Contrast-Free Endovascular Aneurysm Repair Combined With Fibrin Sealant Filling for Treating Abdominal Aortic Aneurysm: Technical Note.

INTRODUCTION: Endovascular aneurysm repair using iodinated contrast agents risks contrast-induced nephropathy, especially in high-risk patients. This technical note describes a contrast-free endovascular aneurysm repair (EVAR) protocol using preoperative imaging measurement and fibrin sealant (FS) filling. TECHNIQUE: Preoperative imaging measurement and intraoperative guidewire manipulation facilitated anatomical identification without contrast. After endograft deployment, the aneurysm sac was filled with FS if endoleak was indicated by pressure fluctuations. RESULT: Between 2017 and 2020, 6 high-risk patients underwent contrast-free EVAR with FS filling. Complete exclusion was achieved in all cases. Over follow-up, no endoleaks, deterioration in renal function, or other complications were observed. CONCLUSION: Contrast-free EVAR with FS filling shows early feasibility as an alternative technique for contrast-induced nephropathy (CIN) high-risk patients, while larger studies with long-term monitoring are imperative to validate outcomes. CLINICAL IMPACT: This study showcases a contrast-free EVAR technique with fibrin sealant filling for high-risk CIN patients. It offers a safer approach for those with renal challenges, reducing CIN risk. The technique's feasibility in a small cohort suggests its utility in treating AAA without iodinated contrast, crucial for patients with specific health risks. For clinicians, it introduces a method that decreases nephrotoxic risks, potentially changing practice for vulnerable patients.

A comparative study on the transbrachial and transfemoral approaches for the treatment of superior mesenteric artery lesions.

BACKGROUND: Superior Mesenteric Artery (SMA) lesions present a significant challenge in endovascular surgery. Both the transbrachial (TBA) and the transfemoral (TFA) approaches have been employed for the treatment of these lesions, but the comparative effectiveness of these methods remains unclear. MATERIALS AND METHODS: A retrospective analysis was conducted on patients who underwent TBA and TFA at a tertiary center between June 2020 and February 2023. Key parameters including technical success, procedural details, and complication rates were examined. RESULTS: In a study of 99 patients, 66 underwent Transfemoral Approach (TFA) and 33 underwent Transbrachial Approach (TBA). No significant age or gender differences were noted between groups. TFA procedures were longer (90.0 vs 63.5 min, p = 0.002) and had higher fluoroscopy times (59.0 vs 43.0 min, p = 0.02) and selective SMA times (366.0 vs 245.0 min, p = 0.038) compared to TBA, especially with a smaller aortomesenteric angle (<90°). Technical success rates were high in both groups (TFA 97%, TBA 93.9%, p = 0.60). Complication rates were similar between groups, with no significant predictors for access site complications identified. CONCLUSION: Both the TBA and the TFA are effective for the treatment of SMA lesions, with TBA potentially offering advantages in terms of efficiency and patient recovery, particularly in cases with certain anatomy. No significant differences in complication rates were found between the two groups. Further research, including prospective randomized trials, is needed to confirm these findings.

Emergency EVAR for Abdominal Aortic Aneurysm Ruptured Into the Duodenum With an Aortic Dissection.

We report a case of aortoduodenal fistula formed after an abdominal aortic aneurysm ruptured into the duodenum. There is also an aortic dissection involving the celiac trunk, superior mesenteric artery and renal arteries. Successful treatment was achieved through endovascular aortic repair, followed by anti-infective and supportive therapy over 3 months.

Retrievable Inferior Vena Cava Filter Trapped Embolus: A Risk Factor of Detachment of Thrombus Analysis Based on a Multicenter Prospective Observational Study.

