Comparison of the outcomes between open and hybrid approaches in the treatment of thoracoabdominal aortic aneurysms repair / 北京大学学报(医学版)

OBJECTIVE@#Thoracoabdominal aortic aneurysm is one of the most challenging aortic diseases. Open surgical repair remains constrained with considerable perioperative morbidity and mortality. The emergence of a hybrid approach utilizing visceral debranching with endovascular aneurysm repair has brought an alternative for high-risk patients. This study aimed to compare the short- and long-term outcomes between hybrid and open repairs in the treatment of thoracoabdominal aortic aneurysms.@*METHODS@#In this retrospectively observational study, patients with thoracoabdominal aortic aneurysm treated in a single center between January 2008 and December 2019 were reviewed, of whom 11 patients with hybrid repair, and 18 patients with open repair were identified. Demographic characteristic, operative data, perioperative morbidity and mortality, freedom from reintervention, and long-term survival were compared between the two groups.@*RESULTS@#In the hybrid repair group, the patients with dissection aneurysm, preoperative combined renal insufficiency, and American Society of Anesthesiologists (ASA) score of 3 or more were significantly overwhelming than in the open repair group. The operation time of debranching hybrid repair was (445±85) min, and the intraoperative blood loss was (955±599) mL. There were 2 cases of complications in the early 30 days after surgery, without paraplegia, and 1 case died. The 30-day complication rate was 18.2%, and the 30-day mortality was 9.1%. The operation time of the patients with open repair was (560±245) min, and the intraoperative blood loss was (6 100±4 536) mL. Twelve patients had complications in the early 30 days after surgery, including 1 paraplegia and 4 deaths within 30 days. The 30-day complication rate was 66.7%, and the 30-day mortality was 22.2%. The bleeding volume in hybrid repair was significantly reduced compared with open repair (P < 0.001). Besides, the incidence of 30-day complications in hybrid surgery was significantly reduced (P=0.011). During the follow-up period, there were 4 reinterventions and 3 deaths in hybrid repair group. The 1-year, 5-year, and 10-year all-cause survival rates were 72%, 54%, and 29%, respectively. In open repair group, reintervention was performed in 1 case and 5 cases died, and the 1-year, 5-year, and 10-year all-cause survival rates were 81%, 71%, and 35%, respectively. There was no significant difference between hybrid repair and open repair in all-cause survival and aneurysm-specific survival.@*CONCLUSION@#Hybrid approach utilizing visceral debranching with endovascular aneurysm repair is a safe and effective surgical method for high-risk patients with thoracoabdominal aortic aneurysms. The incidence of early postoperative complications and mortality is significantly reduced compared with traditional surgery, but the efficacy in the medium and long term still needs to be improved.

Spinal cord stimulation for non-reconstructable chronic ritical limb ischemiae: a case report / 北京大学学报(医学版)

Peripheral arterial disease is one part of systematic atherosclerosis, becoming a heavy burden of human health. Patients in end stage of peripheral arterial disease manifest critical limb ischemia with severe rest pain and refractory ulcer. Surgical revascularization is the optimal option for patients with critical limb ischemia to avoid major amputation and improve quality of life. However, some of them contraindicate surgical revascularizations owing to coexisting morbidities. Spinal cord stimulation is reported to be effective and minimally invasive in pain relief and limb salvage for patients with limb ischemia. Here, we reported one case with chronic critical limb ischemia and gangrene of foot who underwent spinal cord stimulation, which was, as we knew, the first case in China. He was diagnosed with Burger disease and accompanied with history of stroke, chronic obstructive pulmonary disease and Castleman's disease. It showed totally occlusive lesions of external iliac and femoropopliteal artery and no outflows below the knee in the computed tomography angiography. Given the complexity of lesions and weakness of the patient, spinal cord stimulation was indicated for control of rest pain and limb salvage. As specified, we implanted the temporary neurostimulator as the first step. After 2 weeks from temporary neurostimulator implantation, the patient achieved significant relief in intensity of pain, and acquired 20% improvement of transcutaneous oxygen pressure. The satisfactory results indicated probable effectiveness of spinal cord stimulation, thus we performed the permanent neurostimulator implantation 1 month later. During 2 months of follow-up, the patients stabilized at Fountain III with pain relief with one kind of nonsteroidal anti-inflammatory drug. In our case, we confirmed the significant validity of spinal cord stimulation for pain control and consequent improvement of quality of life in non-reconstructable chronic critical limb ischemia. Furthermore, we reviewed that a number of published studies suggested that spinal cord stimulation be a reasonable option for patients with critical rest pain, especially who contraindicated surgical revascularization. The application of spinal cord stimulation in pain relief for non-reconstructable chronic critical limb ischemia was approved by related guidelines released by European Society of Cardiology and Trans-Atlantic Inter-Society Consensus. Further investigations are required for assessing the long-term outcome in limb salvage.

