Off-the-Shelf Devices for Treatment of Thoracic Aortic Diseases: Midterm Follow-up of TEVAR With Chimneys or Physician-Made Fenestrations.

Purpose: To evaluate the midterm outcomes of thoracic endovascular aortic repair (TEVAR) using chimney grafts (ch-TEVAR) or thoracic stent-grafts with fenestrations made on the back table (f-TEVAR) to treat thoracic aortic dissection (TAD) and thoracic aortic aneurysm (TAA). Materials and Methods: A retrospective analysis was conducted of 474 consecutive patients (mean age 62.3±10.7 years; 346 men) treated with either f-TEVAR (n=110) or ch-TEVAR (n=364) for 352 TADs (81 f-TEVAR and 271 ch-TEVAR) or 122 TAAs (29 f-TEVAR and 93 ch-TEVAR) from 2008 to 2016. The primary endpoints at 30 days and during follow-up were overall mortality, aorta-related mortality, and major complications. The secondary endpoints were endoleak and reintervention. The patency of the target branches, cost of hospitalization, and the use of antiplatelet drugs were also analyzed. Results: Intraoperative type I endoleaks were treated in 69 (14.6%) cases (4 f-TEVAR and 65 ch-TEVAR, p<0.01) to achieve 100% technical success. Four (0.8%) patients died within 30 days [1 (0.9%) f-TEVAR and 3 (0.8%) ch-TEVAR]. Perioperative cerebral ischemia (1 fatal stroke) occurred in 9 (1.9%) patients: (1 f-TEVAR and 8 ch-TEVAR, p=0.39). During the mean follow-up of 50.6±20.0 months (49.5±18.3 months in f-TEVAR and 50.9±20.6 months in ch-TEVAR), 11 (2.3%) patients died of an aorta-related event. Type I endoleak was present in 40 (8.4%) patients (1 f-TEVAR and 39 ch-TEVAR, p<0.01). Eleven (2.3%) patients experienced stent-graft migration and 13 (2.7%) had a retrograde dissection. One hundred (16.9%) of the 593 branch stents occluded (4/75 in the f-TEVAR group and 96/518 in the ch-TEVAR group, p<0.01). The branch reintervention rate was 7.2% (34/474). The f-TEVAR group had a significantly higher probability of freedom from branch occlusion (92%) than the ch-TEVAR group (83%, p=0.007). Conclusion: Off-the-shelf techniques employing chimney grafts and homemade fenestrations are both suitable options for TAD and TAA involving the supra-aortic branches, with a low incidence of reintervention. Fenestrated TEVAR seems to have more favorable short- and midterm outcomes. Further study of these off-the-shelf techniques for aortic arch repair is warranted.

Blocking Interleukin-1 Beta Reduces the Evolution of Thoracic Aortic Dissection in a Rodent Model.

OBJECTIVE: Thoracic aortic dissection (TAD) is associated with matrix changes, biochemical changes, and inflammatory markers like interleukin-1 beta (IL-1ß). However, the exact mechanism remains unknown. This study aimed to investigate the role of IL-1ß, matrix metalloproteinase (MMP)-2, MMP-9, smooth muscle cell apoptosis, and elastic fibre fracture in the development of TAD in a rat model. METHODS: The TAD rat model was induced by ß-aminopropionitrile (BAPN). TAD was investigated in 112 male Sprague-Dawley rats, which were equally divided into four groups of 28 rats (Control, BAPN, BAPN + IL-1ß, and BAPN + IL-1ß antibody). Systolic blood pressure, survival, and the development of TAD were measured after six weeks. Expression of IL-1ß, MMP-2, and MMP-9 was measured by Western blot. Apoptosis, aortic elastin concentration, and biomechanical characteristics were measured by the TdT mediated dUTP nick end labelling assay, Victoria blue staining, and in vitro testing. RESULTS: During six weeks, the mortality was 0% (0/28) in the control group, 53.6% (15/28) in the BAPN group (p < .001 compared with the control group), 75.0% (21/28) in the BAPN + IL-1ß group (p = .007 compared with the BAPN group), and 35.7% (10/28) in the BAPN + IL-1ß antibody group (p = .023 compared with BAPN group and p < .001 compared with the BAPN + IL-1ß group). IL-1ß treatment deteriorates BAPN induced mortality and aneurysm expansion, which were attenuated by anti-IL-1ß treatment. In BAPN + IL-1ß group, stress and strain parameters were decreased by 13.5%-53.5% and elastin content was decreased by 14%, and IL-1ß, MMP-2, and MMP-9 were expressed higher by 117%, 108%, and 75% when compared with the rats in the BAPN group. Contrarily, in the BAPN + IL-1ß antibody group, the above changes could be completely (strain, elastin content, and expression of MMP-2) or partly (elasticity modulus, stress, and expression of MMP-9) blocked by anti-IL-1ß treatment. CONCLUSION: IL-1ß plays a critical role in TAD formation by altering the expression of MMP-2 and MMP-9, degrading the aortic wall matrix, causing elastic fibre rupture, and changing the stress or strain of the aortic wall. Anti-IL-1ß reduces the later effects and could be one of the molecular targets for prognosis and drug treatment of TAD in the future.