PURPOSE: Up to now, the indications of inferior vena cava filter placement still remain controversial in the academic field. The aim of this study was to determine the risk factors of detachment of thrombus and to evaluate the necessity of inferior vena cava filter placement to prevent fatal pulmonary embolism. MATERIALS AND METHODS: A total of 2892 patients participated in the multicenter prospective observational study from January 1, 2018, to December 31, 2018, and underwent retrievable inferior vena cava filter (RIVCF) placement in 103 centers in China. The primary endpoint of the study was RIVCF trapped embolus detected by inferior vena cava venography/ultrasound/computed tomography scanning or visible macroscopic thrombus before or during RIVCF retrieval. The relative factors of RIVCF trapped embolus were analyzed accordingly. RESULTS: The average age of the patients was 61.0 (50.0-71.0) years. Retrievable inferior vena cava filter trapped embolus occurred in 308 patients (10.65%). The fracture location, surgery location, and endovascular intervention differed between RIVCF trapped embolus and non-RIVCF trapped embolus groups (p<0.001, respectively). By multivariate analysis, RIVCF trapped embolus were less common in older patients (odds ratio [OR]=0.998; p<0.001) and more common in patients with below-the-knee fracture (OR=1.093, p=0.038), thigh fracture (OR=1.118, p=0.007), and pelvis surgery (OR=1.067, p=0.016). In addition, compared with patients without endovascular intervention, patients with percutaneous mechanical thrombectomy (PMT) + catheter-directed thrombolysis (CDT) were more prone to develop RIVCF trapped embolus (OR=1.060, p=0.010). However, RIVCF trapped embolus was less common in patients with CDT (OR=0.961, p=0.004). CONCLUSIONS: Lower limb fracture, pelvis surgery, and PMT + CDT are prone to cause trapped embolus. As a trapped embolus often represents the possibility of severe pulmonary embolism, lower limb fracture, pelvis surgery, and PMT + CDT could be risk factors of fatal pulmonary embolism. Due to the low incidence of trapped embolus, it is not necessary to place filters in elderly patients and CDT-only patients. CLINICAL IMPACT: The purpose of this paper is to standardize the use of inferior vena cava filter and avoid unnecessary filter implantation through the summary and analysis of a large number of clinical data. At the same time, more attention should be paid to and active treatment should be given to high-risk groups of pulmonary embolism.

A Chinese expert consensus on thoracic endovascular aortic repair of type B aortic dissection with a single-branched stent graft for revascularization of the left subclavian artery.

Thoracic endovascular repair (TEVAR) is currently the recommended and most widely used treatment for type B aortic dissection. A major challenge is revascularization of the left subclavian artery in order to extend the landing zone to zone 2 (Ishimaru classification). Various strategies have been used for revascularization, including branched stent graft, fenestrated stent graft, the chimney technique, the parallel technique, and bypass surgery. Single-branched stent graft is one of the most promising strategies, and several products have recently been reported as potential candidates for use with this approach. The Castor single-branched stent graft is the only off-the-shelf product available; this product has been developed through collaboration between Chinese corporations and clinicians. In this Perspective article, clinical experience and data obtained from TEVAR with the Castor single-branched stent graft are summarized by experienced Chinese experts.

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.

A novel endovascular robotic-assisted system for endovascular aortic repair: first-in-human evaluation of practicability and safety.

OBJECTIVES: To assess the practicability and safety of a novel endovascular robotic system for performing endovascular aortic repair in human. METHODS: A prospective observational study was conducted in 2021 with 6 months post-operative follow-up. Patients with aortic aneurysms and clinical indications for elective endovascular aortic repair were enrolled in the study. The novel developed robotic system is applicable for the majority of commercial devices and various types of endovascular surgeries. The primary endpoint was technical success without in-hospital major adverse events. Technical success was defined as the ability of the robotic system to complete all procedural steps based on procedural segments. RESULTS: The first-in-human evaluation of robot-assisted endovascular aortic repair was performed in five patients. The primary endpoint was achieved in all patients (100%). There were no device- or procedure-related complications or no in-hospital major adverse events. The operation time and total blood loss in these cases were equal to those in the manual procedures. The radiation exposure of the surgeon was 96.5% lower than that in the traditional position while the radiation exposure of the patients was not significantly increased. CONCLUSIONS: Early clinical evaluation of the novel endovascular aortic repair in endovascular aortic repair demonstrated practicability, safety, and procedural effectiveness comparable to manual operation. In addition, the total radiation exposure of the operator was significantly lower than that of traditional procedures. CLINICAL RELEVANCE STATEMENT: This study applies a novel approach to perform the endovascular aortic repair in a more accurate and minimal-invasive way and lays the foundation for the perspective automation of the endovascular robotic system, which reflects a new paradigm for endovascular surgery. KEY POINTS: • This study is a first-in-human evaluation of a novel endovascular robotic system for endovascular aortic repair (EVAR). • Our system might reduce the occupational risks associated with manual EVAR and contribute to achieving a higher degree of precision and control. • Early evaluation of the endovascular robotic system demonstrated practicability, safety, and procedural effectiveness comparable to that of manual operation.

