compared with 14 CP patients of 40 controls (P = 0.000, 0.000, 0.026 and 0.011, respectively). The corresponding sensitivity were 79.4%, 75.7%, 91.9% and 73.5%, respectively; the specificity were 92.9%, 100%, 85.7% and 85.7%, respectively; and the AUCs of these microRNAs were 0.887, 0.855, 0.925 and 0.815, respectively. These data indicate that plasma miR-15a and miR-23a have promising clinical value in diagnosing AAD.

Outcomes of Endovascular Repair of Ascending Aortic Dissection in Patients Unsuitable for Direct Surgical Repair.

BACKGROUND: Stent grafting is a therapeutic option for patients who are unable to undergo urgent surgical repair of ascending aortic dissections. However, follow-up regarding outcomes is limited. OBJECTIVES: This study reports mid-term outcomes with endovascular repair for ascending aortic dissections in patients deemed high risk for open repair. METHODS: Between May 1, 2009 and January 31, 2011, 15 ascending aortic dissection patients (ages 45 to 78 years) ineligible for direct surgical repair underwent endovascular repair (1 acute dissection, 7 subacute dissections, and 7 chronic dissections) and were closely followed up for a median of 72 months (range 61 to 81 months). RESULTS: The mean interval between aortic dissection onset and treatment was 25.5 (range 6 to 353) days. Technical success was achieved in all patients. No major morbidity or deaths occurred perioperatively. During the follow-up period, there were no deaths, 8 complications occurred, and there were 4 reinterventions. A new dissection in the aortic arch was treated with a branched endograft. One patient developed retrograde aortic dissection and a left ventricular pseudoaneurysm was successfully treated with open surgery. One cardiovascular ischemia was treated with stenting and 1 supraventricular tachycardia was treated with radiofrequency ablation. Other morbidities included perigraft endoleak, a bird-beak sign, a temporary pericardial effusion, and a left kidney atrophy. Significant enlargements of true lumens and shrinkage of false lumens and overall thoracic aorta were observed at 12 months. No significant changes were detected subsequently. Minimal impact on aortic valve function was recorded over time. CONCLUSIONS: Our results with the novel endovascular procedure appear acceptable. Additional evidence and studies with larger sample size and longer follow-up are needed to support the durability of this new technique.

Reintervention after endovascular repair for aortic dissection: A systematic review and meta-analysis.

OBJECTIVES: Thoracic endovascular aortic repair has been chosen as a less-invasive alternative to open surgery for the treatment of aortic dissections; however, the advantages have been challenged by the postoperative reintervention during the follow-up period. This study aimed at evaluating the incidence, reasons, and potential risk factors for reintervention. METHODS: Studies reporting reintervention after endovascular repair were identified by searching PubMed and Embase in accordance with preferred reporting items for systematic reviews and meta-analyses guidelines, and by reviewing the reference lists of retrieved articles. Sensitivity analysis and subgroup analyses were performed to determine the sources of heterogeneity. Funnel plot and Egger's test were used to determine the publication bias. RESULTS: A total of 27 studies encompassing 2403 patients with aortic dissection were identified. The pooled incidence of reintervention after endovascular repair was 15% (95% confidence interval, 12-19) during 33.7 months of follow-up. The 3 most common reasons for reintervention were endoleak (33.2%), false lumen perfusion and aortic dilation (19.8%), and new dissection (6.9%). The potential factors for reintervention were the mean age of onset and diabetes mellitus determined by performing a single meta-regression analysis (P < .001 and .044, respectively). CONCLUSIONS: Current data suggest that the incidence of reintervention after endovascular therapy is relatively high during midterm follow-up. Advanced age of onset is a risk factor and diabetes mellitus is a protective factor of reintervention after endovascular therapy. The possible mechanism that diabetes mellitus protects patients from reintervention should be explored further.

The new indication of TEVAR for uncomplicated type B aortic dissection.