Long-term outcome of sac filling with fibrin sealant after endovascular aneurysm repair of abdominal aortic aneurysm with challenging aortic neck anatomy.

OBJECTIVE: A retrospective single-center study is reported here to assess the safety and long-term effectiveness of applying a fibrin sealant (FS) sac-filling strategy to eliminate type IA endoleak (TIAE) after endovascular aneurysm repair (EVAR) of abdominal aortic aneurysm. METHODS: Characteristics of abdominal aortic aneurysm patients who had challenging proximal aortic neck anatomy (short or angulated) and underwent FS sac filling to resolve TIAE after traditional EVAR in Changhai Hospital between December 2006 and July 2010 were collected and reviewed. Intrasac pressure was measured with a preloaded catheter before and after FS filling to observe the immediate curative effect. The 7- to 10-year long-term effect was evaluated on the basis of the occurrence of endoleak, maximum aneurysm diameter, all-cause mortality, and other severe complications by annual aortic computed tomography angiography check. RESULTS: There were 107 patients with short (≤15 mm; 83/107 [77.6%]) or angulated (>60 degrees; 27/107 [25.2%]) aneurysm neck who underwent FS sac filling. The mean age of the patients was 71.1 ± 12.1 years (68 male patients). Of the 107 endoleaks, 106 (106/107 [99.1%]) were resolved, and 3 (3/107 [2.8%]) patients died in the perioperative period. Intrasac systolic, diastolic, mean, and pulse pressures decreased significantly in the treated cases (systolic pressure, 114.1 ± 16.7 mm Hg vs 59.5 ± 20.4 mm Hg; diastolic pressure, 65.0 ± 10.4 mm Hg vs 51.4 ± 18.2 mm Hg; mean pressure, 81.3 ± 11.4 mm Hg vs 54.1 ± 18.8 mm Hg; pulse pressure, 49.1 ± 12.8 mm Hg vs 8.2 ± 5.2 mm Hg; P < .01). During a median follow-up period of 89.1 months, the mean maximum aneurysm diameter became significantly smaller than that observed before the operation (53.23 ± 10.9 mm vs 59.86 ± 11.77 mm). The postoperative maximum aneurysm diameter decreased in 76 patients and was stable in 22 patients. One patient with aneurysm enlargement was transferred to open surgery because of a type IV endoleak, and another patient with no blood flow into the aneurysm sac observed by computed tomography angiography was closely followed up. Four patients received repeated endovascular treatment after the occurrence of type IB endoleak and aneurysm enlargement. After a median follow-up of 89.1 months, the cumulative survival rate was 90.7%, 80.4%, 72.0%, 58.9%, and 51.4% after 1 year, 3 years, 6 years, 8 years, and 10 years after the operation, respectively. There was no recurrent type I endoleak, distal embolization, migration, kinking, or malfunction after FS injections during the perioperative period and follow-up. CONCLUSIONS: FS sac filling combined with intrasac pressure measurement is a simple and effective treatment method to eliminate TIAE after EVAR, especially for patients with challenging proximal neck anatomy. This method could expand the current indications of EVAR.

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.

Combined endovenous laser therapy and pinhole high ligation in the treatment of symptomatic great saphenous varicose veins.

