Factors associated with sleep quality in patients undergoing cardiac surgery: A longitudinal study.

BACKGROUND: Poor sleep quality is associated with multiple factors in cardiac surgery patients. AIM: To examine the trajectory of sleep quality and its associated factors over 3 months in Taiwanese patients undergoing cardiac surgery. STUDY DESIGN: A longitudinal study. This study enrolled 95 patients undergoing cardiac surgery in northern Taiwan. Sleep quality was measured using the Pittsburgh Sleep Quality Index and Epworth Sleepiness Scale before surgery, at discharge, and at 1 month and 3 months postsurgery. RESULTS: The majority of participants reported poor sleep quality before cardiac surgery (76.8%) and at discharge (81.6%), and they showed significant improvements in sleep quality at 1 month (B = -0.93, p = .023) and 3 months postsurgery (B = -1.50, p < .001). Significant daytime sleepiness was reported by 25.3% of patients before cardiac surgery, and this proportion significantly decreased at 3 months postsurgery (B = -2.59, p < .001). The significant predictors of sleep quality in cardiac surgery patients were symptom distress, sleep medications, occupation, left ventricular ejection fraction, ACE-I drugs and potassium ions, which explained 53.7% of the total variance in sleep quality. Having a nap habit was an independent predictor of daytime sleepiness in cardiac surgery patients, which could explain 3.7% of the total variation. CONCLUSION: Poor sleep quality was common in patients undergoing cardiac surgery and was associated with multiple factors, including symptom distress, cardiac function, medications, and psychosocial and environmental factors. RELEVANCE TO CLINICAL PRACTICE: Poor sleep quality was observed in cardiac surgical patients before surgery and at discharge postsurgery. Patient education on symptom management, medication adherence and sleep hygiene are suggested to improve sleep quality in patients undergoing cardiac surgery.

Blood pressure levels within normotensive range are independently associated with increased risk of arterial stiffness in adults without hypertension or prehypertension.

BACKGROUND AND AIMS: High blood pressure (BP) indices, including systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), and pulse pressure (PP) predict cardiovascular diseases and mortality. However, the association of these BP indices with arterial stiffness (AS) in the normotensive population (BP < 120/80 mmHg) remains unclear. METHODS AND RESULTS: Study participants who underwent health checkups at a tertiary referred center were recruited between November 2018 to December 2019. 2129 participants were enrolled after excluding those aged <18 years old, with elevated BP, history of hypertension, cardiovascular disease, and stroke, or with incomplete data. The brachial-ankle pulse wave velocity (baPWV) values were examined for evaluation of AS. Participants with higher blood pressure indices had significantly higher baPWV. Multiple linear regression revealed that all BP indices were positively associated with baPWV. According to the binary logistic regression analysis, participants in the higher SBP and MAP quartiles were significantly related to AS. The odds ratio (OR) for SBP Q2, Q3 and Q4 vs. Q1 were 6.06, 10.06 and 17.78 whereas the OR for MAP Q2, Q3 and Q4 vs. Q1 were: 5.07, 5.28 and 10.34. For DBP and PP, only participants belonging to the highest quartile were associated with AS(OR for DBP Q4 vs. Q1: 2.51; PP Q4 vs Q1: 1.94). CONCLUSIONS: BP indices were linearly related to the baPWV. Normotensive participants with higher quartiles of SBP, DBP, MAP, and PP, remained associated with increased AS. The SBP and MAP levels exhibited a more prominent relationship with AS.

Fatigue trajectory and its associated factors in patients after cardiac surgery: A longitudinal study.

