Abstract:In April 2020, the National Comprehensive Cancer Network (NCCN) released the first edition of the 2020 guidelines for cancer-associated venous thromboembolic disease (VTE). The guidelines mainly provide recommendations on how to prevent and treat VTE for cancer patients in inpatient and outpatient settings. Here, the authors focus on the comparison between the 2020 edition and the 2019 edition of NCCN guidelines, and interpret the updated risk assessment methods and prevention and treatment measures of VTE combined with clinical practical problems, so as to help the relevant medical workers to better understand and follow the guidelines.

Abstract:Background and Aims Octoparms? is the first retrievable conical inferior vena cava filter (VCF) made in China. To investigate the safety and effectiveness of this VCF in prevention of pulmonary embolism (PE), this study was conducted for a non-inferiority comparison between this VCF and foreign imported VCF.Methods Using a randomized multicenter, positive parallel controlled design, the eligible patients with acute deep venous thrombosis (DVT) of lower extremities from 10 centers from September 2017 to March 2019 in China were enrolled and designated to study group and control group at a 1∶1 ratio. The variables concerning safety and effectiveness were compared between Octoparms? filter and USA Celect filter.Results A total of 188 patients were enrolled with 94 cases in each study group and control group. The baseline data of the two groups of patients were balanced, and all filters were successfully implanted. Filter was successfully retrieved in 87 cases (92.6%) in study group a the median retention time of 11 (7-31) d, and 26 cases (27.6%) thrombus interception. Filter was successfully retrieved in 91 cases (96.8%) in control group a the median retention time of 12 (7-21) d and 35 cases (37.2%) had thrombus interception. During the filter implantation and removal, no symptoms of PE occurred in both groups, and no severe filter shift or rupture was observed. The self-centering effect of filter in study group was better than that in control group (P<0.05). In the 104 cases (55.3%) undergoing thrombolytic therapy, the filter was not removed in 2 cases (1.9%) and the hemorrhage event occurred in 17 cases (16.3%); in the 84 cases (44.7%) who did not receive thrombolytic therapy, the filter was not removed in 8 cases (9.5%) and the hemorrhage event occurred 5 cases (5.9%). There were statistical differences in filter retrieval rate and incidence of hemorrhage event between patients with and without thrombolytic therapy (χ²=3.928, P=0.048; χ²=4.858, P=0.028).Conclusion Using Octoparms? conical VCF for prevention of PE is safe and effective, and the overall efficacy is similar with that of foreign imported VCF. In addition, thrombolytic therapy can effectively reduce the load of DVT and increase the filter removal rate, but it will increase the risk of hemorrhage in patients.

Abstract:Background and Aims The unibody single-branched stent graft with the delivery system is a new stent system, which is suitable for aortic dissection with inadequate proximal landing zone, and is a new choice for aortic dissection involving the left subclavian artery (LSA). Here, the authors evaluate the short-term efficacy and safety by summarizing the cases with acute Stanford B aortic dissection and insufficient proximal landing zone undergoing thoracic endovascular aortic repair (TEVAR) with unibody single-branched stent graft.Methods The clinical data of 8 patients with acute Standford B aortic dissection and insufficient landing zone undergoing TEVAR using the Castor^? branched aortic stent graft in Fuwai Yunnan Cardiovascular Hospital from April 2019 to January 2020 were retrospectively collected. The surgical procedures and perioperative complications were analyzed.Results The 8 patients included 7 male cases (87.5%) and 1 female case (12.5%), with a median age of 42 (33-64) years, and BMI of (25.5±3.8) kg/m². The stenting procedure was successfully completed in all patients, the initial technical success rate was 100%, no perioperative death or neurological complications occurred and type I endoleak was noted. The average length of hospital stay was (14.8±3.7) d. The follow-up was performed for 223(60-370) d, and all the main body and branch stent grafts were patent, no associated type I and III endoleak occurred, and no neurological complications and symptoms of left upper limb ischemia were observed.Conclusion The unibody single-branched stent graft combined TEVAR technique is a safe and effect approach for type B aortic dissection with inadequate landing zone. The mid-and long-term results still need further follow-up.