BACKGROUND: The aim of this study was to determine the effectiveness and short-term outcomes of endovenous laser therapy (EVLT) combined with pinhole high ligation (PHL) in the treatment of great saphenous varicose veins. METHODS: From February 2011 to May 2012, 200 patients with great saphenous varicose veins were treated using combined EVLT and PHL. Sixty-eight of them had concurrent TriVex suction. There were 118 men and 82 women with a median age of 61 (range 28-82) years. All patients had more than one of the following presentations, including lower extremity heaviness, pain, edema, varicose vein, skin changes, or ulceration. Based on the CEAP clinical classification, 20 patients had C2, 85 had C3, 48 had C4, 23 had C5, and 24 had C6 chronic venous disease. Ninety patients had VV involving the left lower extremity, 56 involving the right lower extremity, and 54 involving the bilateral lower extremities. Duplex ultrasound (US) was performed for all the 200 patients, and showed great saphenous valve dysfunction and reflux in 148 patients. Fifty-two of the 200 patients had concurrent mild femoral vein reflux. Deep venous thrombosis (DVT) was ruled out in all the patients. RESULTS: Technical success rate of PHL and laser ablation was 100%. Median follow-up was 9 months, ranging from 3 to 20 months. Symptoms were resolved or significantly improved in all patients after surgery. The ulcers healed in 23 of the 24 patients (96%) within 3 months. Ten patients developed subcutaneous hematoma, and 8 had slightly worsening edema. Ten patients with complications of numbness due to saphenous nerve burning injury were treated with mecobalamin, and the numbness sensation improved within 1 month and disappeared within 3 months. Nine patients sustained saphenous vein thrombophlebitis postoperatively and were treated with ibuprofen and a heating pad. There was no recanalization of the great saphenous vein, deep venous thrombosis (DVT), or deaths in this group of patients. CONCLUSIONS: Combined EVLT and PHL are less invasive and are effective in the treatment of symptomatic great saphenous varicose veins. PHL prevents DVT, and significantly decreases recanalization of the great saphenous vein after endovenous laser ablation. Short-term outcomes have been satisfactory, but long-term follow-up is needed.

Endovascular management of pararenal aortic aneurysms with multiple overlapping uncovered stents.

OBJECTIVE: This study aims at evaluating the safety and efficacy of a porous stent system consisting of multiple overlapping uncovered stents in the treatment of complex aortic aneurysms with vital branches. METHODS: Data of all patients with aortic aneurysms treated in our center with multiple overlapping uncovered stents between February 2010 and December 2011 were retrospectively reviewed. Preoperative characteristics, intraoperative details, and follow-up outcomes were documented. Technical success was defined as successful deployment of the stents to target locations without procedure-related complications. Clinical success was characterized by complete shrinkage or stabilization of the aneurysm, preservation of vital branches, and absence of major complications. Patients were grouped, according to rapidity of aneurysm thrombosis, into fast-thrombosis group (complete thrombosis of aneurysmal sac was achieved in ≤6 months) and a delayed-thrombosis group (>6 months required for complete thrombosis). Possible factors affecting the speed of thrombosis were analyzed statistically with the Fisher exact test and the t-test. RESULTS: This porous stent system was used to treat 34 patients (23 men, 11 women; mean age, 65.7 years). Technical success was achieved in all patients (100%). Regular follow-up over 6 months was achieved in 29 patients (mean length of follow-up, 11.4 months). Complete thrombosis of the aneurysm sac within 12 months was observed in 24 patients (83%). Aneurysm shrinkage was documented in seven patients (24%) and stabilization in 21 (72%). All branch arteries covered by bare stents stayed patent during follow-up. The overall clinical success rate reached 97% in the follow-up group. Risk factors for delayed thrombosis included fewer stents implanted (P = .013), longer sac entrance (P = .043), and use of antiplatelet medication (P = .040). CONCLUSIONS: An alternative method of management of complicated aortic aneurysm appears to be feasible using overlapping bare stents, which may prevent aneurysm growth while preserving vital branches. The short-term outcome of our study seems encouraging but is not sufficient to draw a robust conclusion. Further hemodynamic and clinical studies are warranted to evaluate long-term efficacy.

Multiple overlapping bare stents for endovascular visceral aneurysm repair: a potential alternative endovascular strategy to multilayer stents.

BACKGROUND: Multilayer stent has become a new endovascular strategy for visceral artery aneurysm repair. However, its use was not allowed in some areas, such as China. This study evaluates an alternative method: multiple overlapping bare stents for repairing visceral artery aneurysms. METHODS: Twenty-four patients with celiac artery aneurysm (n = 2), splenic artery aneurysm (n = 8), hepatic artery aneurysm (n = 3), superior mesenteric artery aneurysm (n = 6), and renal artery aneurysm (n = 5) were treated with 2 to 4 overlapping bare stents. Long-term results, including clinical achievement ratio and target artery patency, were followed up with computed tomographic angiography. RESULTS: Insertion of overlapping bare stents was successful in all patients. Five aneurysms (21%) were totally excluded 3 months after operation, increasing to 12 (50%) and 20 (83%) aneurysms with total isolation at 6 and 12 months' follow-up, respectively. The clinical achievement ratios of multiple overlapping bare stents on splenic artery aneurysms, hepatic artery aneurysms, renal artery aneurysms, celiac artery aneurysms, and superior mesenteric artery aneurysms were 75%, 100%, 80%, 50%, and 100%, respectively. All cases combined had 100% target artery patency. CONCLUSIONS: Preliminary experience showed that repair using multiple overlapping bare stents seemed to be a potential alternative strategy for treating visceral artery aneurysm, resulting in target artery patency. However, the exact mechanism requires further study and more cases should be involved.