BACKGROUND: Fatigue is associated with multidimensional factors in heart failure patients. Investigating longitudinal changes in fatigue and its association in patients undergoing cardiac surgery is needed to create interventions for improving fatigue during recovery. AIMS: This study examined the trajectory of fatigue and its associated factors over time in patients undergoing cardiac surgery. METHODS: This longitudinal study enrolled 125 patients undergoing cardiac surgery in northern Taiwan. Patients completed questionnaires before surgery, at discharge, and at 1, 3 and 6 months post-discharge. Fatigue was measured using the General Fatigue Scale. Generalised estimating equation models were fitted to identify variables associated with fatigue over time. This study complied with the STROBE checklist. RESULTS: The sample (mean age = 60.70 ± 10.42) was mostly male (68%). High fatigue was found in 73.6% of patients before cardiac surgery and significantly decreased over the six months after discharge. NYHA III/IV, lower haemoglobin level, more symptom distress, poor sleep quality, higher anxiety and depression and lower social and family support were significantly associated with an increase in fatigue levels over time. Compared with before discharge, decreases in sleep quality at 1, 3 and 6 months were significantly associated with an increase in fatigue levels (p < .001). The increases in social support (B = 0.20, p = .016) and family support (B = 0.37, p = .002) at 6 months were significantly associated with an increase in the fatigue scores. CONCLUSION: Fatigue was common and associated with symptoms, sleep quality, emotion and social support in patients undergoing cardiac surgery. In addition to symptom management, improving sleep quality and social support are important to manage fatigue for the long-term care of patients undergoing cardiac surgery. RELEVANCE TO CLINICAL PRACTICE: Patient education on symptom management, sleep hygiene and family support is suggested to improve fatigue in patients recovering from cardiac surgery.

Aortic remodeling of the provisional extension to induce complete attachment technique in DeBakey type IIIb aortic dissection.

BACKGROUND/PURPOSE: Data about volumetric remodeling of the provisional extension to induce complete attachment (PETTICOAT) technique on DeBakey type IIIb aortic dissection in acute and subacute phases were scarce. The proper timing to perform this technique to promote false lumen reduction was also unknown. METHODS: Patients with DeBakey type IIIb aortic dissection who underwent the PETTICOAT technique between December 2005 and March 2017 were reviewed and divided into acute (treatment occurred ≦14 days after symptom onset) and subacute (15-90 days) groups. Remodeling parameters of the true and false lumens were analyzed. Receiver operating characteristic curve was used to deduce the timing of this technique. RESULTS: In the 2-year follow-up, the acute group (N = 20) demonstrated significant true lumen expansion and false lumen regression in the thoracic, abdominal, and total aorta. However, the subacute group (N = 20) only showed significant shrinkage in the false lumen of the thoracic and total aorta. Using PETTICOAT technique within 36 days after the aortic event may result in better total false lumen reduction. CONCLUSION: For DeBakey type IIIb aortic dissection, more prominent true lumen expansion and false lumen reduction were noted when using the PETTICOAT technique in the acute phase. When performed within 36 days after symptoms onset, the PETTICOAT technique may potentiate better total false lumen regression.

Efficacy of ascending aortic banding technique concomitant with type I hybrid aortic arch repair in high-risk patients.

Banding of the ascending aorta has been introduced as a less complex procedure to optimize the proximal landing zone of the stent graft in hybrid aortic arch surgery. However, data about the long-term results and effects of this technique are still limited. We aimed to study the efficacy of banding of the ascending aorta in hybrid aortic arch repair. The study included 11 high-risk patients with dilated ascending aorta (wider than 38 mm in diameter) undergoing ascending aortic banding for hybrid arch repair. Clinical outcomes, including technical success, endoleaks, perioperative mortality and morbidity, and sequential remodeling of the ascending aorta were investigated. The average diameter of the ascending aorta had been reduced (p = 0.02) from 42.1 mm (range = 39.0-46.4) to 37.2 mm (range = 35.6-38.6) after banding procedure. The technical success rate was 100.0%. No type I endoleak occurred, but 2 cases of distal stent graft-induced new entry required re-interventions. The 5-year survival and freedom from aortic events rates both were 81.8%. The ascending aortic diameter remained stable and no proximal migration of the stent graft was observed during the study period. The 5-year results validated the durability of this therapeutic modality, especially in high-risk patients.

The Sandwich Technique with Body Flossing Wire to Revascularize Left Subclavian Artery in Thoracic Endovascular Aortic Repair.