A systematic review and meta-analysis of thoracic endovascular aortic repair with the proximal landing zone 0.

Background: Thoracic endovascular aortic repair, initially intended for thoracic aortic disease treatment, has extended its application to the proximal zone of the aorta. However, the safety and surgical outcomes of extending the proximal landing zone into the ascending aorta (zone 0) in selected cases remain unknown. Thus, we performed a systematic review and meta-analysis of zone 0 thoracic endovascular aortic repair (TEVAR) to obtain a deeper understanding of its safety, outcomes, and trends over time. Methods: A literature search was performed using PubMed, EMBASE, and Web of Science databases in accordance with the preferred reporting items for systematic reviews and meta-analyses guidelines, from January, 1997 to January, 2022. Only studies involving zone 0 TEVAR were included. The retrieved data from the eligible studies included basic study characteristics, 30-day/in-hospital mortality rate, indications, comorbidities, stent grafts, techniques, and complications. Summary effect measures of the primary outcomes were obtained by logarithmically pooling the data with an inverse variance-weighted fixed-effects model. Results: Fifty-three studies with 1,013 patients were eligible for analysis. The pooled 30-day/in-hospital mortality rate of zone 0 TEVAR was 7.49%. The rates of post-operative stroke, type Ia endoleak, retrograde type A aortic dissection, and spinal cord ischemia were 8.95, 9.01, 5.72, and 4.12%, respectively. Conclusions: Although many novel stent grafts and techniques targeting zone 0 TEVAR are being investigated, a consensus on technique and device selection in zone 0 TEVAR is yet to be established in current practice. Furthermore, the post-operative stroke rate is relatively high, while other complication rates and perioperative death rate are comparable to those of TEVAR for other aortic zones.

Fibrin Glue Sac Filling for Preventing Type II Endoleak, Short-Term Outcomes of a Prospective Randomized Controlled Trial.

OBJECTIVE: Type II endoleak (T2EL) worsens the long-term results of endovascular aneurysm repair (EVAR). How to prevent T2ELs remains controversial. This study aimed to evaluate the efficacy and safety of fibrin glue sac filling (FGSF) to prevent T2ELs after EVAR. METHODS: A prospective randomized controlled trial was conducted. Patients were randomly divided into group A (standard EVAR + FGSF) and group B (standard EVAR). The follow-up plans included outpatient or telephone consultation at 1 and 3 months and computed tomography (CT) angiography at 6 months, 1 year, and once a year after EVAR. RESULTS: A total of 64 abdominal aortic aneurysm (AAA) patients were randomized to the 2 groups. All patients were followed up for more than 6 months. The 2 groups showed similar baseline characteristics. The rate of T2ELs on immediate angiography in group A (9.6%) was significantly lower than that in group B (33.3%, p=0.033). Moreover, the sac area change was significantly reduced in group A at 6 months after EVAR (p=0.021). However, T2EL incidence was similar at the 6-month (p=0.055) and 1-year (p=0.057) follow-ups, and AAA diameter change was also similar at 1 year. There were similar operation times, radiation doses, severe adverse events (SAEs), and reinterventions between the 2 groups. CONCLUSION: Fibrin glue sac filling could prevent short-term type II endoleaks and promote AAA shrinkage after 6 months. The FGSF procedure is swift and straightforward; however, patients are at risk of bowel ischemia, especially after previous bowel resections or concomitant superior mesenteric artery (SMA) disease. CLINICAL IMPACT: Standard endovascular aneurysm repair (EVAR) couldn't prevent type II endoleak (T2EL). In this study, we found fibrin glue sac filling (FGSF) could prevent T2EL and promote AAA shrinkage in a short term. And the FGSF procedure is easy, it will be a useful supplement to standard EVAR for clinicians. And FGSF might have potential usefulness on ruptured aneurysms, although without direct evidence.Fibrin glue is often used to hemostasis and tissue adhesion in surgical patients and burn patients, we firstly carry out a randomized controlled study and prove that fibrin glue sac filling could prevent T2EL and promote sac remodeling.