Comparison of ß-aminopropionitrile-induced aortic dissection model in rats by different administration and dosage.

This study compared three ß-aminopropionitrile (BAPN) treatment rats to find the optimal BAPN model for thoracic aortic dissection and aneurysm in one study. Sixty rats were divided into five groups: control, injected control, 0.25% and 0.4% BAPN treatment (orally), and 667 mg/kg/day BAPN injection subcutaneously. Incidence of aortic dissection and aneurysm, aortic weight and diameter were measured directly. Thickness of media and area of aorta were measured by hematoxylin and eosin and Victoria blue staining. The mortality, incidence of aortic dissection and the rupture rate of dissected aneurysm in 0.25% group was much higher than in the other two BAPN treatment groups. The diameter of thoracic aorta in 0.25% and the whole aorta in 0.4% group significantly increased. Media thickness and area of thoracic aorta were increased by 91% and 54% in 0.25% group, and by 17% and 12% in the BAPN injection group. Thickness and area were increased by 49% and 35% on thoracic aorta, and 29% and 46% on abdominal aorta in 0.4% group. In conclusion, 0.25%, 0.4% and BAPN injection groups might be appropriate for aortic dissection and pharmaceutical study, thoracic-abdominal aortic aneurysm or dilation and biomechanical research, respectively.

A novel strategy for development of glucocorticoids through non-genomic mechanism.

Glucocorticoids (GCs) are routinely believed to take effect through genomic mechanisms, which are also largely responsible for GCs' side effects. Beneficial non-genomic effects of GCs have been reported as being independent of the genomic pathway. Here, we synthesized a new type of GCs, which took effect mainly via non-genomic mechanisms. Hydrocortisone was conjugated with glycine, lysine and phenylalanine to get a bigger molecular structure, which could hardly go through the cell membrane. Evaluation of the anti-inflammatory efficacy showed that hydrocortisone-conjugated glycine (HG) and lysine could inhibit neutrophil degranulation within 15 min. HG could inhibit IgE-mediated histamine release from mast cells via a non-genomic pathway, and rapidly alleviate allergic reaction. Luciferase reporter assay showed that HG would not activate the glucocorticoid response element within 30 min, which verified the rapid effects independent of the genomic pathway. The work proposes a novel insight into the development of novel GCs, and provides new tools for experimental study on non-genomic mechanisms.

Dramatic decrease of aortic longitudinal elastic strength in a rat model of aortic dissection.

BACKGROUND: This study aimed to evaluate thoracic aortic longitudinal elastic strength in a rat model of aortic dissection (AD). METHODS: Young Sprague Dawley rats were fed 0.25% ß-aminopropionitrile (BAPN). Biomechanical and biochemistry properties of the aorta were analyzed. Elasticity modulus, maximum stretching length, draw ratio, maximum load, maximum strength, and maximum extensibility were measured. RESULTS: More than one-half of BAPN-treated rats (52.9%) died of aortic rupture secondary to AD during the experiment. The diameter of the aneurysms was 6.33 ± 1.17 mm and the length was 9.33 ± 4.95 mm. The maximum diameter was significantly increased in BAPN-treated rats with AD (group B2) compared with rats without AD (group B1) and control group (group A) (P = 0.001 and P < 0.001, respectively), but was not different between group B1 and group A (P = 0.108). Thickness of media and initial area in aorta of BAPN-treated rats were significantly increased compared with control group (P = 0.001 and P < 0.001, respectively), but no difference in initial area was observed between group B1 and group B2 (P = 0.54). Maximum stretching length, draw ratio, maximum load, maximum strength, maximum extensibility, and elasticity modulus were dramatically decreased in group B2 compared with group B1 and group A (group B2 vs. group B1: P < 0.001; group B1 vs. group A: P < 0.001). CONCLUSIONS: We successfully established a rat model of AD with a high incidence of rupture and mortality. Examinations of strain and stress parameters as well as elasticity modulus of the dissected and the nondissected aorta help understand pathogenesis of AD.