BACKGROUND: To evaluate the safety and efficacy of the sandwich technique with the body flossing wire to revascularize the left subclavian artery (LSA) in thoracic endovascular aortic repair (TEVAR). METHODS: From April 2014 to April 2015, 20 consecutive patients with a variety of thoracic aortic pathologies who underwent LSA revascularization with the sandwich technique and body flossing wire during TEVAR were included. Outcomes including technical success, endoleaks, perioperative mortality and morbidity, and graft patency were analyzed. RESULTS: There were 13 patients (65.0%) who presented with aortic dissection, 3 (15.0%) with thoracic aortic aneurysm, 3 (15.0%) with penetrating aortic ulcer, and 1 (5.0%) with traumatic aortic disruption. Technical success rate was 100%. But one type Ia endoleak (5.0%) was noted and treated with extended endografting. One sandwiched gutter leak (5.0%) resolved spontaneously at 6 months. One sandwiched graft (5.0%) was occluded but not treated because no related complications were found. At a mean follow-up of 9.7 months (range 4-17), all the patients with aortic aneurysm, penetrating aortic ulcer, or traumatic aortic disruption had complete thrombosis of the aortic pathologies. Patients with aortic dissection had thrombosed false lumen down to the distal aortic endograft edge (12/13, 92.3%) or the celiac artery level (8/13, 61.5%). There was no neurological deficit but 2 non-procedure-related late deaths during the study period. CONCLUSIONS: Our early experience showed that the sandwich technique with the body flossing wire to maintain blood flow to the LSA is a safe and effective method. This technique can be applied in various clinical situations with a high technique success rate. However, outcomes are preliminary and larger studies are required.

The Impact of Aortic Tortuosity on Delayed Type I or III Endoleak after Endovascular Aortic Repair.

BACKGROUND: Endovascular aneurysm repair (EVAR) becomes the treatment of choice for patients with abdominal aortic aneurysm (AAA). Type I or III endoleak is related to high risk of rupture and reintervention, but little is known about the delayed presentation of these. We sought to evaluate the delayed type I or III endoleak after EVAR and assess the early morphological portending factors. METHODS: We retrospectively reviewed a database of 249 patients who underwent endovascular repair with a Zenith AAA stent graft (Cook Medical, Bloomington, IN) in a single institute from October 2005 to December 2013. Age, aneurysm size, angulation, tortuosity index (TI), and follow-up evaluations were recorded and analyzed. Patients having <1 year of follow-up were excluded. RESULTS: One hundred eighteen patients were included in this study. There was no delayed type Ia endoleak. Ten patients (9.3%) were found to have a delayed type Ib or III endoleak. The mean diagnosis time was 49.1 months (range, 22-91 months) after EVAR. All of them were treated with endovascular repair except one had combined open revision. Three of the patients (30%) with delayed endoleaks presented with a ruptured aneurysm, and two of them (20%) died after reintervention. Postoperative TI was found to be the most significant morphological factor associated with increased risk of type Ib or III endoleak. CONCLUSIONS: Delayed type Ib or III endoleak was not rare in our study population and was found to have a high risk of rupture and mortality. Aneurysm tortuosity is associated with increased risk of endoleaks, and postoperative TI can be an indicator in the early period of follow-up.

Carotid blowout and cerebral gas embolism related to bidirectional carotid-esophageal fistula: a serious complication of esophageal cancer under radiotherapy.

Carotid-esophageal fistula (CEF) could be a serious complication of esophageal cancer in a patient receiving radiotherapy. We reported a 47-year-old male patient with advanced cervical esophageal cancer under radiotherapy who developed CEF with the presentations of unstable vital signs and disturbances of consciousness. Carotid-esophageal fistula-associated life-threatening conditions of carotid blowout syndrome and cerebral gas embolism were diagnosed after presentation. Subsequently, intramural dissection of esophageal and gastric walls, profound hemoperitoneum, and hypovolemic shock occurred. When a patient who had an underlying cervical esophageal cancer treated by radiotherapy develops unstable vital signs and neurological symptoms, CEF should be kept in mind in the differential diagnoses. Physicians must be alert of the associated complications of carotid blowout syndrome and cerebral gas embolism and perform timely management including decompression, fluid resuscitation, and aggressive endovascular procedure when indicated.

Percutaneous pharmacomechanical thrombectomy offers lower risk of post-thrombotic syndrome than catheter-directed thrombolysis in patients with acute deep vein thrombosis of the lower limb.