A multicenter retrospective analysis of the clinical outcome following endovascular treatment of extremity arteriovenous malformation.

BACKGROUND: The arteriovenous malformation (AVM) represents a complicated pathology with high recurrence risk. This study aimed at reporting the clinical outcome of embolotherapy in treating extremity AVMs and exploring the potential risk factors for the recurrence of the lesion. METHODS: A multicenter retrospective review of the electronic medical records database was performed to enroll extremity AVM cases. Based on the follow-up findings, patients were allocated into the recurrence group and non-recurrence group. Univariable comparisons were performed to find relevant factors for AVM recurrence, then each potential factor was assessed by Kaplan-Meier analysis to determine whether it could influence the time-dependent recurrence possibility. RESULTS: Between January 2010 and December 2020, we screened 339 cases and enrolled 35 patients (24 male, average age: 45.23±17.57 years). During an average follow-up period of 5.91±3.22 months, recurrence of AVM was found in 18 cases. Univariable analysis documented type IIIb AVM and previous surgical attempts potentially indicated a high recurrence possibility, whereas type II, application of coil and ethanol during the intervention, as well as optimal embolization might be helpful to control the pathology. Of these relevant factors, further Kaplan-Meier analysis found that previous surgical attempts (P=0.002), application of ethanol (P=0.015), AVM type II (P=0.048), and IIIb (P=0.030) might have a significant impact on recurrence probability. CONCLUSIONS: Previous surgical attempts might increase the recurrence risk after embolotherapy of the AVM, whereas using ethanol as the embolic agent seems to contribute to a lower recurrence probability. Type II AVM may respond better to embolization than type IIIb.

The effect of different frames filters on the prevention of pulmonary embolism in fracture patients subsequent with deep venous thrombosis on a multicenter prospective observational study.

BACKGROUND: A retrievable inferior vena cava filter (RIVCF) is used for the prevention of a pulmonary embolism, especially originated from deep venous thrombosis (DVT). However, which frame of RIVCF has an better effect on the specific thrombus has not been reported. METHODS: All patients enrolled underwent RIVCF placement in the study, and the placement and retrieval followed the respective instructions of different brands of RIVCFs. During the study period, the frame of the filter, the combined fracture site and operation, and the filter trapped embolus (TE) were collected. The primary observation indicators of this study were the occurrence of TE in two frames of filters and different fracture sites. Secondary observation indicators were the occurrence of TE with two different frames filters in different fracture site and surgical site subgroups. RESULTS: In all 2892 patients enrolled, RIVCF TE was detected in 308 cases (10.7%) according to our definition. Among them, there were 1968 cases of fusiform RIVCF and 924 cases of umbrella RIVCF. There were 663 patients combined with fractures before DVT. The incidence of TE was significantly higher in patients with fusiform RIVCF (230 [74.68%]) than in those with umbrella RIVCF (78 [25.32%]) (P < .05). In patients with below-the-knee fracture surgery, there was significant difference in the incidence of TE between the two frames of RIVCF (P < .05). CONCLUSIONS: This conclusion suggests that, in patients with DVT secondary to below-the-knee fracture, the detached thrombus may be more suitable for prophylaxis with fusiform frame RIVCF.

Novel Endovascular Interventional Surgical Robotic System Based on Biomimetic Manipulation.

Endovascular therapy has emerged as a crucial therapeutic method for treating vascular diseases. Endovascular surgical robots have been used to enhance endovascular therapy. However, to date, there are no universal endovascular surgical robots that support molds of different types of devices for treating vascular diseases. We developed a novel endovascular surgical robotic system that can independently navigate the intravascular region, advance and retract devices, and deploy stents. This robot has four features: (1) The bionic design of the robot can fully simulate the entire grasping process; (2) the V-shaped relay gripper waived the need to redesign special guidewires and catheters for continuous rotation; (3) the handles designed based on the feedback mechanism can simulate push resistance and reduce iatrogenic damage; and (4) the detachable design of the grippers can reduce cross-infection risk and medical costs. We verified its performance by demonstrating six different types of endovascular surgeries. Early evaluation of the novel endovascular robotic system demonstrated its practicability and safety in endovascular surgeries.