[Biomechanical properties study of aorta in ß-aminopropionitrile-induced rat model].

OBJECTIVE: To investigate thoracic aortic longitudinal elastic strength in ß-aminopropionitrile (BAPN) treated rat model of aortic dissection (AD). METHODS: Twenty-nine young rats (Sprague-Dawley) were divided into tow groups, control group (n = 12) and BAPN group (n = 17). Seventeen rats were treated with 0.25% BAPN mixed in feed for 6 weeks. All the rats were sacrificed in the end of experiment and aorta was harvested for biomechanical and pathological study. Longitudinal elastic strength and stress were detected and analyzed by material testing machine. Elasticity modulus as well as maximum stretching length, draw ratio, maximum load, maximum strength, and maximum extensibility was calculated according to the analysis with thickness and area of aortic media. RESULTS: Nine BAPN-treated rats died of aortic dissecting aneurysm rupture during the experiment. The diameter of the aneurysms was (6.33 ± 1.17) mm and the length was (9 ± 5) mm. The maximum diameter significantly increased in BAPN-induced rats with AD (group B2) compared with without AD (group B1) and control group ((6.49 ± 1.20) mm vs. (1.45 ± 0.11), (1.25 ± 0.26); F = 165.257, P = 0.001 and 0.000, respectively), but there was no significance between group B1 and control group (P = 0.108). Thickness and area of aortic media in BAPN-induced rats significantly increased compared with control group (F = 27.277 and 27.153, P = 0.000 and 0.000, respectively), but there was no significance of area between group B1 and B2 (P = 0.540). Maximum stretching length, draw ratio, maximum load, maximum strength maximum extensibility and elasticity modulus were significantly decreased from group B2, group B1 to control group (P < 0.01, respectively). CONCLUSIONS: This study built a successful model of AD. Biomechanical analysis and the decrease of maximum stretching length, draw ratio, maximum load, maximum strength maximum extensibility and elasticity modulus may explain the formation of AD partly.

[Fibrin glue embolization treating intra-operative type I endoleak of endovascular repair of abdominal aortic aneurysm: long-term result].

OBJECTIVES: To analyze the long-term results of fibrin glue embolization to eliminate type I endoleaks after endovascular aneurysm repair (EVAR), and to assess the feasibility and durability of this technique. METHODS: From August 2002 to June 2010, among the 953 EVAR patients, 51 (5.4%) patients underwent intraoperative transcatheter fibrin glue sac embolization to resolve type I endoleak persisting after initial intraoperative maneuvers to close the leak or in necks too short or angulated for cuff placement. Computed tomographic angiography was performed to assess the outcome after 3, 6, and 12 months and annually thereafter. A retrospective study was conducted, and characteristics of the patients, intra-sac pressure, hospital course, and long-term outcomes were recorded. RESULTS: Among the 51 patients, 19 (37.3%) patients had proximal necks long < 10 mm, and 6 (11.8%) patients had proximal neck angulation > 60°; 22 patients (3 additional iliac extension, 14 cuffs, and/or 8 stents) had been placed with additional devices. After fibrin glue injection, 50 (98.0%) of the 51 endoleaks were successfully resolved, and intra-sac pressure (including systolic, diastolic, mean pressures, pulse pressure, and the mean pressure indexes) decreased significantly in these cases. The patient who failed embolotherapy was converted to open surgery (2.0%); he died 2 months later from multiorgan failure. And other two (4.8%) patients died in the peri-operative period from myocardial infarction. The median of follow-up of 48 patients was 45 months (range 4 - 106 months). The mean maximal aneurysm diameter fell from the baseline (61.5 ± 15.2) mm to (48.8 ± 10.1) mm (P = 0.000). Three (6.2%) patients died in the follow-up duration (1 aneurysm-related, died of renal failure which was caused by the compromised renal artery). Cumulative survival was 97.9% at 1 year, 94.5% at 3 years, and 90.8% at 4 years. No recurrent type I endoleak or glue-related complications were observed in follow-up. CONCLUSIONS: Fibrin glue embolization to eliminate type I endoleak after EVAR has yielded promising results in this study, and it can effectively and durable resolve the type I endoleaks. Balloon occlusion of the inflow of the endoleak must be done during glue injection, to enhance the safety and facilitate formation of a structured fibrin clot.