Open and Endovascular Treatment of Trans-Atlantic Inter-Society Consensus II D Aortoiliac Occlusive Lesions: What Determines the Rate of Restenosis? / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Open surgery is the preferred approach for the treatment of type D lesions according to the Trans-Atlantic Inter-Society Consensus (TASC) II guideline, but endovascular solutions also appear to be a valid option in selected patients. The study aimed to identify the risk factors of restenosis after open and endovascular reconstruction of symptomatic TASC II D aortoiliac occlusive lesions (AIOLs).</p><p><b>METHODS</b>Fifty-six patients (82 limbs) who underwent open repair and endovascular treatment (ET) for symptomatic TASC ΙΙ D AIOLs between March 2005 and December 2012 were retrospectively reviewed. Baseline characteristics, preoperative and postoperative imaging, and operation procedure reports were reviewed and analyzed. Restenosis after revascularization was assessed by duplex ultrasound or computed tomography angiogram. Kaplan-Meier survival analysis, Log-rank test, and multivariate Cox regression were used to evaluate the relevance between risk factors and patency.</p><p><b>RESULTS</b>The mean duration of follow-up was 42.8 ± 23.5 months (ranging from 3 to 90 months). Primary patency rates at 1-, 3-, 5-, and 7-year were 93.6%, 89.3%, 87.0%, and 70.3%, respectively. Restenosis after revascularization occurred in 11 limbs. Kaplan-Meier survival analysis and the Log-rank test revealed that diabetes, Rutherford classification ≥5 th and concurrent femoropopliteal TASC II type C/D lesions were significantly related to the duration of primary patency. According to the result of Cox regression, diabetes and femoropopliteal TASC ΙΙ type C/D lesions were identified as the risk factors for restenosis after revascularization.</p><p><b>CONCLUSION</b>This study demonstrated that diabetes and femoropopliteal TASC ΙΙ type C/D lesions are risk factors associated with restenosis after open and ET of TASC II D AIOLs.</p>

Analysis of surgical treatment results in 120 cases of Budd-Chiari syndrome / 中华外科杂志

<p><b>OBJECTIVE</b>To evaluate the results of the surgical treatment of patients with Budd-Chiari syndrome (BCS).</p><p><b>METHODS</b>The clinic data of 120 BCS patients who underwent various consecutive surgical treatments from July 2001 to October 2010 was analyzed. There were 82 male and 38 female patients, aging from 11 to 72 years with a mean age of (41 ± 13) years. All patients experienced various examinations to identify the pathological type of BCS. There were 5 cases of small hepatic veins type, 28 cases of large hepatic veins (LHV) type, 31 cases of inferior vena cava (IVC) type and 56 cases of combined obstruction of LHV and IVC. Totally, 25 patients experienced interventional treatment, include percutaneous transluminal angioplasty and/or stenting for stenosis of hepatic vein and/or IVC, 77 patients experienced open-thorax operation for BCS radical resection under protection of right atrium by-pass with extracorporeal circulation.</p><p><b>RESULTS</b>Totally 97 cases were followed up from 1 to 120 months after various surgical treatment methods. Perioperative mortality was 6.2% (6/97). Follow-up period mortality was 8.2% (8/97). The restenosis of IVC and/or hepatic vein happened in 3 cases out of 25 cases in intervention treatment group in contrast with 15 cases out of 77 cases in radical resection group. The 5-year patency and survival rate of IVC/hepatic vein were 64.5% and 83.3%.</p><p><b>CONCLUSIONS</b>The surgical treatment of BCS need to get accurate diagnosis and pathological classification firstly, then, to choose appropriate therapeutic strategies based on individual pathological classification. The BCS radical resection can be an alternative method in some particular pathological classifications and the cases who failed in interventional treatment.</p>