Outcomes of Zone 1 Thoracic Endovascular Aortic Repair With Fenestrated Surgeon-Modified Stent-Graft for Aortic Arch Pathologies.

OBJECTIVES: This study evaluated the feasibility and safety of zone 1 thoracic endovascular aortic repair (TEVAR) with fenestrated surgeon-modified stent-graft (SMSG) for aortic arch pathologies. METHODS: Between March 2016 and November 2020, 34 consecutive patients underwent zone 1 TEVAR with fenestrated SMSG for aortic arch pathologies. Outcomes included technical success, perioperative, and follow-up morbidity and mortality. RESULTS: During the study period, 34 patients were treated with zone 1 TEVAR with fenestrated SMSG. Twenty-four (70.6%) patients presented with type B aortic dissections, 9 (26.5%) patients presented with aneurysms (7 located on the lesser curvature side of aortic arch), 1 (2.9%) patient presented with type Ia endoleak after previous TEVAR owing to traumatic aortic dissection. The proximal landing zone for all patients were in zone 1, and all supra-aortic trunks were reconstructed, except for one left subclavian artery. Technical success was achieved in all cases. The 30-day estimated survival (±SE) was 90.9% ± 5.0% [95% confidence interval (CI): 77.0%-97.0%]. The 30-day estimated freedom from reintervention (±SE) was 87.9% ± 5.7% (95% CI: 73.4%-95.3%). At a median follow-up of 48 months (range, 12-68 months), 2 patients died, including 1 aortic-related death and 1 non-aortic-related death. One patient had reintervention 13 months after the operation owing to type Ia endoleak. All supra-aortic trunks were patent. The estimated survival (±SE) during follow-up was 85.1% ± 6.2% (95% CI: 69.9%-93.6%). One (2.7%) patient had stroke. The estimated freedom from reintervention (±SE) during follow-up was 84.2% ± 6.5% (95% CI: 69.9%-93.5%). CONCLUSIONS: Zone 1 TEVAR with fenestrated SMSG is an alternate option for treatment of aortic arch pathologies in experienced centers.

Which Frequency of Ankle Pump Exercise Should Be Chosen for the Prophylaxis of Deep Vein Thrombosis?

INTRODUCTION: Ankle pump exercise (APE) is an effective method to prevent deep vein thrombosis (DVT) in the lower extremities. However, traditional APE at a frequency of 3 times/min applied in the clinic lacked high compliance, and individuals were found to prefer an APE of 30 times/min. This study aimed to compare the effects of APEs with the above two different frequencies on the venous hemodynamics and fatigue of lower extremities. METHODS: The study applied a randomized cross-over design, and 307 healthy adults were randomly assigned into two groups, whose left feet performed 5 minutes of traditional APE (3 times/min, after 10 minutes of rest) and 5 minutes of selected APE (30 times/min, after 10 minutes of rest) in different orders. The diameters and blood flow velocities of the external iliac vein, femoral vein, and popliteal vein of the left extremities were recorded with the color doppler ultrasound when participants were at rest and after 5 minutes of traditional or selected APE. The fatigue of lower extremities was assessed with the Rating of Perceived Exertion (RPE) after the participants performed 5 minutes of different APEs. RESULTS: After both traditional APE and selected APE, the diameters and blood flow (peak systolic) velocities of the external iliac vein, femoral vein, and popliteal vein increased significantly in the participants (P<.01), and the effects of the two APEs on venous hemodynamics of the lower extremities had no significant difference (P>.05). However, participants reported that traditional APE caused higher fatigue, and 252 (82.1%) participants preferred APE at 30 times/min. CONCLUSION: Both traditional and selected APE could increase venous blood flow in the lower extremity. Despite the equivalent effects, the selected APE of 30 times/min may cause less fatigue than the traditional one of 3 times/min.

Anatomical Feasibility Study on Novel Ascending Aortic Endograft With More Proximal Landing Zone for Treatment of Type A Aortic Dissection.