[Aortorenal bypass with autologous saphenous vein in Takayasu arteritis-induced renal artery stenosis: an analysis of 33 cases].

OBJECTIVE: To clarify the outcome of surgical reconstruction for renal artery in Takayasu arteritis-induced renal artery stenosis (TARAS). METHODS: A retrospective chart review was conducted on 33 consecutive patients with TARAS, who underwent aortorenal bypass (ARB) with autologous saphenous vein graft. There were 9 male and 24 female patients, with a mean age of (25 ± 11) years. The effects on blood pressure and renal function were analyzed. Primary, primary assisted, and secondary patency rates were determined. The effects of various factors on primary patency rate were analyzed. All patients showed hypertension. The mean blood pressure was (175 ± 26)/(100 ± 19) mmHg (1 mmHg = 0.133 kPa). The mean antihypertensive dosage was (2.1 ± 0.6) defined daily dose (DDD). Seventeen patients showed intractable hypertension. Mean estimated glomerular filtration rate was (78 ± 5) ml/min. One patient was dialysis-dependent, and 3 patients were combined with congestive heart failure. RESULTS: ARB was performed for the 39 renal arteries, including 27 unilateral and 6 bilateral bypasses. Postoperative morbidity was 15.2%. All patients survived. During follow-up of mean (56 ± 18) months, two graft occlusions and four graft restenoses occurred. All graft restenoses were eliminated successfully with percutaneous angioplasty, but one patient experienced restenosis again six months later. At 1, 3, and 5 years of follow-up, primary patency was 92%, 89%, and 79%, respectively, primary assisted patency was 95%, 95%, and 91%, respectively, and secondary patency was 95%, 95%, and 91%, respectively. ARB resulted in a decrease in mean blood pressure to 139/85 mmHg (one month post-ARB, P = 0.000) and 136/80 mmHg (last follow-up, P = 0.000), and a reduction in mean antihypertensive dosage to 1.4 DDD (one month post-ARB, P = 0.084) and 0.6 DDD (last follow-up, P = 0.000). Mean estimated glomerular filtration rate increased to 82 ml/min (P = 0.458) one month post-ARB, and 91 ml/min (P = 0.044) at last follow-up, respectively. The dialysis-dependent patient no longer required hemodialysis, and left ventricular dysfunction resolved in all of the three patients. CONCLUSION: ARB using the autologous saphenous vein graft is safe, effective and durable for treating TARAS.

[Efficacy of Chinese herbal medicine Mailuo Shutong Granule and Hirudoid cream for chronic venous disorder-induced pigmentation in lower extremities: a prospective, randomized controlled trial].

BACKGROUND: Chronic venous disorder (CVD) of the lower extremities generally induces dermatologic complications in lower extremity skin, such as hyperpigmentation. If not treated effectively, the lesions may develop into severe outcomes, including dermal ulcer or necrosis. OBJECTIVE: To evaluate the clinical efficacy of Mailuo Shutong Granule, a compound traditional Chinese herbal medicine, and Hirudoid cream (heparinoid), in treatment of patients with dermal hyperpigmentation of skin caused by CVD. DESIGN, SETTING, PARTICIPANTS AND INTERVENTIONS: A total of 108 CVD outpatients with pigmentation from Department of Vascular Surgery, Shanghai Changhai Hospital were randomly divided into Mailuo Shutong group, Hirudoid group and combined therapy group, with 36 patients in each group. Patients in the Mailuo Shutong group and the Hirudoid group were treated with Mailuo Shutong Granule or Hirudoid cream, respectively, while those in the combined therapy group were treated with Mailuo Shutong Granule plus Hirudoid cream. They were all treated for 28 d. MAIN OUTCOME MEASURES: Before and after the 28-day treatment, area and average gray value of pigmentation lesions were measured and evaluated. RESULTS: Thirty-three cases in the Mailuo Shutong group, 34 cases in the Hirudoid group and 31 cases in the combined therapy group were included for analysis. After treatment, area of pigmentation decreased and average gray value of pigmentation declined in all the 3 groups (P<0.05). The reductions of area and average gray value in the combined therapy group were more significant than those in the Mailuo Shutong group and Hirudoid group (P<0.05). There were no differences in improvement of pigmentation between the Mailuo Shutong group and Hirudoid group (P>0.05). CONCLUSION: These data suggest that both Mailuo Shutong Granule and Hirudoid cream can improve CVD-induced hyperpigmentation, and combined treatment of the two drugs results in better clinical efficacy.