Abstract:Background and Aims Thoracic endovascular repair (TEVAR) has become the first choice for the treatment of aortic arch lesions. However, this procedure requires a proximal landing zone of at least 15 mm in length, so reconstruction of the major branches of the aortic arch is usually necessary to ensure the safety of the operation in those with insufficient landing zone. Among the current reconstruction techniques, in-situ fenestration technique is most frequently used, because of its greater level of the supra-aortic branch preservation and relatively low risk of endoleak. Therefore, this study was to investigate the feasibility and effect of application of in-situ needle fenestration of Ankura aortic stent graft for revascularization of the supra-aortic branches.Methods The clinical data of 47 patients with aortic disease and short proximal landing zone treated in Ningbo Hwa Mei Hospital of University of Chinese Academy of Sciences from March 2017 to December 2020 were retrospectively analyzed. Among them, there were 38 cases of thoracic aortic dissection, 6 cases of thoracic aortic aneurysm, and 3 cases of thoracic aortic ulcer. According to the preoperative CTA image data, the number of fenestrations and the size of the fenestration stent were determined; during the operation, the Ankura aorta stent graft was used to perform in-situ fenestration and reconstruction of the supra-aortic branches. Aortic CTA regularly performed after surgery.Results All patients were successfully operated. A total of 47 Ankura thoracic aorta stent grafts, 51 Gore Viabahn stent grafts, and 20 Cordis Smart bare stents were implanted. Four cases were converted to chimney stent implantation during the operation. The success rate of in-situ fenestration was 91.5% (43/47), which included left subclavian artery (LSA) fenestration, left common carotid artery (LCCA) fenestration+LSA embolization in 1 case, LSA fenestration+ in 29 cases left vertebral artery chimney in 1 case, LSA fenestration+LCCA chimney in 9 cases, LCCA and LSA fenestration+innominate artery (IA) chimney in 1 case, and LCCA fenestration+IA chimney+LSA embolization in 2 cases. The operative time for the whole group of patients was 160-300 min, with an average of (200±20) min, and the operative time for fenestration was 18-45 min, with an average of (30±8) min. Postoperative endoleak (type 1) occurred in 3 cases, retrograde tear occurred in 2 cases (1 case improved after ascending aorta replacement, and 1 case died), cerebral infarction occurred in 2 cases, and no paraplegia occurred. The average follow-up time was (28.4±14.7) months. During the follow-up period, the endoleak disappeared in 2 cases and did not further increase in 1 case, which was treated by observation, and there was no occlusion in the fenestrated branch vessels.Conclusion Using in-situ needle fenestration of Ankura aortic stent graft for revascularization of the supra-aortic branches is a feasible and effective treatment method, with favorable short-term results.

Abstract:Background and Aims Type II endoleak is a common complication after endovascular aortic aneurysm repair (EVAR). However, there is still no agreement on whether surgical intervention is required or the timing of intervention for this condition. Therefore, this study was conducted to evaluate the safety and efficacy of the surgical methods for type II endoleak after EVAR and their efficacy and safety, so as to provide information for clinical decision making.Methods The clinical and follow-up data of patients undergoing EVAR between January 2016 to December 2020 in Department of Vascular Surgery of Xiangya Hospital, Central South University were reviewed. The incidence of type II endoleak after EVAR as well as the efficacy, complications and follow-up results in those undergoing the second surgical intervention were analyzed.Results A total of 282 patients underwent EVAR during the study period. The follow-up was performed for 1 month to 54 months with an average of 17.9 months. During the follow-up, simple type II endoleak occurred in 68 patients (24.1%), in whom, the type II endoleak was spontaneously healed in 31 cases (45.6%), the aneurysmal diameter did not significantly increase in 25 cases (36.8%), and 12 cases (17.6%) underwent a second surgical intervention because the aortic aneurysm diameter increased >10 mm or relevant clinical symptoms were noted. In patients undergoing second surgical intervention, 10 patients underwent percutaneous arterial embolization, of whom 8 cases with embolization of the responsible artery were followed-up for 12 months and had no recurrence of endoleak with reduced aneurysmal diameter, and 2 cases undergoing embolization were follow-up 24 months and the type II endoleak was still visible, but the aneurysmal diameter did not increase; 2 patients underwent open surgery, of whom, 1 case had acute myocardial infarction after surgery, and emergency PCI was performed, and then was uneventfully recovered, and another case had a massive hemorrhage during surgery and the length of hospital was prolonged to 16 d. The 2 patients were followed up after open surgery for more than 6 months, and no further adverse events occurred and the endoleak completely disappeared.Conclusion Most patients with type II endoleak after EVAR have good prognosis. In those with rapid growth of aneurysmal diameter and clinical symptoms, the embolization of the responsible blood vessels can obtain good clinical results. Open surgery is a relatively traumatic procedure, with high incidence of serious complications, so the choice needs to be carefully considered.