BACKGROUND: Despite optimal anticoagulant therapy, patients with proximal deep vein thrombosis (DVT) will often develop post-thrombotic syndrome (PTS). Early thromboreduction can potentially decrease the risk of PTS by restoring venous patency and preserving valvular function. This study was undertaken to compare the efficacy and treatment outcomes of patients with acute proximal DVT of the lower limb who underwent either catheter-directed thrombolysis (CDT) or percutaneous pharmacomechanical thrombectomy (PMT). METHODS: Thirty-nine patients with acute proximal DVT of the lower limb who were diagnosed by Wells' Score, PMT or CDT was chosen depending on the patient. They underwent early thromboreduction, and 3 died postoperatively in less than 12 months, while 2 were removed for not following-up. Thirty-four patients, 16 in PMT and 18 in CDT, were followed up for more than 1 year. Venous Registry Index (VRI) was used to evaluate the postprocedural patency, while PTS was assessed using the Villalta scale. RESULTS: The technical success was 100% in both the groups, without any 30-day mortality. VRI changed from 13.1 ± 4.3 preoperatively to 2.4 ± 1.5 postoperatively in the PMT group, and from 11.8 ± 2.4 to 3.6 ± 2.2 in the CDT group. Thrombolysis rate was 81.5 ± 8.5% and 67.7 ± 21.0% in the PMT and CDT groups, respectively (P = 0.059). There were no differences in complications, thrombus score, and VRI between the 2 groups. Primary patency rate at 1 year was 93.8% in the PMT group and 88.9% in the CDT group (P = 0.648). The Villalta scale was 2.1 ± 3.0 in the PMT group and 5.1 ± 4.1 in the CDT group (P = 0.030). CONCLUSIONS: Both PMT and CDT are effective treatment modalities in patients with acute proximal DVT. Compared with CDT, PMT provides similar treatment success, but with lower risk of PTS at 1-year follow-up.

The impact of bird-beak configuration on aortic remodeling of distal arch pathology after thoracic endovascular aortic repair with the Zenith Pro-Form TX2 thoracic endograft.

OBJECTIVE: Structural changes and incomplete endograft apposition to the aortic arch (bird-beak configuration) after thoracic endovascular aortic repair are poorly understood. The aim of this study was to analyze the morphologic changes, conformability, and angulation factors in patients who underwent stainless steel-based stent graft repair of thoracic aortic pathology. METHODS: From March 2011 to March 2012, the study enrolled 19 patients with aortic pathology requiring proximal fixation in zones 2 and 3 who underwent stent graft repair using Zenith Pro-Form TX2 stent grafts (Cook Medical, Bloomington, Ind). For comparison, another 19 patients who received Zenith Z-Trak stent grafts were selected from December 2009 to February 2011. Chest computed tomography scans were analyzed at baseline, and then at 1, 6, and 12 months postoperatively. Arch angulation and bird-beak configuration were evaluated according to sealing zones of attachment by Aquarius iNtuition software (TeraRecon, San Mateo, Calif). RESULTS: The treated diseases included chronic type B aortic dissection in 17 patients and degenerative aneurysms in 21. Significant arch angle transformation was noted at the zone 2 level between the Pro-Form and Z-Trak treated groups (150° ± 11° vs 158° ± 6°; P = .033) and left subclavian artery level (152° ± 12° vs 160° ± 8°; P = .031) during 1 year of follow-up. The bird-beak configuration was detected in six patients (32%) in the Pro-Form group and in 11 (58%) in the Z-Trak group (P = .096) at 1 month, and in six (32%) in the Pro-Form group and in 14 (74%) in the Z-Trak group (P = .022) at 12 months. The mean bird-beak angle was significantly less in Pro-Form-treated patients at 1 month (5° ± 9° vs 15° ± 13°; P = .019) and at 1 year (6° ± 10° vs 18° ± 15°; P = .033). In the Pro-Form platform, a preoperative zone 2 angle <151.1° was a better estimation of the presence of a postoperative bird-beak configuration, with a sensitivity of 86% and specificity of 83%. CONCLUSIONS: Aortic remodeling after stainless steel stent graft repair of thoracic aortic pathology is a continuous process. Significant arch angle transformation was discovered over the zone 2 and left subclavian artery levels. TX2 Pro-Form stent grafts improved arch conformation after 1 year of follow-up. Furthermore, in the patients with dissection, a preoperative distal arch angle of zone 2 was predictive of postoperative bird-beak configuration, regardless of whether they were treated with a Pro-Form stent graft.

Downregulation of Sirt1 as aging change in advanced heart failure.

