Abstract:Carotid atherosclerotic stenosis is a main cause for ischemic stroke. Evaluation of plaque characteristics is a crucial step for intervention method selection from the comprehensive scheme of treatment of carotid stenosis. At present, no objective diagnostic standards for plaque vulnerability have been finalized, and the pathological diagnosis remains the most reliable assessment approach. A great number of studies on the plaque vulnerability evaluation have been made by investigators in China and abroad during recent years, and the achievements from them may positively influence choice of treatment plan for carotid stenosis.

Abstract:Preservation or occlusion of the hypogastric artery in endovascular abdominal aortic aneurysm repair (EVAR) has long been a focus issue arising in the course of development of EVAR. Based on review of several dozen papers, the author extracts and analyzes the anatomical studies of the hypogastric artery system form a century ago to the present time, and the clinical consequences after ligation or embolization of the hyogastric artery in non-vascular operations or open surgery of the abdominal aorta and iliac artery, and after using different embolization methods of hypogastric artery during EVAR, as well as various risk factors for complications from pelvic ischemia. The final conclusion is that maintaining hypogastric artery patency in EVAR is essential. Moreover, for cases with no allowance for a patent hypogastric artery due to inevitable embolization, the measures to prevent or reduce pelvic organ ischemia, detailed operative skills and intraoperative attention points are also addressed.

Abstract:Peripheral arterial disease (PAD) may cause claudication and critical limb ischemia. Currently, the therapeutic options for complex PAD involving the common femoral artery (TASC C and TASC D) include traditional open surgery and hybrid surgery, and the latter is becoming increasingly preferred in clinical practice in recent years. However, there is no relevant literature or guidelines providing detailed operation procedures and efficacy evaluation of hybrid surgery at present. The author, based on the experience of a single center and literature review, systematically describes the hybrid technology as a guide for clinical practice.

Abstract:Modified video-assisted lateral neck dissection (M-VALND) is an ideal surgical technique that incorporates surgical safety, oncological completeness, minimal invasiveness and cosmetic satisfaction. At the same time, the M-VALND is characteristically close to the traditional open surgery and easily reproducible. The author, based on personal experience in more than 400 cases of M-VALND during recent 5 years, describes the procedure in detail and in terms of the selection of surgical indications, creation of surgical working space, choice of surgical instruments and their application techniques, as well as the procedural surgical steps and attention points.

Abstract:

Objective: To investigate the strategies and attention points for endovascular repair of proximal descending aortic disease with an insufficient proximal landing zone in patients with concomitant severe coronary heart disease who have undergone or were soon likely to receive coronary artery bypass grafting surgery requiring preservation of the left subclavian artery. Methods: The clinical data of 9 patients with proximal descending aortic disease, who had concomitant severe coronary heart disease and insufficient proximal landing zone, undergoing thoracic endovascular aortic repair in Vascular Surgery Center of Fuwai Hospital from April 2016 to July 2016 were retrospectively analyzed. Of the patients, 7 cases were male and 2 cases were female, with an average age of 60 (37–76) years. All patients underwent thoracic endovascular aortic repair, with preservation of the left subclavian artery for preserving the left internal mammary artery that was the best choice for bypass of the diseased left anterior descending coronary artery. Results: The surgical success rate was 100%, no surgical death occurred, and the left subclavian artery was preserved in all patients. Type I endoleak occurred in one patient (11.1%) after operation, which disappeared 3 months later, and one patient (11.1%) underwent percutaneous coronary angioplasty 4 months after operation due to stenosis of the left circumflex coronary artery. All patients received follow-up by outpatient visits or telephone. The clinical symptoms disappeared or were significantly alleviated, the quality of life was improved in all patients and no death occurred during the follow-up period for an average of 6 (4–7) months. Conclusion: In patients who have undergone coronary artery bypass grafting with left internal mammary artery to the left anterior descending artery, or will undergo coronary artery bypass surgery soon, the left subclavian artery can be preserved by personalized measures during thoracic endovascular aortic repair, and thereby to preserve the left internal mammary artery. Adjunctive techniques such as chimney-stenting can be used when necessary.