Management of prosthetic graft infection after lower limb arterial bypasses / 中华外科杂志

<p><b>OBJECTIVE</b>To summarize the experience in management of prosthetic graft infection (PGI) after lower limb arterial bypasses and investigate optimal measures for prevention and treatment.</p><p><b>METHODS</b>Records of 15 cases of PGI between January 2004 and December 2009 were retrospectively analyzed, including 14 male and 1 female with the average age of 64.8 years (ranged from 40 to 84 years). PGI occurred from 5 d to 59 months (average 6.4 months) after the last reconstructive procedures with symptoms as follow: nonhealing wound with vascular graft exposure in 8 cases, persistent sinus related to vascular graft with purulent secretion in 5 cases and without secretion in 1 case, and ill-incorporated graft with peri-graft fluid in 1 case. Broad-spectrum antibiotics were administrated in all PGI cases. Surgical treatments included local debridement and drainage in 4 cases (one death from postoperative acute myocardial infarction), local debridement and skin flap rotation in one case, complete removal of the occluded infected grafts in 8 cases including major amputation in 3 cases, removal of patent infected graft and extra-anatomic bypass with silver-bonded Dacron vascular graft in 1 case, and partial removal of patent infected graft without reconstruction in 1 case with a re-canalized stent-graft.</p><p><b>RESULTS</b>Limb salvage was achieved in 9 cases, and 4 cases received major amputation. One case was failed to follow-up and one died of postoperative acute myocardial infarction. Initially 13 patients were followed and 2 died during follow-up (because of colon carcinoma and intracranial hemorrhage respectively). Eleven patients were followed for 1 to 70 months (average 22.3 months) including 8 cases with limb salvage and 3 with major amputation. Accumulative mortality rate, amputation rate, and graft occlusion rate were 20% (3/15), 26.7% (4/15), and 53.3% (8/15) respectively.</p><p><b>CONCLUSIONS</b>PGI after lower limb arterial bypasses is a devastating complication with high risk of graft occlusion and amputation. Removal of the infected grafts may be mandatory for most cases, but local management for patent infected grafts may be recommendable for selected cases.</p>

Single-stage replacement of total aorta for type I dissection with renal failure / 中华外科杂志

<p><b>OBJECTIVE</b>To investigate the feasibility of one-stage replacement of total aorta for patient with renal failure.</p><p><b>METHODS</b>The patient was male, 43 years old. The type I aortic dissection was secondary to type III aortic dissection 4 months after endovascular treatment of descending aorta using stented graft 1 year ago. All important branches from aorta were irrigated by false lumen of dissection except left renal artery. The patient has been dialyzed because of renal failure before 5 months with low platelets. Single-stage replacement of total aorta from ascending aorta to iliac artery was successful under deep hypothermia and cardiopulmonary bypass. The operation lasted 12 h. Blood loss during operation was 9000 ml and infusion of blood and blood plasma 7300 ml (including 1500 ml of blood retrieval) and blood platelet 800 ml.</p><p><b>RESULTS</b>Autonomic activity of four limbs was recovered 2 d after operation, and mind recovered 4 d after surgery. The intubation of trachea was extracted 1 week after operation. Re-check through CT showed all vascular prostheses and reconstructed visceral arteries and intercostal arteries were patent though no recovery of renal function.</p><p><b>CONCLUSION</b>One-stage replacement of total aorta for patient with renal failure is feasible.</p>

