Abstract:Deep venous thrombosis (DVT) of the lower extremity is one of the common diseases in vascular surgery. Accumulating evidences have shown that early thrombus removal is safe and effective, and can reduce the occurrence of post-thrombotic syndrome (PTS) with limb inflammatory swelling and skin ulcers as the main clinical manifestations, while improving the patients' quality of life. The methods of thrombus removal mainly include open thrombectomy, catheter-directed thrombolysis (CDT) and percutaneous mechanical thrombectomy (PMT). The diversification of thrombus removal methods and the rapid update of equipment have provided technical reinforcement to clinicians. In addition, the rational application of the inferior vena cava retrievable filter has greatly improved the safety of thrombus removal surgery. The application of iliac vein balloon and stent after thrombus removal can avoid the recurrence of thrombus. Although there are some controversies in clinical practice and lack of high-quality and high-level research evidence, positive agreements on the necessity, efficacy and safety of thrombectomy for lower limb DVT have gradually been reached. Here, the authors present and summarize the key problems in clinical practice.

Abstract:Abdominal aortic aneurysm (AAA) is a permanent and irreversible localized dilatation of the abdominal aorta with a mortality after rupture ranging from 60% to 70%. Endovascular abdominal aortic aneurysm repair (EVAR) has been considered as the first-line option for the treatment of AAA owing to its clinical safety and effectiveness. However, the occurrence of complications in long-term follow-up such as stent displacement and endoleak is still raising concern. To date, "ENGAGE" is the largest long-term registration study of endovascular treatment of AAA. Here, the authors, based on the 8-year follow-up results of the "ENGAGE" study and relevant literature analysis, systematically introduce the current situation and outlook of endovascular treatment of AAA.

Abstract:The first management guidelines in the field of venous thrombosis, European Society for Vascular Surgery (ESVS) 2021 Clinical Practice Guidelines on the Management of Venous Thrombosis was published in the European Journal of Vascular and Endovascular Surgery in 2021. The guidelines address acute deep vein thrombosis (DVT) of the lower extremity, upper extremity DVT, superficial vein thrombosis (SVT), and thrombosis in unusual sites, with a total of 72 recommendations. In addition to treatment-related recommendations, the guidelines also cover topics such as health economics and special patient populations. The recommendations in the guidelines have been formulated by analysis and evaluation of the available scientific evidence, and may have great referential value for clinical work. However, as technology, available evidence and disease knowledge continue to advance, the guidelines may need to be updated regularly. Here, the author's team emphatically interprets the recommendations given in the guidelines based on the medical evidence updated in the guidelines and combined with the hot issues in clinical practice, so as to better understand the guiding principles and practical recommendations.

Abstract:Background and Aims Thoracic outlet decompression with a subclavian artery bypass is considered to be the standard surgical procedure for arterial thoracic outlet syndrome (TOS), and it requires different surgical approaches for different locations of arterial compression. The efficacy of above surgery is reliable, and the long-term functional prognosis of the affected limb is usually satisfactory after surgery. However, above surgical procedure is technically difficult with a long learning curve, and will result in great trauma and many complications such as bleeding and nerve damage, as well as slow recovery of patients after the surgery. In recent years, the advancement of endovascular technology and the innovation of vascular devices have enabled a considerable number of vascular stenotic lesions to be effectively treated by interventional surgery. However, there are few previous reports on the use of endovascular techniques for the treatment of arterial TOS. Therefore, this study was to investigate the primary clinical efficacy of Rotarex mechanical debulking combined with drug-coated balloon (DCB) dilatation for arterial TOS, aiming to provide a new and reliable treatment approach for this condition.Method The clinical data of 6 patients with arterial TOS who underwent Rotarex mechanical debulking combined with DCB dilatation from January 2019 to December 2021 in Beijing Jishuitan Hospital were retrospectively analyzed. The surgical success rate, operative time, length of hospitalization, and surgical complications as well as the arterial patency rate and revascularization rate of the target lesion on postoperative 3 months were analyzed. The cervical brachial symptom and McGill pain questionnaire scores as well as the radial-artery pulses of the patients before and after operation were compared.Results In the 6 patients, the surgical success rate was 100%, the mean operative time was (52.3±18.7) min, mean length of hospitalization was (5.7±1.6) d, and mean intraoperative blood loss was (31.5±20.7) mL. There were no surgery-related complications. Three months after operation, the artery patency rate was 100%, and the revascularization rate of the target lesion was 16.67%. The postoperative cervical brachial symptom of the patients was significantly lower than that before operation (59.3±17.3 vs. 83.1±11.2, P<0.05), but the McGill pain questionnaire score of the patients showed no statistical difference with that before operation (45.3±12.5 vs.51.9±9.2, P>0.05), and the postoperative radial-artery pulse of the patients was significantly improved compared with preoperative status (P<0.05).Conclusion Rotarex mechanical debulking combined with DCB dilatation is a minimally invasive, safe and effective method for the treatment of arterial TOS with a satisfactory short-term effect. However, the indications for endovascular surgery should be strictly controlled, and the TOS patients undergoing this procedure should be carefully selected, and meanwhile timely follow-up is also needed. The mid- and long-term efficacy of this treatment method remains to be further observed.