A study of the expression and interaction of Destrin, cofilin, and LIMK in Debakey I type thoracic aortic dissection tissue.

OBJECTIVE: Our previous proteomic research has indicated that some cytoskeleton proteins show differential expression between thoracic aortic dissection and normal control groups, which suggests a possible mechanism involved in the pathogenesis of the vascular remodeling of this disease. This study was to investigate the expression of these cytoskeleton proteins and their possible molecular pathway in the remodeling process of thoracic aortic dissection. METHODS: Ascending aortic segments were obtained from thoracic aortic dissection patients (Debakey type I, n = 13) and age-matched normal donors (n = 8). Quantitative differences of Destrin, cofilin, and LIM protein kinases (LIMK) were investigated using RT-PCR and Western blot analysis. The relationships between the expression of these proteins and clinical parameters such as age, hypertension and maximal aortic diameter of the patients were analysed statistically. RESULTS: Western blotting showed that the protein expression of cofilin and LIMK was significantly decreased in thoracic aortic dissection tissue compared with normal control, (p = 0.004 for cofilin, p < 0.001 for LIMK). The mRNA levels of cofilin and LIMK were lower in thoracic aortic dissection than normal control and were coincident with the protein expression (p = 0.0039 for cofilin, p = 0.017 for LIMK). A significant correlation (Spearman's rho = -0.521, p = 0.019) was found between LIMK protein expression and maximal aortic diameter; lower levels of LIMK expression were associated with larger aortic diameters. CONCLUSIONS: Changes in the expression of cytoskeletal regulatory proteins such as LIMK and cofilin may play a role in weakening thoracic aortic medial tissue, as a precondition to thoracic aortic dissection.

Local upregulation of interleukin-1 beta in aortic dissecting aneurysm: correlation with matrix metalloproteinase-2, 9 expression and biomechanical decrease.

OBJECTIVES: Our goal was to examine whether interleukin-1 beta (IL-1ß) originates locally and its possible relationship with matrix metalloproteinases (MMPs), apoptosis, elastin fibres and biomechanics in aortic dissecting aneurysms (DAs). METHODS: Aortic DAs were induced in 24 rats with ß-aminopropionitrile (BAPN); another 12 rats without BAPN were designated as controls. Then IL-1ß levels were measured both in the circulation and in local aortic specimens. The expression of MMP-2 and MMP-9 and Victoria blue and TUNEL staining were also detected. Biomechanical parameters such as the elasticity modulus were used to detect the biomechanical changes in the aortic wall. The correlation of IL-1ß, MMP-2, MMP-9, apoptosis and biomechanical properties was analysed. RESULTS: Seventeen rats (17/24, 71%) in the BAPN-treated group died of DA rupture. IL-1ß levels were dramatically increased in the DA specimens but not in the circulation. Victoria blue staining confirmed the formation of the DA and the reduction of elastin content after induction by BAPN. The extent of apoptosis in the aortic media was dramatically higher in rats with BAPN-induced DA than that in the control group and that in rats treated with BAPN but without DA. MMP-2 and MMP-9 levels were significantly increased in BAPN-treated rats compared to the controls, but no statistical significance was found between rats with and without DA. There were significant differences in biomechanical parameters, such as the elasticity modulus. Among the 3 groups, IL-1ß was positively correlated with MMP-2 and MMP-9 levels and with the elasticity modulus but not with apoptosis. CONCLUSIONS: Local IL-1ß might participate in the formation of aortic DA through the upregulation of MMP-2 and MMP-9 and the breakage of elastin fibres, which finally weakens the biomechanical properties of the aortic wall.

[Effect of the size of abdominal aortic aneurysm on endovascular exclusion and its results].

OBJECTIVE: To evaluate the effect of the diameter of abdominal aortic aneurysm (AAA) on endovascular exclusion (EVE) and its results. METHODS: From March 1997 to June 2007, 429 AAA patients were treated with endovascular stent-graft exclusion. According to the maximal diameter of abdominal aortic aneurysm, the patients were divided into two groups: group A (diameter < 55 mm, n = 274) and group B (diameter > or = 55 mm, n = 155). The diameter of AAA, involvement of iliac artery, length, diameter and distortion of aneurismal neck in the two groups were recorded and compared retrospectively. RESULTS: Patients in group B were significantly older than group A (73.7 vs 71.1 years, P < 0.05). More patients in group B was complicated with coronary artery disease than those in group A (P < 0.05). The mean diameter of AAA in group A was (46.6 +/- 6.8) mm, and (66.8 +/- 11.2) mm in group B (P < 0.05). Proximal aneurysmal necks were shorter, wider and more tortuous in group B than those in group A (P < 0.05). Extraperitoneal approach, embolism of inner iliac artery and reconstruction of another inner iliac artery and stretch technique were more applied in group B. There were more endoleak during operation in group B and more stent-grafts were used. There was significant difference in morbidity rate between the two groups, while no statistic difference in mortality. And in group B, there were a high rate of endoleak and secondary intervention post operation. CONCLUSIONS: The diameter of AAA affects EVE and its results. In small aneurysms, EVE carries better outcome than in big aneurysms.