Abstract:Objective: To investigate the efficacy of hybrid procedures or endovascular repair for type B aortic dissection concomitant with aberrant subclavian artery and Kommerell’s diverticulum. Methods: The clinical data of 5 patients with type B aortic dissection complicated by aberrant subclavian artery and Kommerell’s diverticulum treated from January 2013 to December 2016 were retrospectively analyzed. The patterns of aortic arch variations, the location of the proximal tear and surgical options as well as the perioperative and follow-up results of the patients were summarized. Results: According to the patterns of aortic arch variations and location of the proximal tear of the patients, 2 cases underwent hybrid surgery and 3 cases underwent endovascular aortic repair alone. The operative time ranged from 90 to 538 min, with an average of 294 min. Postoperative immediate angiography showed the completely occluded tears, and normal blood flow in the branches of the aortic arch or bypass grafts. One patient died of massive cerebellar infarction on one week after operation but the other 4 patients were alive during postoperative follow-up period, and no symptoms of brain or upper limb ischemia were noted and no stent displacement or endoleak occurred. Conclusion: The variations of aortic arch branches along with the vascular frangibility of the Kommerell’s diverticulum cause surgical inconvenience. Hybrid surgery or endovascular repair is feasible in treatment of aortic dissection concomitant with aberrant subclavian artery and Kommerell’s diverticulum. However, the treatment experience for this condition should be further enhanced, and the long-term efficacy remains to be determined.

Abstract:Objective: To investigate the features of aortic remodeling in Stanford type B subacute aortic dissection after thoracic endovascular aortic repair (TEVAR) and the influential factors. Methods: The pre- and postoperative clinical and imaging data of 50 patients with Stanford type B sub-acute aortic dissection undergoing TEVAR in Department of Vascular Surgery of Anhui Provincial Hospital from January 2008 to June 2016 were retrospectively analyzed. The changes in the true lumen and false lumen of different segments of the aorta at postoperative 3, 6 and 12 months after TEVAR as well as the influential factors for postoperative aortic remodeling were analyzed. Results: The technical success rate of TEVAR was 100%. Eight patients were lost to follow-up after operation. The imaging data of the remaining 42 patients showed that at each time point after TEVAR, true lumen diameter was significantly increased and the false lumen diameter was significantly decreased compared with their preoperative values in the segment of the thoracic aorta (all P<0.05), while no significant changes were observed in both true lumen and false lumen of the abdominal aortic segment compared with their preoperative values (all P>0.05); the complete false lumen thrombosis rate of the thoracic aorta was higher than that of the abdominal aorta. Multivariate analysis showed that branches perfused from the false lumen (OR=27.45, P<0.05) and the presence of multiple tears (OR=19.02, P<0.05) were independent risk factors for adverse aortic remodeling in Stanford type B subacute aortic dissection after TEVAR. Conclusion: The aortic remodeling in the thoracic aorta is better than that in the abdominal aortic segment. The branches perfused from the false lumen and presence of multiple tears are independent risk factors for adverse aortic remodeling after TEVAR.

Abstract:Objective: To investigate short- and long-term efficacy of surgical treatment for Stanford type A acute aortic dissection (AAD) in elderly patients. Methods: The clinical data of 196 patients with Stanford type A AAD undergoing surgical treatment in the Department of Cardiovascular Surgery of the Second Affiliated Hospital of Zhengzhou University from June 2013 to September 2016 were retrospectively analyzed. All patients underwent surgical repair under general anesthesia with deep hypothermic circulatory arrest and unilateral selective cerebral perfusion. The patients consisted of 33 cases with age equal to or over 60 years (elderly group) and 163 cases with age below 60 years (nonelderly group). The clinical variable and outcomes of the two groups of patients were compared. Results: In elderly group compared with nonelderly group, the proportion of male cases was lower (45.5% vs. 73.0%, P=0.000), the proportion of DeBakey type II dissection was increased (21.2% vs. 6.7%, P=0.009); the proportion of cases undergoing ascending aortic replacement plus total aortic arch replacement with stent elephant trunk implantation was decreased (9.1% vs. 28.2%, P=0.021), but the proportion of cases undergoing a simple ascending aortic replacement was increased (21.2% vs. 2.5%, P=0.000); the average extracorporeal circulation time, aorta occlusion time and operative time were all shortened (215.70 min vs. 252.98 min, P=0.000; 121.12 min vs. 134.00 min, P=0.008; 489.15 min vs. 533.52 min, P=0.004); the length of the postoperative ICU stay was prolonged (235.27 h vs. 163.55 h, P=0.011), and the incidence of postoperative renal dysfunction (21.2% vs. 6.7%, P=0.009) and infections (30.3% vs. 9.8%, P=0.002) were increased; the postoperative survival showed no significant difference (P=0.1466). Statistical analysis of the entire group of patients showed that extracorporeal circulation time was an independent risk factor for postoperative in-hospital death (OR=0.987, 95% CI=0.977 0.997, P=0.011), while the age (OR=1.790, 95% CI=0.651 4.921, P=0.259) and other factors were not significantly associated with the risk of postoperative in-hospital death. Conclusion: For elderly AAD patients, surgical procedure selected according to the extent of the dissection involvement may offer a satisfactory result. Surgical efficacy can be improved by keeping the extracorporeal circulation time as short as possible.