BACKGROUND: In congestive heart failure the balance between cell death and cell survival in cardiomyocytes is compromised. Sirtuin 1 (Sirt1) activates cell survival machinery and has been shown to be protective against ischemia/reperfusion injury in murine heart. The role of Sirt1 in heart failure, especially in human hearts is not clear. RESULTS: The expression of Sirt1 and other (associated) downstream molecules in human cardiomyocytes from patients with advanced heart failure was examined. Sirt1 was down-regulated (54.92% ± 7.80% in advanced heart failure samples compared with healthy control cardiomyocytes). The modulation of molecules involved in cardiomyocyte survival and death in advanced heart failure were also examined. The expression of Mn-superoxide dismutase and thioredoxin1, as well as an antiapoptotic molecule, Bcl-xL, were all significantly reduced in advanced heart failure cardiomyoctes (0.71 ± 0.02-fold, 0.61 ± 0.05-fold, and 0.53 ± 0.08-fold vs. control, respectively); whereas the expression of proapoptotic molecule Bax was significantly increased (1.62 ± 0.18-fold vs. control). Increased TUNEL-positive number of cardiomyocytes and oxidative stress, confirmed by 8-hydorxydeoxyguanosine staining, were associated with advanced heart failure. The AMPK-Nampt-Sirt1 axis also showed inhibition in advanced heart failure in addition to severely impaired AMPK activation. Increased p53 (acetyl form) and decreased FoxO1 translocation in the nucleus may be the mechanism of down-regulation of antioxidants and up-regulation of proapoptotic molecules due to low expression of Sirt1. CONCLUSION: In advanced heart failure, low Sirt1 expression, like aging change may be a significant contributing factor in the downregulation of antioxidants and upregulation of proapoptotic molecules through the p53, FoxO1, and oxidative stress pathways.

Outcomes of abdominal false lumen embolization for chronic aortic dissection after prior proximal repair with stent-graft.

BACKGROUND: Persistent false lumen (FL) perfusion with aneurysmal formation is common after thoracic endovascular aortic repair (TEVAR) for typical extended aortic dissection and is associated with poor outcomes. Endovascular FL embolization (FLE) has recently been tried for treatment of postdissection aortic aneurysm (PDAA). However, most reports address thoracic rather than abdominal FLE. In this study, we present the results of abdominal FLE in patients with residual patent abdominal FL following stent-graft repair for aortic dissection. METHODS: Between 2015 and 2019, 24 patients (mean age: 56.7 ± 11.8 years, range: 40-84 years, 18 male) received endovascular abdominal FLE using vascular plugs, coils, or candy plugs as the main surgery (5 patients) or auxiliary procedure (19 patients) after earlier stent-graft repair for aortic dissection (Type A: 9, Type B: 15). The medical records were reviewed and aortic remodeling was examined comparing the preembolization computed tomography (CT) and the most recent CT before reintervention. RESULTS: Technical success was achieved without any intraoperative complications, early morbidity, or mortality. Median follow-up was 34.4 months (range: 12-71). Regarding thoracic FL, 15 patients exhibited complete thrombosis before the procedure and did not change status thereafter except for 1 patient with distal stent-graft-induced new entry. In the other 9 patients, 6 exhibited increased thrombosis. With regard to the abdominal aorta, increased FL thrombosis only occurred in 8 patients with 3 (12.5%) achieving complete thrombosis. The maximal thoracic aortic diameter did not change (1.4 ± 5.6 mm) statistically, but the abdominal diameter increased significantly (4.3 ± 3.7 mm, p < 0.005). CONCLUSION: From our results, abdominal FLE is a safe procedure. However, covering all the re-entry tears is complex and the possibility of complete FL thrombosis is low. The abdominal aortic diameter appears to become enlarged in these patients. Continuous follow-up is necessary after FLE.

Arterial stiffness is associated with high-risk colorectal adenomas and serrated lesions: A cross-sectional study in a Taiwanese population.

BACKGROUND: Little is currently known about the association between arterial stiffness and colorectal serrated lesions. This study was aimed toward an investigation of the association between arterial stiffness and colorectal precancerous lesions, including colorectal adenomas and serrated lesions. METHODS: 7262 eligible adult subjects who underwent health check-ups with colonoscopies and brachial-ankle pulse wave velocity (baPWV) were recruited. Patients were categorized as polyp-free, low-risk and high-risk adenomas, and low-risk and high-risk serrated lesions based on the presence of polyps. The severity of arterial stiffness was categorized into four subgroups based on the baPWV quartile. RESULTS: After adjusting for multiple covariates, the baPWV values were found to be positively correlated with the occurrence of low-risk adenomas. With respect to high-risk polyps, the third and highest baPWV quartiles were significantly associated with the occurrence of both high-risk adenomas and high-risk serrated lesions. A more significant association was found in the highest baPWV quartiles combined with smoking in cases classified with high-risk serrated lesions. CONCLUSIONS: Increased arterial stiffness was independently associated with precancerous colorectal lesions, not only adenomas but also high-risk serrated lesions. Individuals with increased arterial stiffness, especially those who are smokers, should be more aware of the risk of colorectal cancer.