Objective: Type A aortic dissection (TAAD) is associated with high morbidity and mortality, and open surgery is the best treatment option. Development of endovascular repair devices for TAAD will benefit patients deemed unfit for open surgery. In this study, we performed a thorough investigation of anatomical features in Asian patients with TAAD to learn about the patient eligibility of a novel ascending aortic endograft technique. Methods: Computed tomography angiography (CTA) images of TAAD cases in our institution from January 2015 to November 2021 were reviewed, and three-dimensional reconstructions were performed with the Endosize software (Therenva, Rennes, France). Anatomic structures including length measured along centerline and greater/lesser curvature, ascending aorta/aortic root dimensions, as well as location of entry tear and extent of dissection were analyzed. Results: A total of 158 patients were included [median age 58 years, interquartile range (IQR), 30-76 years; 115 males, 72.8%]. In 99 (62.7%) of the cases, entry tear was distal to the sinotubular junction (STJ). In 106 (67.1%) of the cases, the pathology proximally extended into the aortic root, which was intramural hematoma in 37 (23.4%) of the cases, and the aortic root was free from the pathology in 52 (32.9%) of the cases. The median distance from the STJ to the proximal edge of the ostium of the innominate artery (IA) measured along the centerline was 65 mm (IQR 58-74 mm). The median distance from the distal edge of the higher coronary ostium to the STJ was 7.95 mm (IQR 5.625-10.9 mm). The bare metal stent part was set between the edge of the higher coronary ostium and the STJ. In our series, 63 (39.9%) of the cases had this distance >10 mm. The relative difference was <20% between the STJ and the proximal edge of the ostium of the IA in 92 (58.2%) of the cases. Ascending aorta radius of curvature was 52.2 mm (IQR 43.7-63.7 mm). Conclusions: Our study demonstrates that 56.3% of the TAAD cases would be amenable to endovascular repair by the novel ascending aortic endograft, with sufficient landing zone free of the dissected aorta.

Hsa_circ_0087352 promotes the inflammatory response of macrophages in abdominal aortic aneurysm by adsorbing hsa-miR-149-5p.

Abdominal aortic aneurysms (AAA) is a common cardiovascular disease with the risk of rupture. Macrophage depletion can significantly limit the formation of experimental AAA. However, how macrophages in the arterial wall affect the focal distribution and progression of AAA remains unclear. Here, we aimed to evaluate whether circRNAs characterized by stable structure and high tissue specific expression can regulate the inflammatory response of macrophages in AAA. First, we applied bioinformatics to analyze circRNA expression profile in human AAA specimens, and screened out hsa_circ_0087352, which is up-regulated in human AAA specimens and related to inflammatory response of THP-1 macrophages induced by LPS. Besides, hsa_circ_0087352 is stably expressed in THP-1 and mainly distributed in the nucleus. Then, we constructed ceRNA network of circRNA-miRNA-mRNA (IL-6/CCL2/NF-κB) in AAA and found that hsa_circ_0087352 promotes IL-6 transcription and the secretion of inflammatory cytokines by sponging endogenous hsa-miR-149-5p in macrophages. Dual luciferase reporter gene and RNA pull-down suggested hsa_circ_0087352 directly binds to hsa-miR-149-5p. Fluorescence in situ hybridization assay showed the localization of hsa_circ_0087352 and hsa-miR-149-5p in the nucleus of macrophages. Further, western blot demonstrated hsa_circ_0087352 expands the signal transduction of ERK/NF-κB pathway, then IκB phosphorylation promotes NF-κB p65 phosphorylation and nuclear translocation. In addition, hsa_circ_0087352 overexpression in macrophages induces human vascular smooth muscle cells (VSMC) apoptosis in macrophage-VSMC coculture system via the release of proapoptotic cytokines, such as IL-6, TNF-α and IL-1ß. Overall, this study provides experimental evidence that hsa_circ_0087352 can be used as a new biomarker and therapeutic target for abdominal aortic aneurysm.

Endovascular treatment of complicated aortic aneurysms using a modified flow-diverting strategy: Mid- to long-term outcome from a multicenter cohort study.