Abstract:Background and Aims Early thrombus removal and debulking for deep vein thrombosis (DVT) of the lower extremities can restore venous patency and relieve symptoms. At present, AngioJet is the most commonly used venous thrombus removal system in China, while Aspirex is infrequently used. Therefore, this study was conducted to investigate the efficacy and safety of percutaneous mechanical thrombectomy (PMT) using Straub Aspirex in the treatment of patients with acute lower extremity DVT after trauma.Methods The clinical data of 54 patients with DVT after trauma treated in the Department of Vascular Surgery of Beijing Jishuitan Hospital from May 2016 to August 2020 were retrospectively analyzed. All patients underwent inferior vena cava retrievable filter implantation, with Dneali in 35 cases (64.8%), Celect in 3 cases (5.6%), Cordis in 14 cases (25.9%), and Octoparms and Tempofilter II in one case (1.9%) each. The iliofmoral and inferior vena cava vein thrombosis in all patients were identified by color ultrasound examination or venography after surgery and fixation for trauma. Among them, 22 cases (40.7%) had iliofemoral vein thrombosis, 4 cases (7.4%) had iliac and inferior vena cava vein thrombosis, 11 cases (20.4%) had inferior vena cava thrombosis, and 17 patients (31.5%) had iliofemoral and inferior vena cava vein thrombosis. All patients underwent Straub Aspirex PMT under local anesthesia via femoral or popliteal vein approach, combined with manual aspiration thrombectomy (MAT), catheter-directed thrombolysis (CDT), balloon dilation, and stent implantation. The technical success rate, immediate clinical success rate (symptom remission rate), perioperative bleeding rate and filter removal rate were calculated. One-year follow-up was performed, and the target venous patency rate and the incidence of post-thrombotic syndrome (PTS) were evaluated by ultrasound.Results Of the 54 patients, 3 cases (5.6%) underwent mechanical thrombosis alone, 17 cases (31.5%) underwent manual aspiration thrombectomy, 3 cases (5.6%) underwent CDT, 18 cases (33.3%) underwent CDT and MAT, 12 cases (22.2%) underwent MAT and iliac vein balloon dilation, and 1 case (1.9%) underwent MAT and stent implantation. Both technical success rate and immediate clinical success rate were 100%. Grade III thrombus clearance was achieved in 12 patients (22.2%), grade II clearance was obtained in 33 patients (61.1%), and 9 patients (16.7%) had grade I clearance. The success rate of thrombus removal was 83.3%. In the perioperative period, cerebral hemorrhage occurred in one patient (1.9%), and hematoma absorption was seen on head CT examination without sequelae 2 weeks after discontinuation of thrombolysis and anticoagulation, epistaxis and puncture point hematoma occurred in 2 patients (3.7%), which were relieved after compression, and there were no complications such as symptomatic pulmonary embolism and death occurred. The filter retention time was (61.4±84.8) d, and filter retrieval was attempted in 51 patients (94.4%), being successful in all of them. There was no recurrence of thrombosis and other complications after operation. At one year after operation, the incidence of PTS was 33.3%, and the target venous patency rate was 75.9%.Conclusion For patients with acute iliofemoral and inferior vena cava DVT after trauma, PMT using Straub Aspirex has demonstrable efficacy with reliable safety, and the combination of manual aspiration thrombectomy, CDT and iliac venoplasty can improve the venous patency rate.