The classical therapeutic indication for type B aortic dissection is based on either medication or open surgery; medication therapy is recommended for relatively stable uncomplicated type B aortic dissection. With improvements in endovascular repair and the potential risk of disease progression, it is now necessary to evaluate the requirement for revision of the therapeutic choice of uncomplicated type B aortic dissection based on morphological features and time window. Data from 252 patients diagnosed as uncomplicated type B aortic dissection from 1992 to 2015 were analyzed retrospectively. Among these cases, 117 patients received medication therapy and 135 patients underwent endovascular repair. The 60-month survival rate in the endovascular group was higher than that in the medication group (92.3% vs 67.6%). According to the morphological evaluation, visceral artery involvement and false/true lumen ratios over 0.7 were strong risk factors for medical treatment alone. Increased surgical time and blood loss were found in patients treated in the chronic phase, compared with those who underwent endovascular repair within 14 days of the onset of symptoms. With improvements in aortic remodeling techniques, endovascular repair has been shown to improve long-term survival rates of patients with uncomplicated aortic dissection. Considering the potential risk of death, we recommend that patients with visceral artery involvement and a false/true lumen ratio over 0.7 should receive endovascular repair aggressively. Furthermore, delayed endovascular repair in the chronic phase does not improve the long-term outcome of uncomplicated type B aortic dissection.

Alternative management of the left subclavian artery in thoracic endovascular aortic repair for aortic dissection: a single-center experience.

BACKGROUND: Since the new 2009 guidelines for left subclavian artery (LSA) management using thoracic endovascular aortic repair (TEVAR), a few studies have been published about alternative LSA management. The objective of this study was to present the follow-up results of covered or revascularized LSA during TEVAR. METHODS: From January 2010 to August 2012, 109 consecutive patients were treated with TEVAR at the Department of Vascular Surgery, Changhai Hospital, for aortic dissection extending near the LSA. After evaluating the bilateral vertebral arteries, fifty-two LSAs were covered and not revascularized (covered group), while 57 LSAs were preserved (revascularized group). Complications were stratified according to the time of occurrence after surgery. RESULTS: Emergency operations were more common (17.3 vs. 3.5 %, P = 0.017) and operation time was shorter (96.9 ± 16.3 vs. 135.3 ± 38.4 min, P < 0.001) in the covered group. Pulselessness and intermittent claudication of the left arm occurred in most patients in the covered group (P < 0.001). Incidence of stroke and cold shoulder feeling were higher in the covered group compared with the revascularized group (P = 0.026 and <0.001, respectively). There were five aorta-related deaths in the covered group and one in the revascularized group. Eight endoleaks were observed in the revascularized group (P = 0.006). CONCLUSIONS: The results of this study suggest that due to occurrence of complications, LSA should be preserved or revascularized to reduce complications and to improve patients' quality of life.

Suppression of nuclear factor-kappa B and mitogen-activated protein kinase signalling pathways by goshonoside-F5 extracted from Rubi Fructus.

Rubi Fructus, a traditional Chinese medicine, was considered as an anti-inflammatory agent in folk medicine. In the present study, we investigated the signalling pathways involved in the anti-inflammatory effects of goshonoside-F5 (GF5), isolated from Rubi Fructus, in peritoneal macrophages and examined its therapeutic effect in a mouse endotoxic shock model. GF5 decreased NO and PGE2 production in LPS-stimulated macrophages (IC50=3.84 and 3.16µM). This effect involved the suppression of NOS-2 and COX-2 gene expression at the transcriptional level. Examination of the effects of GF5 on NF-κB signalling demonstrated that it inhibits the phosphorylation of IκB-α and IκB-ß, blocking their degradation and the nuclear translocation of the NF-κB p65 subunit. Moreover, inhibition of MAPK signalling was also observed, and phosphorylation of p38 and JNK was suppressed in the presence of GF5. Inflammatory cytokines, including IL-6 and TNF-α, were down-regulated by this compound after activation with LPS (IC50=17.04 and 4.09µM). Additionally, GF5 (30 and 90mg/kg, i.p.) significantly reduced the circulating cytokine levels (IL-6 and TNF-α) and increased survival in a mouse model of endotoxemia. These results show that GF5 significantly inhibits the pro-inflammatory response induced by LPS, both in vitro and in vivo. Our results provide a strong pharmacological basis for further understanding the potential therapeutic role of GF5 in inflammatory disease and shed new light on the bioactivity of ent-labdane diterpene glucoside.

Potential risk factors of re-intervention after endovascular repair for type B aortic dissections.