Abstract:Background and Aims In recent years, the authors' hospital used the in-situ needle fenestration to preserve the left subclavian artery (LSA) in thoracic endovascular aortic repair (TEVAR) for the treatment of thoracic aortic diseases, which achieved satisfactory clinical results. This study was performed the safety and effectiveness of the application of this method through summarizing the relevant data.Methods The clinical data of 25 patients with thoracic aortic diseases undergoing TEVAR with in-situ needle fenestration for LSA revascularization from February 2017 to December 2019 were retrospectively analyzed. There were 22 males (88%) and 3 females (12%), aged 45-68 years, with an average of (62.1 ± 11.2) years.Results Of the 25 patients, technical success was achieved in 24 cases (96%). All patients had no major perioperative adverse events within 30 d. All patients were followed up for 6-31 months and the median follow-up time was 13 months. All type II, III and IV endoleak disappeared at the median follow-up of 13 months. During the follow-up period, the main stent and branch stents were in good shape without obvious stenosis or displacement.Conclusion TEVAR with in-situ needle fenestration for LSA preservation in the treatment of thoracic aortic diseases is feasible and effective, and the short-term follow-up is satisfactory.

Abstract:Background and Aims In recent years, a certain progress has been achieved in techniques for intravascular foreign body (IFB) retrieval with the development of interventional technologies and devices. However, IFB retrieval presents different degrees of operative difficulty due to the different types, lodgment sites and sizes of the IFB. Therefore, the authors summarized and analyzed the treatment processes of patients with iatrogenic and non-iatrogenic IFB admitted in recent years in this paper, aiming to provide some helpful guidance for clinical practice.Methods The data of 15 patients with IFB treated in the Department of General Surgery of the 900th Hospital of the Chinese People's Liberation Army Joint Service Support Force from January 2012 to September 2021 were retrospectively analyzed. The sources and lodgment sites of the IFB, and surgical procedures were summarized, with review of the relevant literature.Results Of the 15 patients, 12 cases were iatrogenic IFB and 3 cases were non-iatrogenic IFB, and 9 cases were males and 6 cases were females, aged 21-79 years, with an average of (56.67±17.63) years. The operative time was 20-110 min, with an average of (51±23.62) min. The primary diseases included 3 cases of trauma, 2 cases of breast cancer, 2 cases of gastric cancer, 2 cases of deep vein thrombosis of lower limbs, 2 cases of lung cancer, 1 case of liver cancer, 1 case of cervical cancer, 1 case of cerebral infarction with carotid artery stenosis, 1 case of renal insufficiency. The IFB was successfully removed in all the 15 patients, the technical success and rate was 100%. Ten cases were removed by interventional therapy alone, 1 case was removed under laparoscopic surgery, 4 cases were removed by incision of the traditional surgery. Except for 1 case of aortic rupture and massive hemorrhage caused by vascular stent displacement before operation, the other cases had no corresponding complications, such as vascular rupture, bleeding, infection, secondary thrombosis. Anticoagulation treatment was administered after operation. Follow-up for the 15 patients demonstrated that no complications occurred in all of them and the vascular patency was maintained as evidenced by ultrasound.Conclusion The IFB in most patients can be treated by emergency surgery, and the preferred treatment is interventional therapy. For simple cases, the IFB can be captured by a gooseneck catcher. For those more difficult to remove, the guide wire can be shaped or a larger annular snare can be used. The operator needs to be patient during the operation. For the difficult cases of interventional operation, the intraoperative treatment conversion to a laparoscopic or open surgery is also recommended, based on the specific clinical conditions.