Abstract:Background and Aims Inferior vena cava (IVC) thrombosis is often secondary to IVC filter implantation. The acute phase mainly manifests as limb swelling and pulmonary embolism (PE), and the chronic phase manifests as IVC stenosis, occlusion and post-thrombotic syndrome. Early removal of acute IVC thrombosis is clinically recommended to reduce complications. AngioJet has been widely used for removing acute lower extremity deep venous thrombosis, but there are few studies on the method and effect of acute IVC thrombus removal. Therefore, this study was conducted to investigate the efficacy and safety of the AngioJet thrombectomy device in the treatment of acute IVC thrombosis.Methods The clinical data of 58 patients with acute IVC thrombosis undergoing AngioJet treatment in the Department of Vascular Surgery of Beijing Jishuitan Hospital from July 2020 to June 2021 were retrospectively analyzed. The surgical safety, incidence of PE, efficacy of thrombus removal and rate of filter removal as well as the increase in postoperative hospital stay and cost for thrombus treatment were evaluated.Results All the 58 patients had retrievable filters implantation, of whom, the filters were successfully removed in 56 cases (96.6%), and 2 cases (3.4%) were lost to follow-up 3 months later without filter removal. After AngioJet treatment, 10 cases (17.2%) had grade III thrombus clearance, 34 cases (58.6%) had grade II clearance, and 14 cases (24.1%) had grade I clearance; after combination of catheter aspiration or catheter-directed thrombolysis (CDT), 14 cases (24.1%) had grade III clearance, 36 cases (62.1%) had grade II clearance, and 8 cases (13.8%) had grade I clearance. During the three-month follow-up, 2 cases (3.4%) developed IVC occlusion, and the venous patency rate was 96.6%. There were 16 patients (27.6%) with PE before operation, PE symptoms occurred or the PE symptoms became exacerbated in 2 cases (3.4%) after operation, and remained unchanged or were relieved in the other cases. The difference in symptoms of PE showed no statistical significance before and after operation (P>0.05). The liver and renal function parameters of the patients were increased after operation, but all of them did not reach the diagnostic criteria for acute liver injury and kidney injury. A total of 22 patients (37.9%) were treated with AngioJet alone, their postoperative hospital stay was increased by (1.45±0.51) d, and medical cost was increased by (27 248±78) yuan; a total of 36 patients were treated with AngioJet combined with catheter thrombectomy and (or) CDT, their postoperative hospital stay increased by (2.22±1.22) d, and the increase in medical expenses was (30 607±1 134) yuan, and the difference had statistical significance (both P<0.05).Conclusion AngioJet thrombectomy is safe and effective for removal of acute IVC thrombus without increasing the risk of symptomatic PE. The combined use of catheter thrombectomy and CDT can increase the thrombus removal effect, but it will prolong the postoperative hospital stay and increase the related medical expenses.

Abstract:Background and Aims All the current treatment strategies for high-risk acute pulmonary embolism (PE) patients will increase the risk of serious bleeding events that include the intracranial bleeding. AngioJet rheolytic thrombectomy (ART) enables a high-pressure pulse injection of thrombolytic agents to break down and dissolve the blood clots, and meanwhile allows aspiration in the pulmonary artery branches at the segmental level, which is theoretically an effective approach for acute PE. However, its safety needs to be further assessed. This study was conducted to analyzed the safety and efficacy of ART for the treatment of acute PE by reviewing the data of 3 patients with acute PE treated with ART.Methods The clinical data of three patients with acute PE treated by ART in the Center of Vascular Surgery of Beijing Anzhen Hospital, Capital Medical University from June 2021 to September 2021 were reviewed. The safety and effectiveness of ART treatment were evaluated by comparing the changes in vital signs and PE-related data of the patients.Results The technical success rate of ART was 100%. After ART, systolic pulmonary artery pressure, systolic displacement of the tricuspid ring, right ventricular diameter/left ventricular diameter ratio, blood oxygen saturation and B-type natriuretic peptide level were significantly improved in all patients. Transient bradycardia occurred in all the 3 patients, which was relieved after symptomatic treatment. No serious complications associated with surgery occurred in all patients during perioperative period. One patient died due to coronary heart disease, infectious-toxic shock, and ischemic hypoxic encephalopathy at 36 d after operation. The other two patients were followed-up for 3 months, and the pulmonary arterial pressure and right heart function of them were significantly recovered.Conclusion ART is a safe and effective method for patients with intermediate high-risk and high-risk acute PE. For reducing the ART-related complications, manipulation should be gentle, aspiration time should be strictly controlled, and close attention should be paid to the changes in blood pressure and heart rate of patients during the operation, and supplementation of low dose thrombolytic agent should be considered after ART if necessary. Meanwhile, adequate perioperative hydration and reduced use of the contrast agent can decrease the renal burden, so as to avoid the occurrence of acute renal insufficiency.