OBJECTIVES: To assess the potential risk factors of re-intervention after thoracic endovascular aortic repair (TEVAR). BACKGROUND: TEVAR has been chosen as a less invasive alternative for Type B aortic dissections (TBADs); however, the potential risk factors of re-intervention remain unclear. METHODS: A total of 252 TBADs patients initially treated with TEVAR between September 1998 and July 2012 were retrospectively reviewed. The indications for the initial TEVAR were 32 aorta enlargement (24 chronic), 71 malperfusion, 46 rupture (32 chronic), 67 refractory pain (54 chronic), and 44 refractory hypertension (38 chronic). The patients were stratified into single-intervention group and multi-intervention group. RESULTS: The mean age was 54.1 years with 81.7% of male. We found the time from symptom onset to TEVAR was longer in multi-intervention group (17 vs. 112.5 days, P = 0.006). Higher proportions of chronic dissection and smoking occurred in multi-intervention group (53.9% vs. 79.2% and 43.9% vs. 70.8%, P = 0.018 and 0.012, respectively). The differences of oversizing, operation time, contrast medium dose, and blood loss between the groups were significant (13.8 ± 2.4% vs. 16.4 ± 2.9%, 92.5 vs. 196 minutes, 110 vs. 210 ml, 100 vs. 300 ml; P < 0.001, <0.001, =0.002, and =0.003, respectively). The mortality within 30 days was 2.4% and the rates of stoke, paraplegia and retrograde dissection were 3.6%, 5.6% and 0.8%, respectively. The most common reasons of re-intervention were endoleaks, new dissections and incomplete thrombosis of the false lumen. CONCLUSIONS: we concluded that chronic phase, smoking and too big oversizing were potential risk factors of re-intervention.

Multiple overlapping uncovered stents as an alternative flow-diverting strategy in the management of peripheral and visceral aneurysms.

OBJECTIVE: In this study we aimed to report on the midterm outcome of multiple overlapping uncovered stents in the treatment of peripheral and visceral aneurysms, and analyze the possible factors affecting the treatment efficacy. METHODS: Data of patients who were regularly followed up over 24 months were retrospectively reviewed. Descriptive statistics were applied to present aneurysm thrombosis process and diameter change at each follow-up point, and a comparison with the baseline level was performed. Patients were divided into a totally thrombosed (TT) group and a residual perfusion (RP) group according to the sac thrombosis ratio (thrombus volume to sac volume ratio) at 3, 6, and 12 months of follow-up. Aneurysm shrinkage in the two groups was compared to explore the effect of the initial RP on the treatment outcome. Patients were also grouped based on their aneurysm morphology (saccular/fusiform). The aneurysm sac thrombosis speed (time to thrombosis) and diameter decrease (DD) ratio (percentage of DD) were compared between the two groups to understand the influence of aneurysm shape on the treatment efficacy. RESULTS: Of the 64 patients treated, the initial 37 patients (25 male; average age, 55.5 ± 13.0 years) were enrolled into this study. Technical success rate was 100%. All patients were regularly followed up. At 24 months, 94.6% aneurysms (35/37) were TT, and the maximum aneurysm diameter decreased from 36.5 ± 9.7 mm preoperatively to 23.6 ± 7.7 mm (P < .001). Overall clinical success rate (complete thrombosis and shrinkage/stabilization of the aneurysm without aneurysm-related mortality) reached 94.6% in the study cohort. Most side branches (31/33) covered by the bare stent stayed patent during follow-up. Initial sac RP at 3, 6, and 12 months might not fully affect the final aneurysm DD ratio (TT group: 0.37 ± 0.09, 0.35 ± 0.09, and 0.35 ± 0.09; compared with the RP group: 0.33 ± 0.09, 0.36 ± 0.11, and 0.36 ± 0.13; P = .153, .964, and .418, respectively). At 3 and 6 months follow-up, saccular aneurysms (n = 29) seemed to have a faster thrombosis speed compared with fusiform aneurysms (78.1 ± 26.8% and 83.9 ± 21.8% vs 47.0 ± 24.4% and 63.9 ± 22.6%; P = .004 and .013, respectively), but there was no significant difference in aneurysm shrinkage ratio at 24 months between the two groups (0.36 ± 0.10 vs 0.33 ± 0.06; P = .357). CONCLUSIONS: Multiple overlapping uncovered stents could be a feasible option for the endovascular treatment of peripheral and visceral aneurysms. Neither the aneurysm shape nor the initial sac RP would affect the midterm treatment outcome. Further validation of this technique is required to substantiate these results.