Management of bypass graft occlusion of lower extremity / 中华外科杂志

<p><b>OBJECTIVE</b>To explore the experience of management of graft occlusion in patients with lower extremity bypass grafting.</p><p><b>METHODS</b>From July 2002 to September 2009, 115 cases of graft occlusion were treated in 64 patients with lower extremity arterial bypass, including medical therapy for 8 cases and redo operations for 107 cases: graft thrombectomy alone for 32 cases, redo bypass operation with prosthetic grafts for 27 cases, graft thrombectomy plus balloon angioplasty for 17 cases, major amputation for 13 cases, graft thrombectomy plus endarterectomy for 10 cases, removal of occluded graft with infection for 4 case, distally bypass grafting with autologous saphenous vein for 3 case, and autologous stem cell transplanting for 1 case.</p><p><b>RESULTS</b>One patient died of acute renal failure during peri-operative period and 3 patients died during follow-up period, 5 patients were lost to follow-up including 2 with medical therapy. The remaining 55 patients were followed up for 4 to 70 months (average 39 months): medical therapy for 8 patients, major amputation for 12 patients (21.8%), and patent grafts after reconstruction in 35 patients (63.6%).</p><p><b>CONCLUSION</b>For graft occlusions after lower extremity bypass grafting, redo bypass operation and graft thrombectomy plus endarterectomy or balloon angioplasty may produce better early results.</p>

Preliminary study on etiology of Budd-Chiari syndrome through clinic and experiment / 中华外科杂志

<p><b>OBJECTIVE</b>To investigate the etiology of Budd-Chiari syndrome (BCS) preliminarily.</p><p><b>METHODS</b>The clinical findings of radical surgery of 109 cases with BCS from March 2001 to May 2009 were analyzed. The pathological components of membranous tissue (MT) from inferior vena cava (IVC) or hepatic vein (HV) of BCS patients were compared with that of thrombus from deep venous thrombosis (DVT), as well as the expression of transforming growth factor beta receptor (TGF-beta R), platelet derived growth factor receptor (PDGFR), endothelin (ET-1), factor VIII related antigen (FVIII-rAg), ferritin and alpha1-antitrypsin in MTs and thrombus through immunohistochemical method.</p><p><b>RESULTS</b>One hundred and four cases of BCS were due to IVC and/or HV membrane or thrombosis except that 4 cases due to IVC tumor or 1 case due to compression of fiber. The new-formed IVC membrane was found in 2 recurred cases whose IVC thrombus was excised before 1 year and 7 years. The development from organized thrombus to MT was found in 3 cases of segmental obstruction of IVC. The IVC membrane located below HV outlet was in 8 cases. Both MTs and thrombus had the pathological components such as fibroblast, neutrophil, granulation tissue, newly-formed blood vessels and so on under the light microscope. The expressions of TGF-beta R, PDGFR, ET-1, FVIII-rAg, and ferritin in MTs and thrombus were as follows: MT 72.3%, thrombus 50.0% (P > 0.05); MT 45.5%, thrombus 100% (P < 0.05); MT 100%, thrombus 0 (P < 0.05); MT 90.9%, thrombus 12.5% (P < 0.05); MT 72.3%, thrombus 100% (P > 0.05).</p><p><b>CONCLUSIONS</b>The membranous tissues and thrombus have the similar homogeneity and cytokines expression. The membrane and thrombus may be different pathological phases.</p>

Balloon dilation alone in treatment of arteriosclerotic stenosis or occlusions of femoropopliteal arteries / 中华外科杂志

