Abstract:Objective: To review the experience of endovascular treatment for Stanford type A aortic dissection with the entrance tear locating at the ascending aorta. Methods: The clinical data of 6 patients with Stanford type A aortic dissection an entrance tear at the ascending aorta who underwent ascending aortic stent-graft implantation or that combined with arch branch revascularization were retrospectively analyzed. Results: Procedures were successfully performed in all patients, of whom 4 cases underwent ascending aortic stent-graft implantation, and the other 2 cases underwent prosthetic carotid-carotid crossover bypass grafting prior to ascending aortic stent-graft implantation. After operation, acute cerebral infarction occurred in one case, acute myocardial infarction occurred in one case, and respiratory insufficiency occurred in two cases. One case died on postoperative day 1 due to hemorrhage from rupture of the aortic dissection, and the remaining cases were safely discharged. During 3- to 48-month follow-up, 2 cases developed type I endoleak, and were continuously followed-up without a second operation. Conclusion: For some high-risk patients who cannot tolerate traditional surgery, endovascular procedures by virtue of their minimal invasiveness can be used as an alternative approach to save their lives.

Abstract:Objective: To explore an innovative approach for left subclavian artery (LSA) reconstruction during thoracic endovascular repair. Methods: In two cases of thoracic endovascular repair requiring LSA reconstruction via fenestration in situ, a commercially available device and equipment were employed. Results: All cases achieved technical success without endoleak or stent graft migration. Conclusion: Fenestration in situ is an effective method for endovascular LSA reconstruction. However, the long term clinical outcome awaits further follow-up.

Abstract:Objective: To investigate the technical essentials and efficacy of endovascular aortic repair (EVAR) in treatment of complex infra-renal abdominal aortic aneurysm (AAA). Methods: The clinical data of 15 patients with complex infra-renal AAA undergoing EVAR were reviewed, and the technical essentials and clinical outcomes were analyzed. Results: The technical success rate of the operation was 100%, without any open conversion. One patient (6.67%) died of acute heart failure 5 days after EVAR. In 2 patients with severe angulation of aneurysmal neck, the operation was completed by brachial-femoral guidewire insertion; in 7 patients with iliac artery stenosis, 4 cases underwent brachial-femoral guidewire insertion and stent placement after balloon dilatation, and in the remaining cases operation was completed by balloon dilatation only; one patient with left iliac artery occlusion was recanalized by leading the guidewire through the occluded segment from the contralateral iliac artery; 8 patients with severe iliac artery distortion underwent correction of the distorted segment by super-hard guide wire and then had stent deployment. No serious complications such as aneurysmal rupture, vascular penetration and iatrogenic dissection occurred during operation. During follow-up, one patient developed spinal tuberculosis 2 years after the surgery and died of multiple organ failure, endoleak occurred in 3 patients and one patient received a second surgical intervention. Conclusion: With the accumulation of experience, technical progress and continued stent development, EVER is feasible and effective therapy for complex infra-renal AAA.

Abstract:Objective: To study the relationship between aortic dissection and obstructive sleep apnea and hypopnea syndrome (OSAHS). Methods: A total of 41 aortic dissection patients with hypertension (study group) and 41 hypertensive patients (control group) of similar age, sex, and body mass index were studied by clinical questionnaire and polysomnography. Results: The prevalence of OSAHS in the aortic dissection group was higher than that in the control group (P<0.05). The aortic dissection patients complicated with OSAHS had a higher AHI and lower average oxygen saturation (P <0.05). Conclusion: Obstructive sleep apnea and hypopnea syndrome may be a risk factor for aortic dissection.

Abstract:Objective: To analyze the occurrence of perioperative death and severe complications of abdominal aortic aneurysm (AAA) and the preventive strategy. Methods: The clinical data of 143 AAA patients undergoing surgical treatment from January 2009 to December 2014 in Xiangya Hospital of Central South University were retrospectively analyzed. Results: In the whole group of patients, there was perioperative (within 30 d after operation) death in 6 cases (4.2%) and severe complications occurred in 20 cases (14.0%). In patients undergoing endovascular repair, the incidence of postoperative death was lower than that in patients undergoing open surgery, but the difference did not reach a statistical significance (1.3% vs. 7.5%, P>0.05), while the incidence of severe complications was significantly lower than that in the latter (6.6% vs. 22.4%, P<0.05). The incidence of postoperative cardiovascular complications in patients with preoperative concomitant coronary artery disease was significantly higher than that in patients with non-coronary artery disease (9.1% vs. 0.9%, P<0.05), but showed no significant increase in patients with hypertension (4.8% vs. 2.5%, P>0.05). Patients with other underlying diseases were not included in statistical analysis due to small number of cases. Conclusion: Endovascular repair has evident superiority to open surgery in respects of reducing perioperative death and severe complications of AAA, and in those patients with preoperative concomitant coronary artery disease, aggressive preventive measures should be taken to avoid the occurrence of cardiovascular complications.