Abstract:Background and Aims Deep vein thrombosis (DVT) in patients after surgery for gynecological cancer will cause pulmonary embolism or sudden death, and poses a serious threat to patient's life. This study was conducted to identify risk factors for postoperative DVT in patients with gynecologic cancer through a Meta-analysis, so as to provide an evidence-based basis for preventing and reducing the occurrence of postoperative DVT in gynecologic cancer patients.Methods The cohort studies or case-control studies concerning risk factors for postoperative DVT in gynecological cancer patients were collected by online search in several national and international databases. The retrieval time was from inception of the database to March 2021. Meta-analysis was conducted by Revman 5.3 software.Results A total of 19 studies were included involving 4 964 patients, with 1 040 patients in the case group and 3 924 patients in control group, in which a total of 36 risk factors were studied. Results of analysis of the pooled data for 10 risk factors showed that previous history of DVT (OR=3.70, 95% CI=2.15-6.35, P<0.001), old age (OR=2.99, 95% CI=1.85-4.82, P<0.001), concomitant hypertension (OR=2.25, 95% CI=1.32-3.83, P=0.003), prolonged operative time (OR=1.03, 95% CI=1.02-1.04, P<0.001), increased BMI (OR=1.87, 95% CI=1.55-2.25, P<0.001), longer postoperative stay in bed (OR=3.17, 95% CI=2.56-3.92, P<0.001), high fibrinogen level (OR=2.80, 95% CI=2.26-3.47, P<0.001), advanced tumor stage (OR=2.56, 95% CI=1.83-3.57, P<0.001), presence of lymph node metastasis (OR=2.88, 95% CI=1.58-5.25, P=0.000 6), and high D-dimer level (OR=2.52, 95% CI=1.84-3.43, P<0.001) were all risk factors for postoperative DVT in gynecologic cancer patients.Conclusion Based on the 10 risk factors identified in this study, the clinicians should aggressively identify the high-risk population for postoperative DVT among gynecologic cancer patients, and then provide specific measures to prevent or reduce the risk of DVT for them.

Abstract:Background and Aims Carotid stenosis is an important cause of stroke, especially ischemic stroke. Early detection and effective treatment are essential for reducing the occurrence of ischemic stroke. Carotid artery stenting (CAS) is a common modality for the treatment of carotid artery stenosis, but various complications may occur during and after this procedure, and there is still the risk of restenosis or occlusion, thus evaluating its efficacy through effective methods is of important clinical significance. This study was conducted to analyzed the assessing abilities of computed tomography perfusion (CTP) and high-resolution magnetic resonance imaging (HR-MRI) in patients with carotid stenosis after CAS.Methods The data of 44 patients with carotid artery stenosis who underwent CAS treatment between February 2017 and February 2020 were collected. All the included patients underwent CTP, HR-MRI and DSA examinations before and 2 months after CAS. The differences in the parameters of CTP and HR-MRI before and after CAS were compared, and using the results of DSA as a gold standard, the relative efficiency of the two methods in detecting residual carotid artery stenosis was compared.Results The results of CTP showed that the relative cerebral blood flow of cerebral artery was increased and the relative transit time and relative time to peak were decreased significantly (all P<0.05), while no significant difference was noted in the relative cerebral blood volume on 2 months after operation compared with their values before operation (P>0.05). The results of HR-MRI showed that there were no significant differences in the vascular area, tube wall area and lumen area (all P>0.05), and the plaque area and plaque load were significantly reduced on 2 months after operation compared with their values before operation (both P<0.05). DSA detected 16 branches of carotid arteries with stenosis, and the improvement rate of carotid artery stenosis was 80.00%, CTP detected 12 branches of carotid arteries with stenosis, and the improvement rate of carotid artery stenosis was 85.00%, and HR-MRI detected 14 branches of carotid arteries with stenosis, and the improvement rate of carotid artery stenosis was 82.50%. The two methods had a similar ability in detecting the residual carotid artery stenosis (P>0.05).Conclusion Both CTP and HR-MRI can be used to evaluate the efficacy of CAS in patients with carotid stenosis. The complementary use of the two methods has certain clinical application value.