<p><b>OBJECTIVE</b>To evaluate the use and efficacy of balloon dilation in arteriosclerotic stenosis or occlusions of femoropopliteal arteries.</p><p><b>METHODS</b>Thirty patients (27 men, 3 women, age from 44 to 78 years, mean 70) with arteriosclerotic stenosis or occlusion of femoropopliteal arteries received balloon dilation. Thirty-one balloons, which included 3 common balloons, 16 cutting balloons, 10 "deep" balloons and 2 small balloons, were used. Follow-up surveillance featured periodic physical examination and duplex scanning.</p><p><b>RESULTS</b>In all 30 patients, the technique success was reached only with 6 minor dissections. Angiography after dilation showed that the treated vessels were all patent with a < 20% stenosis remaining in any given lesions. After treatment and over a follow-up of 1 to 17 months (mean 6 months), the symptoms were relieved and all treated vessels were patent except 1 patient (3.3%) who had a gangrene foot and received limb amputation.</p><p><b>CONCLUSION</b>Balloon dilation has a comparative ratio of one-stage success and short-term patency. Some special balloons seem to have a promising future in the management of femoropopliteal arterial arteriosclerotic lesions.</p>

Radical surgery for Budd-Chiari syndrome through exposure of the entire inferior vena cava of the hepatic segment / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Several kinds of radical surgery for the treatment of Budd-Chiari syndrome (BCS) have been devised. We have described preliminary efforts to treat BCS using a novel radical resection technique to expose the entire inferior vena cava (IVC) of the hepatic segment.</p><p><b>METHODS</b>Sixty patients with BCS were treated by radical resection, including 46 men and 14 women. BCS patients ranged in age from 11 to 62 years, with 3 months to 11 years since the BCS diagnosis. The lesions included membrane occlusion of the IVC in 16 patients, double membranes within the IVC in 2 patients, double membranes within the IVC and the hepatic vein (HV) in 3 patients, IVC membrane with distal thrombosis in 10 patients, long segment thrombosis of the IVC in 5 patients (organized thrombosis in 2 patients, fresh thrombosis in 3 patients), occlusion of the outlet of the HVs due to mural thrombosis in 2 patients, segmental occlusion of the IVC in 3 patients, membranes within the HV with IVC stenosis due to protrusion of HV stent in 1 patient, HV membranes in 11 patients, extensive occlusion of HVs in 1 patient, the whole IVC tumor thrombus with tumor thrombus of 2/3 right atrium resulting from a posterior peritoneum tumor in 1 patient, IVC leiomyosarcoma in 2 patients, IVC leiomyosarcoma with tumor thrombus into 1/2 right atrium in 1 patient, IVC thrombosis extending into right atrium in 1 patient, compression of supra-hepatic segment of IVC due to fiber trabs in 1 patient.</p><p><b>RESULTS</b>All lesions were successfully resected under direct supervision. Three procedures were performed under extracorporeal circulation, 52 patients with catheterization of the right atrium, 4 patients with a cell saver, and one patient with auto-retrieval of blood. The retrieved blood was from 300 ml to 4000 ml. Transfusion of banked blood was from 400 ml to 2000 ml for 14 patients. For the other patients no transfusion of banked blood was required. One patient died of renal failure peri-operatively. Newly formed IVC membrane was found for one recurrent patient whose IVC thrombosis was removed one year prior. Restenosis of the IVC was observed post-operatively without symptoms in one patient. In the other patients, no recurrent symptom was found during the follow-up periods.</p><p><b>CONCLUSION</b>This novel surgery provides a clear visual field during the procedure and yields satisfactory short and long-term results.</p>

Diagnosis and treatment of Budd-Chiari syndrome / 中国医学科学院学报

The etiology and pathology of Budd-Chiari syndrome (BCS) remain unclear. The membrane in some membranous BCS may be derived from the absorption and organization of the thrombus of inferior vena cava (IVC). The long-term efficacies of currently available graft shunt operations are unsatisfactory. Interventional therapy or radical resection of lesion should be recommended. The IVC stenosis actually results from the compression of hepatomegaly and should not be classified as BCS. The membranous BCS is an acquired disease.