Abstract:Objective: To evaluate the clinical efficacy of hybrid procedure in treatment of multisegmental lower extremity arteriosclerosis obliterans (ASO) involving the femoral artery bifurcation. Methods: The data of 46 patients (47 limbs) with multisegmental lower extremity ASO involving the femoral artery bifurcation undergoing hybrid procedure from October 2010 to December 2014 were reviewed. The relevant clinical variables and the influence of the severity of disease and type of procedure on primary patency rate were analyzed. Results: The technical success rate was 98% (46/47), and no perioperative death occurred. The average ankle-brachial index was increased from the preoperative 0.34±0.16 to postoperative 0.69±0.11. The average follow-up time was 21.8 months with a follow-up rate of 93% (43/46), and the cumulative primary patency rate was 67.4%. Kaplan-Meier analysis showed that the primary patency rate was significantly decreased with the higher Fontaine stages of the diseased limb, and primary patency rate was significantly lower when the endovascular intervention was performed in both the proximal and distal segment of the vessel in the surgical area than when performed on only the proximal or distal segment of the vessel (all P<0.05). Conclusion: Hybrid procedure is an effective treatment modality for multisegmental lower extremity ASO involving the femoral artery bifurcation, and it also accords with the principle of individualized therapy.

Abstract:Objective: To investigate the clinical efficacy of hybrid procedures in treatment of acute limb ischemia (ALI). Methods: The clinical data of 43 patients with 46 ALI limbs undergoing combination treatment of conventional surgery and endovascular techniques between March 2011 and April 2014 were retrospectively analyzed. Results: The technical success rate was 97.7% (42/43), residual thrombosis rate was 7.0% (3/43), and the average ankle-brachial index after operation was 0.85±0.48. Nine patients (20.9%) developed osteofascial compartment syndrome and underwent open decompression, and during perioperative period, 3 patients (7.0%) underwent extremity amputation, one patient (2.3%) had toe amputation, and 3 patients (7.0%) died. One patient died of cerebral infarction 3 months after operation, and 35 patients were followed-up for more than 12 months, during which time, restenosis occurred in 2 cases who had popliteal artery stent placement. Conclusion: In the treatment of ALI, hybrid surgery shows high technical success rate and low residual thrombosis rate, thrombus removal and vascular reconstruction can be simultaneously conducted, and is worthy of clinical application.

Abstract:Objective: To investigate the therapeutic efficacy of hybrid procedures for multisegmental lower extremity arteriosclerosis obliterans. Methods: The clinical data of 30 patients (30 affected limbs) with complicated lower extremity arteriosclerosis obliterans undergoing hybrid revascularization procedures from March 2014 to September 2014 were analyzed. Of the 30 patients, the lesion sites involved the aortoiloac, femoropopliteal, profunda femoris and infrapopliteal arteries; all cases underwent endovascular repair, of which, 20 cases were subjected to endarterectomy, 10 cases received arterial embolectomy, and 8 cases had profundaplasty. Results: The hybrid procedures were successfully performed in all the 30 patients, and technical success rate was 100%. The incidence of perioperative complications was 30% (9/30), the clinical success rate was 96.67% (29/30), and the postoperative average ankle-brachial index increased by an average of 0.37±0.19 compared with the preoperative value. The 6- and 12-month primary patency rate was 90% and 73%, and the 12-month limb salvage rate was 97.67%, respectively. Conclusion: The hybrid procedures offer excellent short-term patency and limb salvage rate for complicated arteriosclerosis obliterans of the lower extremities.