Abstract:Background and Aims Although the incidence of high-voltage electrical burns is very low, its potential damage to the muscle, nerve and blood vessel is more insidious than that of flame burns. The limb-threatening ischemia and delayed rupture/bleeding will lead to loss of limb function, disability and even death. There is no definite incidence number for limb vascular injuries after high-voltage electrical burns, nor is there any recommendation of diagnosis and treatment guidelines, and the treatment schemes of each center are different. As a national burn rescue center, our hospital treats a large number of burn patients every year, including high-voltage electrical burn patients with vascular injuries. This paper summarizes the diagnosis and treatment schemes of patients with high-voltage electrical burn wounds combined with vascular injuries treated in our hospital in recent 10 years, trying to analyze the differences between this category of patients and patients with traumatic arterial injuries, and extracting the diagnosis and treatment characteristics of these patients, so as to provide evidence support for future clinical work.Methods A total of 94 patients with limb vascular injuries caused by high-voltage electrical burns treated in our center from January 2010 to January 2020 were reviewed. The vascular repair methods included direct local repair, autologous vascular reconstruction and prosthetic vascular reconstruction. The incidence rates of postoperative complications such as thrombosis, delayed rupture/bleeding, infection, amputation were analyzed, and the differences of the data were compared.Results Of the 94 patients, 83 cases were males and 11 cases were females, with an average age of (30.4±20.1) years. Seven patients underwent amputation due to serious limb damage at initial admission. Eighty-seven patients received vascular repair that included local repair in 29 cases, autologous vascular reconstruction in 53 cases, and prosthetic vascular reconstruction in 5 cases. The technical success rate was 100%. Among patients undergoing local repair, 3 cases developed thrombosis and 2 cases developed pseudoaneurysm within 2 weeks after operation, and all of them underwent repeated operation of autologous revascularization. Among patients receiving autologous vascular reconstruction, thrombosis occurred in 7 cases within 2 weeks after operation, and their blood supply were improved after incision and thrombectomy, delayed rupture/bleeding occurred in 4 cases, of whom, incision, hemostasis and second reconstruction were performed in one case, covered stent was implanted in 3 cases, and limb amputation was performed in 3 cases due to postoperative infection or severe soft tissue necrosis. Among patients with prosthetic vascular reconstruction, one case had thrombosis within 2 weeks after operation, which was resolved by blood supply restoration after incision and thrombectomy, and one case had delayed rupture/massive hemorrhage, and then underwent endovascular covered stent implantation. Follow-up was obtained in 75 patients for 3-6 months, and the vascular patency rate was 89.3% (67/75).Conclusion The vascular injuries after high-voltage electrical burns are far beyond the visible damage, which is different from the injuries associated with general trauma. Before vascular reconstruction, the condition of injured vessels and surrounding tissues should be fully evaluated. On the premise of adequate debridement, both autologous vessels and prosthetic grafts can be satisfactory reconstruction materials; The vascular injuries caused by high-voltage electrical burns will progress over time. The occurrence of thrombosis and delayed rupture/bleeding should be vigilant. Once delayed rupture occurs, incision for hemostasis and reconstruction or endovascular interventional treatment should be performed in time, so as to preserve the affected limb.

Abstract:Background and Aims The aortic injury caused by various high-energy trauma such as car accidents and falls from great heights are often insidious and difficult to determine, which make the condition more complex. Repair of the injured aorta is necessary before surgical intervention for severe trauma. At present, thoracic endovascular aortic repair (TEVAR) has been widely conducted because of its advantage of minimal invasiveness and quick recovery, which provides great help to avoid delaying the specialized treatment of multiple injuries. This study was performed to investigate treatment strategies for traumatic aortic injury (TAI) through analyzing its pathological features and comparing the efficacy of TEVAR for TAI and the Stanford type B aortic dissection.Methods The data of 20 TAI patients (TAI group) undergoing TEVAR during November 2015 to December 2020, and 50 patients with non-traumatic Stanford B aortic dissection (non-TAI group) undergoing TEVAR during the same period in Xiangya Hospital of Central South University were retrospectively analyzed. The clinical variables between the two groups of patients were compared.Results No significant difference was identified in sex and age between the two groups (both P>0.05), but the proportion of patients with hypertension was lower in TAI group than that in non-TAI group (40.0% vs. 74.0%, P<0.05). The proportions of cases with localized tear and the primary tear at the aortic isthmus were higher in TAI group than those in non-TAI group (80.0% vs. 34.0%; 70.0% vs. 24.0%, both P<0.05), while the proportions of cases with the tear number ≥2, the involvement of the supra-arch branches, and the distance from the primary tear to the left subclavian artery (LSA) <15 mm were lower in TAI group than those in non-TAI group (30.0% vs. 78.0%; 10.0% vs. 52.0%; 40.0% vs. 72.0%, all P<0.05). In addition, the oversize of the stent graft was larger in TAI group than that in non-TAI group (P<0.05). The length of hospital stay was significantly longer in TAI group than that in the non-TAI group (16.80 d vs. 11.20 d, P<0.05), and the incidence of postoperative complications was higher in TAI group than that in the non-TAI group (20.0% vs. 4.0%, P<0.05). The follow-up results showed that there were no statistical differences in terms of complication rates and survival time between the two groups (both P>0.05), but the rates of volume changes in the false lumen and thrombus absorption were higher in TAI group than those in non-TAI group (95.0% vs. 72.0%; 90.0% vs. 58.0%， both P<0.05).Conclusion TAI is in urgent, critical and complex situations due to multiple injuries resulting from different causes, so the vascular repair should be performed individually based on the injury types, including the choice of surgical timing, the length of stents, oversize, the judgment of the landing zone and preservation or revascularization of the LSA. After TEVAR, the rates of volume changes in the false lumen and thrombus absorption were significantly higher in TAI patients than those in non-TAI patients, which reflects the appropriate remodeling of the aorta in the mid-term of the TAI, and thereby demonstrates the favorable efficacy of TEVAR in the treatment of TAI. However, its long-term efficacy still needed to be further assessed.