Higher platelet count, even within normal range, is associated with increased arterial stiffness in young and middle-aged adults.

BACKGROUND: Platelet counts and mean platelet volume (MPV) are related to cardiovascular disease, but a thorough investigation into the connection between increased arterial stiffness, MPV, and platelet counts is lacking. This study aimed to explore the association of platelet count and MPV with arterial stiffness in young and middle-aged adults. METHODS: A total of 2464 participants who underwent health checkups at National Cheng Kung University Hospital, Taiwan from November 2018 to December 2019 were included. We excluded participants aged <18 or >50 years; who are pregnant; on medication for dyslipidemia; with abnormal platelet count, incomplete data, and past history of hematologic disorders. We examined the association of platelet counts and MPV values with brachial-ankle pulse wave velocity (baPWV) levels and increased arterial stiffness. RESULTS: Platelet count was significantly higher in participants with increased arterial stiffness than in those without. The multiple linear regression model revealed that platelet counts were positively associated with baPWV levels (ß = 1.88, 95% confidence interval (CI): 0.96 to 2.80). In the binary logistic regression analysis, subjects in the higher platelet counts quartiles had a higher risk of developing increased arterial stiffness (Q2 vs. Q1: odds ratio (OR): 1.54, 95% CI: 1.05 to 2.27; Q3 vs. Q1: OR: 1.57, 95% CI: 1.06 to 2.33; and Q4 vs. Q1: OR: 2.23, 95% CI: 1.50 to 3.30). In contrast, MPV levels were not associated with arterial stiffness. CONCLUSIONS: Platelet count in midlife was positively associated with baPWV levels. Participants in higher platelet quartiles were at risk for increased arterial stiffness.

Incomplete small bowel obstruction in a patient with ankylosing spondylitis.

Small bowel obstruction is a blockage in the small intestine, which is usually caused by adhesion scar tissue, hernia, medication, or malignancy. The symptoms of small bowel obstruction include nausea and vomiting of bile, abdominal distention and obstipation. We present a case of a 61-year-old man with ankylosing spondylitis and scoliosis, who suffered from incomplete small bowel obstruction due to unusual direction of duodenum and externally compressed by liver, gallbladder and pancreas. We gave conservative treatment and inserted a nasojejunal tube for enteral feeding, and the duodenum broke free from the grip of liver, gallbladder and pancreas to its normal anatomical direction. Besides common etiology of small bowel obstruction, unusual body shape and smaller abdominal cavity may cause obstruction due to external compression of neighbor organs. Conservative treatments include gastrointestinal decompression, correction of electrolytes abnormality and nutrition support, while surgical intervention is suggested for the patient without improvement on conservative management.

Flow density of computed tomography aortography for predicting early unfavorable aortic remodeling after TEVAR in type IIIb aortic dissection.

OBJECTIVE: Patients diagnosed of DeBakey type III aortic dissection with partial thrombosis of false lumen (FL) have a higher mortality rate. However, IIIb dissections with full patent FL tend to exhibit a partially thrombosed FL quickly after thoracic endovascular aortic repair (TEVAR); thus, we investigated survival and aortic remodeling in this population. METHODS: We reviewed computed tomography aortograms (CTAs) of 123 patients with TEVAR-treated IIIb aortic dissections from July 2006 to June 2015; contrast density of CTAs represented intraluminal flow. Patients were selected to fit in 2 groups of FL in term of FL contrast density: low flow (LF) group (non-opacification in the midway of FL) and high flow (HF) group (full patent FL). RESULTS: Surgical mortality was 10.3% in the HF group and 4.5% in the LF group (n = 61; LF = 22; HF = 39). 3 patients in the HF group suffered from lethal aortic rupture in 10 days postoperatively. The HF group showed significant increase in maximal diameter, and had larger thoracic (+4.00 ± 2.68 vs -1.16 ± 3.42 mm, P < .001) aortic diameter expansion from preoperation to one week postoperation. Both groups exhibited significant favorable thoracic TL expansion and maximal aortic diameter shrinkage in postoperative one week to one year. However, HF group displayed less thoracic aortic FL regression (-70.9 ± 83.5 vs -113.9 ± 95.0 cm3, P = .1) and TL expansion (+14.5 ± 27.2 vs +36.8 ± 28.3 cm3, P = .008) when compared to LF group. CONCLUSIONS: Preoperative HF in the FL has an unfavorable effect on thoracic aortic diameter in one week post-TEVAR. This might increase the risk of aortic rupture.