Abstract:Objective: To review the experience in management of in-stent restenosis in lower limb arteriosclerosis obliterans (ASO) after endovascular treatment. Methods: The clinical data of 31 lower limb ASO patients (49 limbs) with post-interventional in-stent restenosis treated from June 2012 to December 2014 were analyzed retrospectively. The lesions included restricture in 37 limbs and with reocclusion in 12 limbs, and the length of lesions ranged from 8.5 to 35 cm with an average of 25.2 cm. Results: All patients received endovascular treatment. The treatment modalities included lone balloon dilation angioplasty in 35 limbs, catheter-directed thrombolysis after balloon dilation in 3 limbs, balloon dilation with additional stent implantation in 3 limbs, catheter-directed thrombolysis prior to balloon dilation in 7 limbs, and SilverHawk atherectomy in one limb. After operation, varying degrees of improvement of symptoms occurred in all cases, and the average ankle-brachial index was increased significantly compared with preoperative value (P<0.05). Twenty-eight patients were followed up for 3 to 32 months with an average of 16.2 months, during which period, restenosis recurred in 6 cases (21.4%), and all of them had a repeat balloon dilation angioplasty, and no case had limb amputation or died. Conclusion: In combination with other appropriate endovascular procedures, balloon dilation angioplasty can offer satisfactory efficacy for in-stent restenosis in lower limb arteries.

Abstract:Objective: To investigate the appropriate management for acute limb ischemia (ALI). Methods: The clinical data of 62 patients with ALI treated from March 2011 to September 2014 were analyzed retrospectively. The causes for ALI included acute arterial embolism or thrombosis, inflammatory vascular diseases, and aortic dissection, and all patients had varying degrees of ALI symptoms. According to the clinical categories of ALI and individual conditions, different treatments were performed respectively, which included open surgery (embolectomy, endarterectomy, patch angioplasty or arterial bypass), interventional operation (catheter-directed thromboysis, balloon dilatation or stenting), hybrid procedures or medication treatment alone. Results: Treatment success was achieved in 48 cases (77.4%); 13 cases (21.0%) were subjected to amputation , among which, the amputation rate of those with inflammatory vascular disease was 77.8%, and 3 cases died (due to acute cerebral infarction, acute renal failure and heart failure, respectively). Fifty-five patients were followed up for 3 to 42 months, during which time, 33 cases had no noticeable symptoms and lived a normal life, while 20 cases still suffered varying degrees of intermittent claudication and numbness that required long-term medication for control, and 2 cases died due to cardiac or cerebral vascular events. Conclusion: For ALI, early diagnosis and prompt treatment are critical, and appropriate selection of treatment modality should be the decisive step for obtaining the maximal efficacy.

Abstract:Objective: To investigate the effect of simvastatin on venous wall remodeling during deep vein thrombosis (DVT). Methods: Forty-eight hours after DVT model establishment, 48 New Zealand white rabbits were equally randomized into four groups, and then once daily were administered normal saline (control group), anticoagulant drug (anticoagulation group), simvastatin (statin group) or simvastatin plus anticoagulant drug (combination group), respectively. At different time points during intervention, the pathological changes, deposition of collagen fibers and expression of α-smooth muscle actin (α-SMA) in the wall of the diseased vein from each group of animals were examined. Results: The success rate for DVT model establishment was 100%. Pathological examination found that, as time progressed, the affected venous walls in each group gradually exhibited evident local inflammation, medial thickness, and subintimal proliferation of fibrous tissue, but the degrees of these changes in statin group and combination group were markedly milder than those in control group and anticoagulation group. Results of Masson staining showed that the collagen content of the venous wall at each time point presented in a decreasing order as follows: control group>anticoagulation group>statin group>combination group (partial P<0.05). Results of immunohistochemical staining demonstrated that compared with control group, the α-SMA expression level of venous wall in statin group or combination group was decreased which was more evident in combination group over time (partial P<0.05), but the α-SMA expression level of venous wall showed no significant decrease in anticoagulation group at any time point (all P>0.05). Conclusion: Simvastatin can reduce inflammation, vascular smooth muscle proliferation and deposition of collagen fibers, which may inhibit the process of vascular remodeling of DVT, and these effects can be enhanced by combination with anticoagulants.

Abstract:Objective: To investigate the mechanism of high mobility of protein B1 (HMGB1) in promoting migration and proliferation of vascular smooth muscle cells (VSMCs). Methods: The changes in migration and proliferation ability as well as the expressions of receptor for advanced glycation end-products (RAGE) and P38MAPK were measured in human aortic VSMCs (HA-VSMCs) after exposure to HMGB1. Further, the influence of RAGE antibody or P38MAPK inhibitor SB203580 pretreatment was observed. Results: After exposure to HMGB1, the activity of the cell proliferation and migration, as well as the expression of RAGE and P38MAPK were increased significantly (all P<0.05), and all presented in a concentration-dependent manner. The promoting effects of HMGB1 on migration and proliferation ability were significantly inhibited by either RAGE antibody or SB203580 pretreatment (all P<0.05), and HMGB1-induced P38MAPK expression was significantly inhibited by RAGE antibody pretreatment (P<0.05). Conclusion: HMGB1 can probably promote the migration and proliferation of VSMCs through its binding to cell surface RAGE and then activating P38MAPK expression.