Simultaneous multi-tear exclusion: an optimal strategy for type B thoracic aortic dissection initially proved by a single center's 8 years experience.

BACKGROUND: Endovascular stent-grafting is widely used to treat thoracic aortic dissection. However, little information is available regarding outcome following simultaneous exclusion of multiple tears. This report details eight years of experience using simultaneous multi-tear exclusion for treatment of Stanford type B thoracic aortic dissection resulting in successful aortic remodeling without adverse events. METHODS: From September 1998 to January 2006, 29 type B thoracic aortic dissection patients (24 men, 5 women; 27 chronic, 2 acute; mean age 58 years, range 45 - 77 years) were treated by simultaneous multi-tear exclusion in our center. Magnetic resonance angiography was used as the preoperative evaluation method. Different kinds of stent-grafts were used. The patients were followed up with contrast-enhanced spiral computed tomography at 6 months postoperatively and yearly thereafter. RESULTS: Twenty-nine surgeries were completed successfully using at least 2 stent-grafts per patient (range: 2 - 6, mean: 2.7). No major procedure-related complications, such as rupture, paraplegia, aortic branch ischemia or cerebral infarction, were observed. During follow-up, favorable remodeling of the aorta was observed. CONCLUSIONS: The mid-term result of thoracic aortic dissection with simultaneous multi-tear exclusion was satisfactory. With the improvement of stent-grafts, simultaneous multi-tear exclusion should find wider application and become an optimal strategy for thoracic aortic dissection.

[Aneurysm repair in vitro and renal revascularization and renal autogenous transplantation for complex renal artery aneurysm in solitary kidney].

OBJECTIVE: To discuss the safety and feasibility of aneurysm repair in vitro and renal revascularization and renal autogenous transplantation for complex renal artery aneurysm in solitary kidney. METHODS: A complex hilar renal artery aneurysm involving the bifurcation of renal artery and its branches in a solitary left kidney was diagnosed by computed tomography angiography (CTA). After temporary nephrectomy, aneurysm repair in vitro and renal revascularization were done with the kidney protected by hypothermia and continuous perfusion with preservation solution, and then the kidney was replanted into the right iliac fossa. RESULTS: The operation was done successfully and there were no significant perioperative complications. Although a serum creatinine level temporarily exceeded above 200 micromol/L after the surgery, it recovered gradually within half a month. CTA two weeks later demonstrated patent reconstructed renal arteries and its branches and patent renal vein in the right iliac fossa, and also a patent reconstructed ureter. CONCLUSIONS: This technique is safe and feasible to manage complex renal artery aneurysm in solitary kidney and provide an alternative for similar complex renal diseases.

[Endovascular exclusion of juxtarenal abdominal aortic aneurysm with one-piece customized fenestrated endovascular stent-graft].

OBJECTIVE: To evaluate the technical feasibility of juxtarenal abdominal aortic aneurysm (AAA) repair with fenestrated endovascular stent-graft METHODS: A 64-year-old male was diagnosed with juxtarenal AAA with severe coronary artery stenosis, fenestrations was customized according to precise helical CT data to accommodate visceral and renal arteries. Under general anesthesia and dynamic supervision of digital subtraction angiography (DSA), juxtarenal AAA was excluded with the customized fenestrated stent-graft and balloon expandable mini stent-grafts were deployed into bilateral renal arteries respectively. RESULTS: After operation, DSA showed the patency of the super mesenteric artery, bilateral renal arteries and left hypogastric artery, no endoleak was found. The serum creatinine decreased slightly after operation. CT angiography revealed favorable morphology of the stent-graft without tortuosity, migration, disjoint and endoleak 10 days after the operation and patency of super mesenteric artery, bilateral renal arteries and left hypogastric artery. CONCLUSIONS: The placement of customized fenestrated endovascular stent-graft is a feasible option for juxtarenal AAA.