Endovascular SilverHawk directional atherectomy for thromboangiitis obliterans with occlusion of the popliteal artery.

Thromboangiitis obliterans (TAO), also known as Buerger disease, is a nonatherosclerotic segmental inflammatory disease of small and medium-sized arteries of the distal extremities occurring predominantly in young men who are long-term tobacco smokers. We treated 2 patients who presented with TAO involving popliteal and tibial arteries. Directional atherectomy with a SilverHawk device was used to recanalize the arteries without major complications. During follow-up conducted using computed tomography or sonography, we observed that the treated vessels remained patent. These cases report illustrate the feasibility and immediate effectiveness of endovascular SilverHawk directional atherectomy in TAO patients with occlusion of the popliteal arteries.

Endovascular stent placement for treatment of spontaneous isolated dissection of the superior mesenteric artery.

BACKGROUND: Spontaneous isolated dissection of the superior mesenteric artery (SIDSMA) is a rare condition often associated with a poor prognosis. The goal of this study is to assess the efficacy of endovascular treatment of SIDSMA with stenting and investigate the possible therapeutic mechanisms involved. METHODS: This is a retrospective review of all patients undergoing endovascular treatment of SIDSMA from January 2009 to December 2011. Patient demographics, history, clinical presentation, laboratory tests, image characteristics, endovascular treatments, and follow-up outcome were analyzed. RESULTS: Twenty-four patients with symptoms were treated. All except 1 patient (23 of 24, 96%) underwent successful stent placement (16 with single stent and 7 with overlapping stents). A total of 30 stents (4 balloon-expanded and 26 self-expanding) were placed during the procedures. In the perioperative period and during follow-up, symptom relief was achieved in 20 (83%) patients, and abdominal pain remained unchanged in 4 (17%). No death or serious complications occurred. The median length of hospital stay and follow-up was 3.25 ± 2.23 days (range 2-7 days) and 13.15 ± 8.27 months (range 6-23 months), respectively. Computed tomography angiography (CTA) performed 6 months postoperatively revealed stent patency in 23 cases (100%), false lumen patency in 5 cases (22%), and new development of dissection in the SMA distal to the stent in 1 case (4%). No significant differences were observed in the incidence of false lumen patency between patients treated with a single stent and those treated with overlapping stents, and between patients with and without symptom relief (P > 0.05 for both). CONCLUSIONS: For symptomatic SIDSMA patients without intra-abdominal hemorrhage and intestinal infarction, endovascular stent placement is a feasible treatment choice with a high success rate and good clinical outcome. Overlapping stenting may be proposed for patients with aneurysmal dilation. False lumen patency may occur in some cases during follow-up, but it does not affect improvement of SIDSMA symptoms.

Endovascular therapy for long-segment atherosclerotic aortoiliac occlusion.

OBJECTIVE: This retrospective nonrandomized study investigated the outcomes of endovascular therapy for long-segment atherosclerotic aortoiliac occlusion. METHODS: From May 2008 to January 2013, 20 patients (one woman and 19 men; mean age, 66.1 years; range, 43-89 years) underwent stent implantation, with or without catheter-directed thrombolysis (CDT), for long-segment aortoiliac occlusion (>10 mm). RESULTS: The technical success rate was 95% (19 of 20). No in-hospital mortality was recorded. Aortic thrombus was successfully eliminated with CDT in four patients before percutaneous transluminal angioplasty (PTA) and stenting. Retroperitoneal hemorrhage occurred in one patient, who refused further endovascular surgery. Another 15 patients were treated with PTA and stenting. Postoperative ankle-brachial indexes increased significantly from preoperative values (P < .05). Seventeen patients showed clinical improvement from baseline by an average of 2.5 Rutherford categories. The mean follow-up interval was 17.6 months (range, 4-39 months). The primary patency rates were 93.3% ± 6.4% at 6 months, 83% ± 11.3% at 18 months, and 66.4% ± 17.4% at 24 months. CONCLUSIONS: Through brachial and femoral artery puncture, PTA, stenting, and CDT, endovascular therapy is feasible for complete long-segment infrarenal aortic occlusion, with lower complication rates and favorable midterm patency.