Abstract:Objective: To investigate the changes in apoptosis of cells in different venous walls under high hydrostatic pressure and the mechanisms. Methods: Samples of portal hypertension induced diseased splenic veins (DSV) and varicose great saphenous veins (VGSV) were collected, and samples of normal splenic veins (SV) and great saphenous veins (GSV) were used as control. The apoptotic cells in the venous walls were detected by TUNEL assay and immunofluorescence staining, the apoptosis-related protein Bax and Bcl-xl expressions were determined by immunohistochemical staining, and the cell ultrastructural changes were observed with an electron microscope. Results: In the wall (intima and media) of the DSV and VGSV compared with respective control, the apoptotic ratio was significantly reduced (both P<0.05); the proapoptotic protein Bax expression was reduced, antipoptotic protein Bcl-xl was elevated and Bax/Bcl-xl ratio was significantly decreased (all P<0.05). The endothelial and smooth muscle cells in the walls of DSV and VGSV exhibited fuzzy mitochondrial cristae, medullary changes, and margination of the nuclear chromatin. Conclusion: Under high hydrostatic pressure, there is a similar dysregulation in mitochondrial pathway of apoptosis in different venous walls, which is probably an important mechanism for venous wall dilation and thickness in relevant disease conditions.

Abstract:

Objective: To investigate microRNA-25 (miR-25) expression in rectal carcinoma cells and its action. Methods: The miR-25 expressions in several different rectal cell lines were determined, and then the changes in biological behaviors in rectal cancer cells after up- or down-regulation of miR-25 expression with miR-25 precursor (pre-miR-25) or miR-25 inhibitor (anti-miR-25) transfection were examined. Results: Compared with normal rectal mucosal tissue, the miR-25 expressions in all tested rectal cancer cells were significantly increased with varying degrees (all P<0.05). In rectal cancer HR-834 cells with relatively low miR-25 expression after pre-miR-25 transfection and in rectal cancer SW-837 cells with high miR-25 expression after anti-miR-25 transfection, the proliferation, cell cycle and apoptosis showed no significant change (all P<0.05), but the invasion and migration abilities in HR-834 cells were increased, and SW-837 cells were decreased significantly (all P<0.05). Conclusion: The miR-25 expression is elevated in rectal cancer cells, and its degree of increase is closely related to the invasion and migration abilities of rectal cancer cells.

Abstract:

Objective: To observe the safety and feasibility of laparoscopic high ligation of the hernia sac with lateral umbilical fold reinforcement in inguinal hernia repair through an animal experiment.
Methods: Sixty-four healthy male New-Zealand rabbits (having congenital defect at the internal inguinal ring) were randomized into experimental group and control group. Rabbits in experimental group received laparoscopic right high ligation of the hernia sac with lateral umbilical fold, while those in control group underwent laparoscopic right high ligation of the hernia sac only. On postoperative day (POD) 7, 15, 30, and 60 respectively, 8 rabbits in either group were randomly picked up to observe the abdominal conditions under laparoscope and then to determine the level of anti- abdominal pressure at the repaired internal inguinal ring.
Results: No animal death occurred during the experiment. No intra-abdominal complication was observed in either of the groups, and the lateral umbilical fold was well integrated with the original peritoneum in rabbits of experimental group. After operation, the level of anti-abdominal pressure at the repaired inguinal region in both groups of rabbits were continuously increased as time went on, and both approximately reached a maximum on POD 30, but the level of anti-abdominal pressure at each predefined postoperative time point in experimental group was significantly higher than that in control group (all P<0.05).
Conclusion: Laparoscopic high ligation of the hernia sac with lateral umbilical fold reinforcement for inguinal hernia is safe and effective in rabbits, which may provide an experimental basis for its clinical use.