Abstract:Background and Aims Catheter-related thrombosis (CRT) is one of the main complications of central venous catheterization. At present, the treatment of CRT is mainly based on anticoagulant and thrombolytic therapies. Clot dissolution is of great importance for restoring patency of the affected vessel, and directly affects the occurrence of post-thrombotic complications and the prognosis of patients. Studies have demonstrated that heme oxygenase 1 (HO-1) plays an important role in the process of thrombolysis and recanalization after the formation of deep venous thrombosis. However, its effects in CRT have rarely been reported. Therefore, this study was conducted to investigate the effect of HO-1 in clot dissolution and recanalization in rat model of CRT and the relevant mechanism, so as to provide new ideas and theoretical basis for clinical treatment of CRT.Methods A total of 72 healthy male SD rats aged 7-8 weeks underwent superior vena cava catheterization for 10 d to induce CRT models. Then, rats were equally randomized into model group, HO-1 agonist group and HO-1 inhibitor group. Rats in model control group did not receive any intervention, and those in the latter two groups received abdominal injection of HO-1 agonist cobalt protoporphyrin (CoPP) and inhibitor tin protoporphyrin (SnPP), respectively. Both treatment doses were 5 mg/kg. On the 1st, 7th, 14th and 28th d after that, 6 rats in each group were sacrificed, the blood was collected from the abdominal aorta, and the serum levels of HO-1, IL-6 and IL-10 were determined by ELISA assay; the affected vessels were harvested to observe the thrombolysis and calculate the thrombolysis rate by HE staining, to examine the expression of endothelial mark CD31 by immunohistochemical staining, and to detect the HO-1 mRNA expression by qPCR.Results The results of HE staining showed that thrombolysis was increased with time elapsed in each group, the thrombolysis rate was higher in HO-1 agonist group was lower in HO-1 inhibitor group than that in model group at each defined time point (all P<0.05), and on the 28th d, the vessels presented nearly complete recanalization in HO-1 agonist group, while only partial recanalization in HO-1 inhibitor group. The results of immunohistochemical staining showed that the expression of CD31 was higher in HO-1 agonist group and was lower in HO-1 inhibitor group than that in model group at each defined time point (all P<0.05). The results of ELISA assay showed that the serum levels of HO-1 and IL-10 were increased and the serum level of IL-6 was decreased in HO-1 agonist group compared with model group at each defined time point, while the opposite changes in these variables were observed in HO-1 inhibitor group (all P<0.05). The results of qPCR showed that the HO-1 mRNA expression in the vascular tissue in HO-1 agonist group was higher than that in model group at each defined time point, while the opposite view occurred in HO-1 inhibitor group (all P<0.05).Conclusion HO-1 can promote the clot dissolution and recanalization of CRT in rats, and its mechanism may be related to its inhibiting inflammatory response and promoting angiogenesis.

Abstract:Background and Aims The pathogenesis and development of aortic dissection are not fully understood at present. However, a lot of studies have shown that hemodynamic factors have an important influence on the occurrence and development of aortic dissection. This study was conducted to determine the changing pattern of the hemodynamic parameters in the aorta without dissection and with dissection of different development stages by computational fluid dynamics method, aiming to investigate the occurrence and development of dissection from the perspective of fluid dynamics.Methods Based on the aorta size data of a patient with type B aortic dissection, the idealized aortic models without dissection and with dissection in different development stages were constructed using 3D modeling software Pro/E. Two-way fluid-structure coupling simulation was completed by Workbench platform, and the changing pattern of the hemodynamic parameters such as blood velocity, pressure and Von Mise stress of vascular wall were analyzed.Results During the accelerated ejection period, the maximum blood velocity increased about 0.6 m/s with the presence of the dissection, and the blood flow condition in the false lumen became more complex with the development of the aortic dissection. The maximum blood pressure increased about 0.3-0.6 kPa, and the hypertensive area of the lateral wall of the ascending aorta entrance was also enlarged. The peak and fluctuation of the maximum Von Mise stress in the vascular wall were increased with the development of the aortic dissection, and the maximum Von Mise stress was mainly located in the laceration of the tear location, the lateral wall and the outer wall of the false lumen.Conclusion In the presence of aortic dissection, the false lumen compresses the true lumen, resulting in increased blood velocity of vascular branches and increased blood pressure and hypertension area of the ascending aorta. Vortex near the tear location may cause further tearing or even rupture the blood vessel. The risk of further tearing and rupture of the blood vessel increases with the development of the aortic dissection, and the prevention of rupture of the blood vessel at the tear location, lateral wall and the outer wall of the false lumen should be focused.