Abstract:Objective: To investigate the efficacy of using preclose technique in endovascular exclusion of type B aortic dissection. Methods: One-hundred and nine patients with type B aortic dissection were designated to observation group (55 cases) and control group (54 cases). Patients in observation group received preplaced two ProGilde devices for vascular access site repair, and those in control group received the traditional repair method. The main clinical variables between the two groups of patients were compared. Results: In observation group compared with control group, the average operative time (98.2 min vs. 140.8 min), time to achieve hemostasis after sheath pulling (4.3 min vs. 9.1 min) and length of hospital stay (4.4 d vs. 5.9 d) were significantly reduced, and hospitalization cost (84 000 yuanvs. 81 000 yuan) was significantly increased (all P<0.05), while the duration of immobilization of the lower limb showed no significant difference (P>0.05). The surgical success rates and blood vessel diameters at the surgical site 3 months after operation showed no significant differences between the two groups (both P>0.05). One case in observation group and 3 cases in control group underwent repeat intervention due to apparent endoleak, and the overall incidence of complications in observation group was significantly lower than that in control group (7.27% vs. 24.07%, P<0.05). Conclusion: Using preclose technique in endovascular exclusion of type B aortic dissection is safe and efficient, with reliable surgical results and few postoperative complications.

Abstract:Objective: To investigate the actions of ROCKI/II in phenotypic transformation of human aortic vascular smooth muscle cells (HA-VSMCs) induced by transforming growth factor β1 (TGF-β1). Methods: HA-VSMCs were respectively transfected with ROCKI and ROCKII, and the transfection results were observed by fluorescence microscope. The ROCKI and ROCKII protein expressions in HA-VSMCs with different treatments (ROCKI siRNA transfection, ROCKII siRNA transfection, +TGF-β1, ROCKI siRNAtransfection+TGF-β1, and ROCKII siRNAtransfection+TGF-β1) were determined by Western blot analysis. The protein and mRNA expressions of the contractile phenotype maker α-smooth muscle actin (α-SMA) and smooth muscle 22α (SM22α) and synthetic phenotype marker osteopontin (OPN) in HA-VSMCs with different treatments (+TGF-β1, ROCKI siRNA transfection+TGF-β1, ROCKII siRNA transfection+TGF-β1, and pretreatment of ROCK non-specificity Y-27632+TGF-β1) were determined by Western blot analysis and RT-PCR method, respectively. Untreated HA-VSMCs were used as blank control. Results: Both siRNAs were successfully transfected as evidenced by fluorescence observation and Western blot analysis. In HA-VSMCs after TGF-β1 treatment, the ROCKI protein expression level was significantly up-regulated (P<0.05), but the ROCKII protein expression level did not significantly change (P>0.05), while the ROCKI increasing effect of TGF-β1 was significantly inhibited by ROCKI siRNA transfection (P<0.05). In HA-VSMCs after TGF-β1 treatment, the protein and mRNA expressions of α-SMA and SM22α were decreased and those of OPN were increased significantly (all P<0.05), and these effects were significantly suppressed by ROCKI siRNA transfection or Y-27632 pretreatment (all P<0.05), but were not affected by ROCKII siRNA transfection (all P>0.05). Conclusion: TGF-β1 can induce the transformation of HA-VSMCs from contractile phenotype to synthetic phenotype, which may be associated with the up-regulation of ROCKI expression.