Abstract:

Objective: To analyze and compare the influences of carotid endarterectomy (CEA) and carotid artery stenting (CAS) on cerebral perfusion in patients with carotid stenosis during perioperative period by means of whole brain computed tomography perfusion (WBCTP). Methods: According to the criterion of the North American Symptomatic Carotid Endarterectomy Trial (NASCET), 32 patients with carotid stenosis that was confirmed by whole brain angiography were selected. Of the patients, 11 cases underwent CEA, and 21 cases underwent CAS. All patients underwent WBCTP examination before and one week after operation, and the cerebral perfusion data were recorded. The changes and degrees of the changes in the perfusion parameters that included regional cerebral blood flow (rCBF), regional cerebral blood volume (rCBV), and regional mean transit time (rMTT) of the two groups of patients were analyzed and compared. Results: Compared with preoperative data, rCBF, rCBV and rMTT were all significantly improved in either group (all P<0.05), but the degrees of the changes in all parameters showed no significant difference between the two groups (all P>0.05). Conclusion: Both CEA and CAS procedures can improve the cerebral perfusion in patients with carotid artery stenosis, and they also exhibit similar efficacy.

Abstract:Objective: To investigate the diagnosis and management of gastroesophageal reflux (GER)-associated asthma due to superior mesenteric artery syndrome (SMAS). Methods: The clinical data of 6 cases of GER-associated asthma caused by SMAS were retrospectively analyzed. Results: Of the patients, the main clinical manifestations included intermittent upper abdominal bloating pain, acid regurgitation, heartburn, cough and asthma, and upper gastrointestinal contrast showed compression of the horizontal part of the duodenum; 2 cases received conservative treatment, and 4 cases had surgical treatment. Follow-up ranged from 1.5 to 84 months; of the postoperative patients, the symptoms in 3 cases were improved, and one case developed gastroplegia which was relieved by gastric motility-promoting drugs. The symptoms in the two patients receiving conservative treatment were effectively controlled, but long-term treatment with proton pump inhibitors and gastric motility-promoting drugs were required. Conclusion: Both SMAS and GER should be taken into consideration in diagnosis and treatment of GER-associated asthma caused by SMA, and satisfactory results may be achieved by surgical or conservative treatment.

Abstract:Objective: To investigate the possibility and applicability of the staged operation of laparoscopic sleeve gastrectomy (LSG) and duodeno-ileal omega switch (DIOS) in surgical treatment of morbid obesity. Methods: A female morbidly obese patient with concomitant type 2 diabetes and hyperlipidemia admitted in 2012 underwent staged operation of LSG on 13th April of the same year, and then DIOS on 12th March 2013 after 11-month follow-up. The changes in obesity indexes and other relevant parameters of the patient before and after operation as well as the complications were analyzed. Results: The relevant data of the patient at pre-LSG, pre-DIOS and 2 years after DIOS, indicated the body mass index (47.6, 42.3, and 31.0 kg/m2), body weight (140, 125, and 92 kg), glycosylated hemoglobin (6.3%, 5.7%, and 5.0%), blood triglyceride (2.54, 1.87 and 1.26 g/L) and total cholesterol (2.42, 1.89 and 1.68 g/L) all showed a decreasing pattern, moreover, the patient completely eliminated dependency on glucose lowering drugs at two years after operation. During perioperative and 2-year postoperative period, no short- or long-term complications such as anastomotic leakage, malnutrition, alopecia, dump syndrome or biliary reflux occurred. Conclusion: LSG associated with DIOS owns the features of stepwise bariatric operation, and seems to be promising in clinical practice.

Abstract:Acute changes in hemoglobin and (or) coagulation function may occur after endovascular repair of aortic aneurysm (EVAR), and these have already been given increased attention. However, the pathological mechanisms for these changes and their influence on EVAR outcome remain unclear. In this article, the authors address the characteristics of these postoperative changes and the research progress.

Abstract:Isolated abdominal aortic dissection (IAAD) is a rare condition with the primary entry tear located in the abdominal aorta, which might occur spontaneously, or be the consequence of trauma and iatrogenic events as well. Male, hypertension and concomitant aortic aneurysm may be high risk factors for IAAD. The frequent presentations at onset are abdominal pain, back pain, and intermittent claudication. Therapeutic choices for IAAD include medical treatment, conventional open surgical repair, endovascular repair and hybrid surgery. Recently, endovascular repair has increasingly become the most preferred treatment option. In this article, the authors address the clinical features and management advances of IAAD.

Abstract:Neuroendocrine neoplasms (NENs) are a group of heterogeneous tumors derived from peptidergic neurons and neuroendocrine cells, with neuroendocrine markers, and can produce peptide hormones. The gastrointestinal tract is one of the predilection sites of NENs. The incidence of the disease is on the rise in recent years. The common treatments of gastrointestinal neuroendocrine neoplasms (GI-NENs) include surgery, endoscopic therapy, chemical therapy, biological treatment, radionuclide therapy, and others. Unified understanding on the therapy of NENs has not as yet been reported by domestic and foreign researchers.