Abstract:Background and Aims Juxtarenal abdominal aortic occlusion is an extreme condition of aortoiliac occlusive disease, and its treatment is often challenging. Although endovascular therapy is suitable for such patients, there are still some indications for open surgery. This study was performed to evaluate the efficacy of open surgery for juxtarenal abdominal aortic occlusion and summarize the experience and its treatment strategies.Methods The clinical data of 10 patients with juxtarenal abdominal aortic occlusion undergoing open surgery from July 2018 to May 2022 were collected. The general information, surgical procedures, operative time, intraoperative blood loss, methods for blockage of the blood flow through the abdominal aorta, duration of cross-clamping of the suprarenal abdominal aorta, surgical complications and degree of symptom relief as well as the follow-up results were retrospectively analyzed.Results Operation was successfully completed in all the 10 patients. The operative time was 210 to 420 min with a median operative time of 265 min; the intraoperative blood loss was 200 to 1 200 mL with a median blood loss of 375 mL. The prosthetic bypass from the subphrenic abdominal aorta to bilateral femoral arteries was established in 3 patients, of whom, one case underwent simultaneous amputation; the prosthetic bypass from the subphrenic abdominal aorta to bilateral common iliac arteries with inferior mesenteric artery reconstruction was used in one patient; the prosthetic bypass from the subrenal abdominal aorta to bilateral femoral arteries was created in 5 patients; the prosthetic bypass from the axillary artery to bilateral femoral arteries with carotid endarterectomy was performed in one patient. Subphrenic aortic cross-clamping was performed in 4 cases, sequential cross-clamping of the suprarenal and subrenal aorta was performed in 1 case, and subrenal aortic cross-clamping was performed in 4 cases. The time for subphrenic aortic cross-clamping was 14 to 20 min with a median time of 20 min. No cardiac-cerebrovascular accidents, operative death, renal dysfunction and prosthesis infection occurred during perioperative period. After operation, symptom of intermittent claudication or resting pain was relieved in all the 10 patients, and the pulses of bilateral dorsalis pedis and posterior tibial arteries were palpable. In the 10 patients, follow-up was conducted for 4 to 40 months with a median follow-up time of 27 months, during which time, all prosthetic grafts remained patent, and no anastomotic stenosis, lower limb ischemia and intestinal ischemia were noted.Conclusion Open surgery has demonstrable efficacy in the treatment of juxtarenal abdominal aortic occlusion, with a high long-term patency of the bridging vessels. Individualized treatment should be adopted according to different situations.

Abstract:Background and Aims For patients with aorto-iliac aneurysm accompanied by bilateral internal iliac artery aneurysms (IIAA), iliac branch device (IBD) is the first choice for preserving unilateral internal iliac artery (IIA) at present time. However, the application of commercialized IBD is limited by the individual anatomical differences, so it difficult to meet the conditions of all patients. Therefore, this study was performed to investigate technical feasibility and safety of unilateral IIA preservation by extended application of IBD.Methods The clinical data of 3 patients with aorto-iliac aneurysm including bilateral IIAA whose unilateral IIA was preserved by extended application of G-iliac^TM IBD with different approaches during endovascular abdominal aortic aneurysm repair (EVAR) in Department of Vascular Surgery, Xiamen Branch, Zhongshan Hospital, Fudan University from April 2021 and June 2021 were retrospectively analyzed.Results All the 3 patients were males, aged from 66 to 70 years. The maximum diameter of abdominal aortic aneurysm (AAA) was 29-56 mm, and the valid and maximum diameter of lumen of the preserved IIA was 10-11 mm and 17-20 mm, respectively. The diameter of the common iliac artery (CIA) and external iliac artery (EIA) in the preserved side was 15-28 mm and 13-18 mm, and the maximum diameter of the dilated portion of the embolized IIA was 25-37 mm. In the 3 patients, EVAR was performed, and using the G-iliac^TM IBD, the side with relatively small IIAA was preserved, while the other side with relatively large IIAA was embolized. The technical success rate was 100%. The extended strategies for preserving unilateral IIA included using the bridging stents of IIA to anchor the relatively healthy lumens of its main branches, and utilizing the enlargement characteristic after post-dilation of the distal end of the balloon expandable covered stent to strengthen the sealing area between the stent and the distal end of the dilated IIA. There were no major adverse events such as myocardial infarction, cerebral infarction, massive bleeding, or death occurred during perioperative period. A type Ib endoleak from the preserved IIA occurred in one patient, which disappeared after balloon post-dilation, a type II endoleak from the inferior mesenteric artery occurred in one patient, which showed no obvious change before discharge and on 3 months after operation, and a type II endoleak from the embolized IIA occurred during follow-up in one patient, which disappeared on 3 months after operation. No symptoms of buttock claudication and stent-related complications such as stent fracture, migration, and embolization were noted in all patients during follow-up period.Conclusion For patients with aorto-iliac aneurysm accompanied by bilateral IIA aneurysmal dilation, the extended application of IBD with multiple appropriate strategies for preserving unilateral IIA device is safe and feasible during short-term period. The mid- and long-term results require further follow-up observation.