Abstract:Objective: To investigate the clinical efficacy of using AngioJet in treatment of lower extremity arterial thromboembolic disease and report the preliminary experience. Methods: The clinical data of 10 patients with lower extremity arterial thromboembolic disease (3 cases of acute arterial embolism of the lower extremities, 5 cases of acute thrombosis secondary to arteriosclerosis obliterans of the lower limbs, and 2 cases of primary thrombosis) undergoing thrombus aspiration with AngioJet system from August 2016 to July 2017 in Zhongshan Hospital of Fudan University were retrospectively analyzed. Results: The operations in all the 10 patients (mean age of 61.60 years) were successfully completed by using AngioJet alone or together with other modalities, and the technique successful rate was 100%. Of the patients, stenosis disappeared in 2 cases after AnigoJet aspiration alone, 6 cases underwent balloon angioplasty and 2 cases underwent balloon angioplasty plus stenting due to residual stenosis after AnigoJet aspiration. Due to presence of remnant thrombi, 3 cases undergoing AnigoJet aspiration plus balloon angioplasty and one case undergoing AnigoJet aspiration plus balloon angioplasty and stenting were assisted by pulse-spray thrombolysis, and one case undergoing AnigoJet aspiration plus balloon angioplasty and one case undergoing AnigoJet aspiration plus balloon angioplasty and stenting were assisted by catheter directed thrombolysis (CDT). The average length of postoperative hospital stay was (3.9±2.3) d. The postoperative ankle-brachial index was significantly increased compared with the preoperative value (0.84 vs. 0.37, P<0.05). Hematuria and mild renal impairment occurred in one case each after operation. The treatment effectiveness assessment showed that 6 patients had complete cure and 4 patients had good response. Six-month follow-up was completed in 7 patients, and no exacerbation of limb ischemia was noted. Conclusion: Thrombus aspiration using AngioJet system is safe, effective and less invasive for acute lower extremity arterial thromboembolic disease, and is especially suitable for thromboembolic lesions in the femoropopliteal segment. The residual stenosis after aspiration can be corrected by balloon angioplasty or combined with stent implantation, and CDT can be applied for those with ineffective thrombus aspiration.

Abstract:Objective: To evaluate the short-term efficacy of combined pharmacological and mechanical thrombectomy (AngioJetthromectomy system) in treatment of acute left iliacofemoral venous thrombosis. Methods: The clinical data of 38 consecutive patients with acute left iliacofemoral vein thrombosis (disease onset less than or equal to 14 d) undergoing combined pharmacological and mechanical thrombectomy in two Vascular Surgery Centers from January 2016 to April 2017 were retrospectively analyzed. The immediate effect of thrombus aspiration was evaluated by intraoperative angiography, and the short-term efficacy was assessed by CEAP classification, Doppler ultrasound examination or angiography at 3-, 6- and 12-month follow-up visits. Results: Of the 38 patients, 37 cases received urokinase spray during AngioJet thrombus aspiration, 31 cases underwent first-stage iliac vein stenting after thrombus aspiration, and 11 cases were treated with adjunctive catheter-directed thrombolysis (CDT). After operation, grade III thrombus clearance (complete clearance) was achieved in 20 patients (47.4%), grade II thrombus clearance (50% to 99% clearance) was obtained in 18 patients (52.6%), and grade I thrombus clearance (<50% clearance) was absent. Varying degrees of hemoglobinuria occurred in 37 patients after operation, which all disappeared within 12 to 24 h. During follow-up, one patient (3.3%) required repeated surgical intervention, and no serious complications related to operation or death occurred. Conclusion: For acute left iliacofemoral vein thrombosis, the combined pharmacological and mechanical thrombectomy has demonstrable short-term efficacy and favorable safety. Combined CDT or stent placement may increase the efficiency of thrombus clearance.