Hydrogen Sulfide Attenuates Aortic Remodeling in Aortic Dissection Associating with Moderated Inflammation and Oxidative Stress through a NO-Dependent Pathway.

Aortic dissection (AD) is a highly lethal vascular disease characterized by separation of the constituent layers of the aortic wall. An increasing body of research indicates that inflammatory response and oxidative stress are implicated in vascular remodeling, which plays a key role in the development of AD. Hydrogen sulfide (H2S) has been found to protect against various types of cardiovascular disease, including myocardial infarction, arthrosclerosis, and hypertension. However, research on the effect of H2S on AD is insufficient. This study therefore elucidated the effect of H2S on the development and progression of AD, and the potential mechanism involved. Using ß-aminopropionitrile fumarate (BAPN) and angiotensin II (Ang-II)-induced AD animal models, the administration of NaHS (as H2S donor, 56 µmol/kg body weight/day) was found to retard the development of AD. Murine VSMCs (Movas) exposed to interleukin-6 (IL-6) (20 ng/mL) to induce phenotypic switch. Histological analyses indicated that H2S administration inhibited the accumulation of inflammatory cells in the aortic wall and the related expression of inflammatory genes. Additionally, H2S treatment elevated aortic superoxide dismutase (SOD) activity and ablated malonaldehyde (MDA) and nitric oxide (NO) levels. In mechanistic terms, H2S attenuated IL-6 induced a pathological VSMC phenotypical switch through NO modulation by N(G)-monomethyl-L-arginine acetate salt (L-NMMA) stimulation. H2S inhibits AD formation by decreasing the inflammatory response, and oxidative stress, and by positively participating in vascular remodeling. These findings suggest a role for H2S as a novel and promising therapeutic strategy to prevent AD development.

Midterm result of custom-made iliac branch device for common iliac aneurysm with and without abdominal aortic aneurysm.

OBJECTIVES: Although commercial iliac branch devices offer a new and valid endovascular approach to treating iliac aneurysm and effectively preserve antegrade flow of the internal iliac artery, their use may not be suited for all types of challenging anatomy, especially isolated common iliac artery aneurysm. Our custom-made iliac bifurcation device has a unique design and excludes both combined and isolated iliac branch aneurysm. This study validated the efficacy and safety of the custom device by comparing clinical outcomes between groups receiving commercial and custom devices. METHODS: Data of consecutive patients receiving iliac bifurcation device implantation for iliac aneurysm with or without concomitant endovascular repair for abdominal aortic aneurysm from January 2010 to May 2019 were reviewed. RESULTS: Iliac bifurcation device implantation with or without concomitant abdominal aortic aneurysm stent grafting was completed in 46 patients (commercial, n = 35; custom, n = 11). No significant differences were observed regarding postoperative complications, occlusion or endoleak. Comparisons of primary (80.8% vs 85.7%, P = 0.88) and secondary (86.5% vs 85.7%, P = 0.85) patency and freedom from reintervention (88.2% vs 100%, P = 0.33), all-cause mortality (78.6% vs 100%, P = 0.25) and aneurysm-related mortality (100% vs 100%, P = 1.00) also indicated no differences at a 5-year surveillance point. Furthermore, the iliac aneurysms of the groups displayed similar shrinkage 1 year after procedures. CONCLUSIONS: For iliac aneurysm, the novel custom-made iliac bifurcation device is an adaptable design not inferior to commercial devices with regard to postoperative complications, bridge occlusion, endoleak and short-term aneurysm remodelling. It provides an alternative for treatment, particularly when certain anatomic challenges are present. CLINICAL TRIAL REGISTRATION: 2018-07-050BC, 2017-01-023ACF.