Abstract:Background and Aims Mesenteric artery aneurysm is a rare type of visceral aneurysm, and most patients are diagnosed due to rupture and hemorrhage of the aneurysm, which is a critical condition with high treatment-related risk. Therefore, this study was conducted to investigate the diagnosis and treatment strategy of this disease through a retrospective analysis of the clinical characteristics of patients with ruptured mesenteric artery aneurysm.Methods The clinical data and follow-up results of 8 patients with ruptured mesenteric artery aneurysm treated in the Department of Vascular Surgery of Chenzhou First People's Hospital during January 2016 to December 2020 were retrospectively analyzed.Results In all the 8 patients, definitive diagnosis of ruptured mesenteric artery aneurysm was made by abdominal CTA or enhanced CT scanning. All patients received emergency surgical treatment, of whom, 6 cases underwent coeliac arteriography and aneurysm embolization, 1 case underwent open surgery due to endovascular treatment failure, and 1 case underwent open surgery directly. All the 8 patients were successfully salvaged. Three patients developed abdominal bloating and pain after endovascular treatment, and was resolved after medical treatment, 1 case developed traumatic pancreatitis after open surgery, and was cured and discharged after medical treatment. There were no complications such as rebleeding, intestinal ischemia, and intestinal necrosis, or requirement for reoperation in all patients during hospital stay. All the 8 patients were followed-up for 12 months, abdominal pain or abdominal distension after regular diets as well as rebleeding occurred in none of them, and reexamination of abdominal CT showed the aneurysms were embolized completely, and the abdominal hematoma was obviously absorbed.Conclusion Clinicians should increase their understanding and awareness of ruptured mesenteric artery aneurysm, so as to and make a timely and correct diagnosis. Both open surgery and endovascular treatment are effective and safe in the treatment of ruptured mesenteric artery aneurysm. The selection of surgical procedures should be determined based on patient's condition as well as the shape and position of the aneurysm.

Abstract:Background and Aims A large number of studies have been carried out on the regulatory action of adenosine monophosphate-activated protein kinase (AMPK) on circulation system, and it is confirmed that AMPK can modulate the relaxation and contraction of arterioles by regulating the concentration of free calcium ions in the vascular smooth muscle cells (VSMCs). Previous studies found that AMPK can help the arterial relaxation through increasing cofilin activity that can cause the depolymerization of cytoskeletal protein filamentous actin (F-actin) into the monomer, globular actin (G-actin). Therefore, this study was conducted to further investigate the molecular mechanism for AMPK-induced cofilin activation.Methods The second- and third-order branches of the superior mesenteric artery of C57BL6/N mice were harvested. Using the pressure myograph model, the responses of the isolated arteries to epinephrine and acetylcholine were determined, and the vessels with a contraction rate >30% and a relaxation rate >90% were used for the experiment. Then, the vessels were divided into two groups and added with AMPK activator PT1 (PT1 group) or vehicle DMSO (control group) after pretreatment and pre-contraction with high potassium MOPS solution. The vascular relaxation responses of the two groups of vessels were compared. After that, the expressions of phosphorylated AMPK (p-AMPK) and other relevant downstream proteins of AMPK in the vascular tissues of the two groups were detected by Western blot or immunofluorescent Western blot.Results The vascular activity of all experimental arteries met the requirements. There were no significant differences in contraction and relaxation abilities between the two groups of vessels (both P>0.05), and there were no significant differences in blood vessel diameters during pretreatment and pre-contraction between the two groups of vessels (both P>0.05). After corresponding treatment, the blood vessels in PT1 group were gradually relaxed, while those in control group showed no obvious change, and 60 min later, the average vessel diameter in PT1 group expanded to (196.6±11.5) μm, while it in control group was (136.1±8.1) μm, and the difference had statistical significance (P<0.001). In PT1 group compared with control group, the expressions of p-AMPK and G-actin in vascular tissue were increased, which were (3.25±0.52) and (2.26±0.64) folds of those in control group, while the expression of phosphorylated cofilin (p-cofilin) was decreased, which was (0.48±0.19) folds of that in control group, and the differences had statistical significance (all P<0.05); the expression of total heat shock protein 20 (t-HSP20) showed no obvious change (P>0.05), but the expression of phosphorylated HSP20 (p-HSP20) was increased, which was (2.45±0.52) folds of that in control group, and the difference had statistical significance (P<0.001).Conclusion The results of this study suggest that HSP20 participates in assisting AMPK activating the cofilin, and the mechanism may be associated with the activated AMPK increasing the level of p-HSP20 that competes the binding site of p-cofilin, and then causes its dephosphorylation and increased activity, and thereby reducing cytoskeletal actin homeostasis and promoting vascular relaxation.