Abstract:Objective: To systematically evaluate the efficacy and safety of autologous stem cell transplantation combined with percutaneous transluminal angioplasty (PTA) in treatment of diabetic foot or limb ischemia. Methods: The literature of clinical controlled trials (CCTs) concerning autologous stem cell transplantation combined with PTA in treatment of diabetic foot or limb ischemia was collected by searching several national and international databases. The search included all articles from the inception of the databases until November 2017. After literature screening by two reviewers according to the quality assessment methods and inclusion/exclusion criteria, and then data extraction and assessment of risk of the included studies, Meta-analysis was performed by using Revman 5.3 software. Results: Twelve CCTs were finally included involving 630 patients with diabetic foot or limb ischemia. Meta-analysis showed that in patients undergoing autologous stem cell transplantation combined with PTA compared with those undergoing PTA alone, the ankle brachial index (MD=0.07, 95% CI=0.02–0.13, P=0.01), transcutaneous oxygen tension (MD=4.03, 95% CI=2.94–5.12, P<0.00001), cold sensation of the diseased limb (RR=1.29, 95% CI=1.14–1.45, P<0.0001), claudication distance (MD=372.89, 95% CI=108.97–636.81, P=0.006) and effectiveness evaluation (RR=1.18, 95% CI=1.08–1.29, P=0.0004) were all significantly improved. Conclusion: Autologous stem cell transplantation combined with PTA is superior in efficacy to PTA alone in treatment of diabetic foot or limb ischemia, with better safety. However, the conclusions still need to be supported by large multicenter randomized clinical trials.

Abstract:

Objective: To evaluate the safety and efficacy of tension-free herniorrhaphy in treatment of incarcerated inguinal hernia. Methods: The clinical data of 60 patients with incarcerated inguinal hernia undergoing surgical treatment during January 2013 to December 2014 were retrospectively analyzed. Of the patients, 32 cases underwent tension-free herniorrhaphy with mesh-plug technique (observation group), and 28 cases underwent traditional herniorrhaphy (control group). The main clinical variables between the two groups of patients were compared. Results: The preoperative data of the two groups of patients were comparable. The operative time (53.6 min vs. 51.8 min) and intraoperative blood loss (10.3 mL vs. 11.1 mL) showed no statistical difference between observation group and control group (both P>0.05); postoperative complications occurred in 9 cases (28.1%) in observation group and in 5 cases (17.9%) in control group, which showed no statistical difference (P>0.05); no mesh infection occurred in observation group; the average length of hospital stay in observation group was significantly shorter than that in control group (5.3 d vs. 6.3 d, P<0.05). Follow-up was conducted for 24 to 36 months in both groups, and recurrence occurred in no case in the study group but in 5 cases in control group, and the difference was statistically significant (χ2=4.12, P<0.05). Conclusion: For incarcerated inguinal hernia, tension-free herniorrhaphy can shorten the length of hospitalization and reduce postoperative recurrence, and is safe and effective.

Abstract:Venous leg ulcer (VLU) is a common disease in the field of vascular surgery, and is still a challenge in clinical practice due to its often delayed healing and frequent recurrence after healing. The current therapeutic options for VLU mainly include conservative treatment and surgical intervention. Here, the authors address the progress with regard to its drug therapy, compression therapy, traditional surgery, and endovascular and endoscopic treatment as well as managements for the perforator veins and wound surface, so as to provide reference for the surgery-based comprehensive treatment of VLU in clinical practice.

Abstract:Diabetic foot is one of the most severe chronic complications of diabetes, and approximately 40% to 60% of non-traumatic lower-limb amputations occur in diabetic foot patients. Because of the complex conditions of diabetic foot patients and along with the highly specialized departments at the hospital, the traditional single-discipline treatment model is difficult to meet the requirements for treatment of diabetic foot, while the use of multi-disciplinary team (MDT) model has become a development direction. At present, using MDT model in diagnosis and treatment of diabetic foot has been conducted by a number of teams in China and abroad and satisfactory results have been achieved.

Abstract:Breast reconstruction is an important component of breast cancer treatment, in which the breast reconstruction using free perforator flaps requires skilled surgical technique in microvascular anastomosis. At present, the microvascular anastomosis training program includes a variety of skill training methods and assessment systems. Here, the authors, based on relevant literature, review and discuss the practicability of various methods and the objectiveness of the assessments, to provide learning and practicing suggestions for breast surgeons.