OBJECTIVES: Frequently reported adverse events following flow-diverting stents' treatment of aortic aneurysms indicate further refinements of this technique are required. This study aims at evaluating the clinical efficacy of an improved flow-diverting strategy. METHODS: A modified flow-diverting procedure was utilized in selected patients, in which stent-grafts were used to cover the non-branched segment of the aneurysmal lesion while flow-diverting multilayered bare metal stents were applied to cover the reno-visceral segment. The safety and efficacy of this joint procedure were assessed by regular follow-up. RESULTS: We screened 497 patients and included 67 cases (mean age: 67.07 ± 12.14 years; 53 males) between February 2012 and March 2018. The median number of stent-grafts and bare metal stents used in the procedure were 1 (range: 1 to 3) and 3 (range: 2 to 4), respectively. During a mean follow-up period of 34.54 ± 20.28 months, aneurysm maximum diameter decreased from 64.79 ± 10.31 to 59.32 ± 10.20 mm (p = 0.002), while sac thrombosis ratio increased from 26.01±10.99% to 98.46±4.84% (p<0.001). Aneurysm-related death or conversion to open repair was documented in three patients. The majority side-branches (198/201) remained patent during follow-up. Overall clinical success rate reached 91.04% (61/67). CONCLUSIONS: The joint procedure is characterized by significant aneurysm thrombosis along with high aneurysm stabilization/shrinkage and side-branches' patency rate. It might represent a potential improvement of the flow-diverting strategy in treating complex aortic lesions, yet large-scale, prospective, and randomized trials are anticipated to draw a robust conclusion. ADVANCES IN KNOWLEDGE: The joint procedure could potentially exclude complex aortic aneurysms from circulation while maintaining the collateral branches.

Technical details of thoracic endovascular aortic repair with fenestrations for thoracic aortic pathologies involving the aortic arch: A Chinese expert consensus.

Thoracic aortic pathologies involving the aortic arch are a great challenge for vascular surgeons. Maintaining the patency of supra-aortic branches while excluding the aortic lesion remains difficult. Thoracic EndoVascular Aortic Repair (TEVAR) with fenestrations provides a feasible and effective approach for this type of disease. The devices needed in the procedure are off-the-shelf, with promising results reported in many medical centers. Up until now, there have been no guidelines focusing exclusively on the details of the TEVAR technique with fenestrations. Experts from China have discussed the technical parts of both in situ fenestrations (needle and laser) and fenestrations in vitro (direction inversion strategy and guidewire-assisted strategy), providing a technical reference to standardize the procedure and improve its results.

Outcomes of Total Endovascular Aortic Arch Repair with Surgeon-Modified Fenestrated Stent-Grafts on Zone 0 Landing for Aortic Arch Pathologies.

OBJECTIVES: This study evaluated the feasibility and safety of total endovascular aortic arch repair with surgeon-modified fenestrated stent-graft on zone 0 landing for aortic arch pathologies. METHODS: Between June 2016 and October 2019, 37 consecutive patients underwent total endovascular arch repair with surgeon-modified fenestrated stent-grafts on zone 0 landing. Outcomes included technical success, perioperative and follow-up morbidity and mortality, and branch artery patency. RESULTS: During the study period, 37 patients were treated with total endovascular aortic arch repair with surgeon-modified fenestrated stent-graft. Twenty-one (56.8%) patients were diagnosed with aortic dissections, 15 (40.5%) patients with aneurysms, and 1 (2.7%) patient required reintervention due to endoleak and sac expansion from previous thoracic endovascular aortic repair for thoracoabdominal aneurysm. The proximal landing zone for all patients were in zone 0, and all branch arteries of aortic arch were reconstructed. Technical success was achieved in 34 cases (91.9%). Three (8.1%) patients had fenestrations misaligned with target arteries, and the chimney technique was applied as a complementary measure. Thirty-day mortality rate was 5.4% (n=2). Thirty-day stroke rate was 5.4% (n=2). Thirty-day reintervention rate was 2.7% (n=1). At a median follow-up of 20 months (range, 3-49 months), 5 (13.5%) patients died, including 2 aortic-related deaths, 1 nonaortic-related death, and 2 deaths of unknown reason. One (2.7%) patient had stroke. Four patients (10.8%) had reintervention during the follow-up, including 2 cases of left subclavian artery occlusion and 2 cases of type II endoleak. The estimated survival (±SE) at 2 years was 72.4%±9.7% (95% CI 53.4%-91.4%). The estimated freedom from reintervention (±SE) at 2 years was 87.4%±5.9% (95% CI 75.84%-98.96%). CONCLUSIONS: Total endovascular aortic arch repair with surgeon-modified fenestrated stent-grafts on zone 0 landing is an alternate option for the treatment of aortic arch pathologies in experienced centers.