Abstract:Background and Aims The peripherally inserted central catheter (PICC) provides a safe therapeutic venous access for cancer patients requiring long-term infusions of chemotherapeutic agents. However, with the widespread use of PICC in clinical practice, the PICC-related complications such as thrombosis, infections, phlebitis, and catheter disconnection or displacement have substantially increased, especially the catheters related thrombosis (CRT) in PICC, which seriously interferes the patient management activities of the cancer care departments, and also affects the prognosis of patients. Therefore, this study was performed to investigate the treatment strategies for CRT in cancer patients through a retrospective analysis of the consultation opinions for these patients and their treatment results.Methods The clinical data of 92 cancer patients with CRT who were consulted by the physicians in the Department of Vascular Surgery of Hainan Provincial People's Hospital from April 23, 2014 to January 10, 2020 were retrospectively analyzed. All patients were definitively diagnosed by color ultrasound examination. Of the patients, 74 cases (80.4%) were asymptomatic, 9 cases (9.8%) had infection symptoms, and 9 cases (9.8%) had symptoms of thrombosis. The consultation questions mainly included that the timing of extubation or feasibility of maintaining intubation, requirement of antithrombotic therapy, and necessity of immobilization.Results Direct extubation was recommended in 48 patients (52.2%, 43 cases without symptoms, 3 cases with infection symptoms and 2 cases with symptoms of thrombosis); continuous intubation was advised in 30 cases (32.6%, 23 cases without symptoms, 3 cases with infection symptoms and 4 cases with symptoms of thrombosis); delayed extubation and discontinuation of PICC were suggested in 14 patients (15.2%, 8 cases without symptoms, 3 cases with infection symptoms and 3 cases with symptoms of thrombosis); antithrombotic therapy with anticoagulation and (or) antiplatelet medications were considered in 32 case (34.8%, 20 cases without symptoms, 4 cases with infection symptoms and 8 cases with symptoms of thrombosis), and the other 60 cases （62.5%） were not prescribed antithrombotic therapy; 4 cases were found requiring immobilization of the affected limb (4.3%, 1 case with infection symptoms and 3 cases with symptoms of thrombosis), and the remaining 88 cases (95.7%) were not requested for immobilization or immobilization for them was not mentioned during the specialist consultation. All the 92 patients underwent treatment following the consultation opinions, and no symptomatic or fatal pulmonary embolism, and events of newly developed thrombosis or thrombosis aggravation occurred. Analysis among the 74 asymptomatic patients showed that whether performing antithrombotic therapy or immobilization exerted no significant influences on the occurrence of pulmonary embolism in this type of patients (both χ²=0, P>0.05).Conclusion For asymptomatic CRT patients, direct extubation or continuous intubation can be considered, proper movement of the affected limb is recommended, and antithrombotic therapy yield no obvious clinical benefit. For those combined with infection, treatment should be individualized, appropriate anticoagulation and immobilization are feasible for the severe cases, while anticoagulation is not recommended but proper movement of the affected limb is helpful for the mild cases. For symptomatic CRT patients, the standard antithrombotic treatment and immobilization according to the management protocol and relevant guidelines for the upper extremity deep venous thrombosis are recommended.

Abstract:Background and Aims Most of the epidemiological data on hospital-acquired pulmonary thromboembolism (HA-PTE) are from studies focusing on a single disease, but the hospital-wide epidemiological investigation of HA-PTE are still insufficient. Therefore, this study was conducted to analyse the epidemiological and clinical characteristics of HA-PTE in a hospital-wide setting, so as to provide a reference base for prevention and management of HA-PTE. Methods The clinical and laboratory data of patients with newly diagnosed HA-PTE (case group) in Xiangya Hospital, Central South University from January 1 to December 31, 2018 were collected, and inpatients without HA-PTE （control group） during the same period were matched by sex, age, Caprini thrombosis risk score at admission and whether undergoing surgery or not as well as the grade of surgery in a 1:1 ratio. The incidence, mortality, relevant clinicopathologic factors, risk factors and potential predictive indicators for HA-PTE patients were analysed. Results Among the 122 942 inpatients in 2018, a total of 68 cases (0.55‰) were diagnosed with PA-PTE and no HA-PTE-related death occurred. There were 42.65% (29/68) HA-PTE cases with concomitant deep venous thrombosis. Majority of HA-PTE cases were from neurology ward (14/68, 20.59%), general surgery ward (11/68, 16.18%) and respiratory ward (8/68, 11.76%). The results of univariate analysis showed that the proportions of cases with diseases of the respiratory system or lung infection and undergoing ICU admission in case group were higher than those in control group (OR=4.60, 95% CI=1.75-12.10, P=0.002; OR=2.38, 95% CI=1.04-5.43, P=0.040; OR=11.00, 95% CI=1.42-85.20, P=0.022), the total length of hospital stay was longer and hospitalization expense was greater in case group than those in control group (OR=1.11, 95% CI=1.05-1.18, P<0.005; OR=1.01, 95% CI=1.00-1.03, P=0.005), and the level of fibrinogen degradation products (FDP) in case group was higher than that in control group (OR=1.11, 95% CI=1.03-1.20, P=0.004). The results of multivariate analysis revealed that diseases of the respiratory system (adjusted OR=3.58, 95% CI=1.32-9.71, P=0.012) and ICU stay (adjusted OR=11.38, 95% CI=1.38-93.54, P=0.024) were independent risk factors for HA-PTE. Conclusion Patients with diseases of the respiratory system or undergoing ICU stay are high-risk population for HA-PTE. Patients in neurology, general surgery and respiratory wards are at higher risk of HA-PTE. HA-PTE will result in significant prolonged hospital stay and increased medical costs. FDP level may have certain predictive value for HA-PTE.