Abstract:As a minimally invasive treatment, endovascular therapy has been widely used in different disciplines such as vascular surgery, both interventional cardiology and cardiovascular surgery as well as neurosurgery. There are some problems in sustainability and accuracy in traditional vascular interventional surgery that is operated by manipulation of the catheter and guide wire with hands under X-ray fluoroscopy, meanwhile the operators are at high risk of occupational hazards from long-term X-ray exposure and the burden of the lead apron. The robotic system for endovascular intervention has the advantages of significantly reducing the exposure of the operators to radiation, accurate imaging positioning, as well as precise and stable operation. It not only reduces the contact between the instrument and the vessel wall and minimizes the uncontrolled tremors, but also increases the operator's sensation of comfort, which has currently become the research hotspot of medical robot. Here, the authors introduce some key techniques of endovascular intervention robot system, such as image navigation, structure of mechanical arm, force feedback and safety performance, and describe the progress of endovascular intervention robot system at home and abroad, and also illustrate the importance of these techniques through their clinical applications, and then discuss the development trend of these key techniques. Although the progress of technology has greatly promoted the development of robotic endovascular system, it should be noted that there are still many deficiencies. For example, the lack of haptic feedback limits its application in complex and difficult lesions, such as calcified lesions and chronic occlusive lesions. At the same time, there is a lack of endovascular intervention instruments applicable for the currently commercialized guide wires, catheters, balloons and stents. Frequent replacement of interventional devices will lead to an increase in surgical time and further reduce the controllability of surgery. The rapid development of artificial intelligence and 5G communication technology will provide a more accurate and standardized development direction for endovascular intervention robot system. Furthermore, on the basis of artificial intelligence, the integration of robotic endovascular system with endovascular imaging equipment and the application of virtual reality technology provides a broader prospect for precise vascular interventional surgery, and points out the future research direction. The development of endovascular intervention robot system complies with the present trend of precision medicine, and provides protections for vascular interventional physicians. However, this technology still needs some more time for improvement and perfection, and defining the indications and contraindications, as well as establishing a standard procedure, and assessing the long-term efficacy by a number of clinical trials, so that it can be used more widely.

Abstract:Neutrophil extracellular trapping nets (NETs) are reticular fibrous structures composed of DNA, histone, granule protein and cytoplasmic protein released by neutrophils under the stimulation of bacteria, fungi, viruses, and parasites. According to different stimuli, the formation of NETs mainly falls into two categories: non-nicotinamide adenine dinucleotide phosphate oxidase-dependent pathway and nicotinamide adenine dinucleotide phosphate oxidase-dependent pathway. NETs have both anti-inflammatory and pro-inflammatory effects. On the one hand, they can capture, fix and kill invading pathogens, playing an antimicrobial role, and help inflammation subside. This is a special way for neutrophils to play host defense. On the other hand, when it produces too much or clearance is insufficient, it can directly cause tissue damage, but also recruit other pro-inflammatory cells or proteins to promote the release of inflammatory factors, further to expand the inflammatory response and participate in the pathological damage of a variety of diseases. Therefore, the authors by summarizing the relationship between NETs and lung diseases, liver diseases, intestinal diseases, tumors, and other diseases reveal the roles of abnormal formation and clearance of NETs in tissue and organ injury, to explain the occurrence mechanism of some clinical diseases, and also provide important direction guidance and theoretical basis for exploring the relevant mechanism of drug intervention in NETs and targeted therapy.