Abstract:Background and Aims Pseudo-Kaposi sarcoma, also known as acroangiodermatitis, is a rare disease in the field of vascular surgery. Hence, this article was conducted to investigate the clinicopathologic characteristics as well as the diagnosis and treatment of this disease through reporting a case of pseudo-Kaposi sarcoma caused by venous valve dysfunction, combined with literature review.Methods The clinical data of one patient with pseudo-Kaposi sarcoma were retrospectively analyzed, and the etiology, typology, clinical manifestations, pathological features, diagnosis, and treatment of pseudo-Kaposi sarcoma were summarized with domestic and foreign literature review.Results The patient was a 37-year-old man who had been engaged in physical work in a standing position for a long time. He had several dark purplish-red ecchymoses on the interior sides of the lower portions of both ankles and had pain after prolonged standing during the past month. He was diagnosed with "pseudo-Kaposi sarcoma" by combining clinical and pathological examinations and adjuvant examinations. After wearing elastic stockings, promoting venous reflux, anticoagulation, and improving circulation, there was no obvious pain in the skin lesion on both lower limbs, and no development or growth of the skin lesions were noted.Conclusion Venous valve dysfunction is associated with the occurrence and development of pseudo-Kaposi sarcoma, which is rare and difficult to make a differential diagnosis, and needs to be considered comprehensively according to the lesion characteristics, pathology, and angiographic features. There is currently no specific and effective treatment.

Abstract:Background and Aims With the growing popularity of bariatric surgery in China, the standardization of routine preoperative examinations has become increasingly important. At present, there is some debate as to whether gastroscopic examination should be routinely performed before laparoscopic sleeve gastrectomy (LSG) or laparoscopic gastric bypass (LRYGB). This study was conducted to analyze the relationship between preoperative digestive system symptoms and gastroscopic results in patients scheduled to undergo bariatric surgery, and whether preoperative digestive system symptoms can become the basis for altering the surgical procedure, and also to compare the results between preoperative gastroscopic evaluation and postoperative pathological diagnosis, so as to determine the necessity of routine preoperative gastroscopic examination.Methods The medical records of patients who underwent preoperative gastroscopic examination prior to bariatric surgery in the Gastrointestinal Surgery/Bariatric Center of the First Affiliated Hospital of Jinan University from November 2019 to November 2021 were analyzed retrospectively. The associations of preoperative digestive system symptoms and preoperative gastroscopic findings with the alteration of surgical procedure were analyzed, and the consistency between the gastroscopic results and postoperative pathological results were determined.Results A total of 458 patients were included, with a mean age of (31.3±9.3) years and mean BMI of (38.9±7.5) kg/m². There were 103 patients (22.5%) with preoperative gastrointestinal symptoms. Among the patients, 371 cases underwent LSG and 87 cases underwent LRYGB, of whom, 82 cases (17.9%) had intraoperative changes of surgical procedures, which included hiatal hernia repair, gastric stromal tumor resection, gastric fundectomy and fundoplication in addition to the originally planned LSG or LRYGB. Four-hundred and fifty-six patients (99.6%) had abnormal preoperative gastroscopy findings, all of them (100.0%) had gastric problems such as gastritis, gastric ulcer, and gastric polyps; 53 cases (11.6%) of them had duodenal abnormalities that mainly were inflammation and ulcers; 117 cases of them (25.7%) had esophageal pathologies, which was dominated by esophagitis (94.0%). The statistical results showed that preoperative gastroscopic view was not significantly related to the presence or absence of digestive system symptoms (P>0.05); the existence of digestive system symptoms was significantly associated with the change of surgical procedure (P=0.008), which was mainly due to the significant association between the existence of digestive system symptoms and change of surgical procedure in patients undergoing LSG (P=0.008), but not due to that in patients undergoing LRYGB (P=1). Consistency analysis was performed between the preoperative gastroscopy findings and postoperative pathological diagnosis in the 370 patients undergoing LSG, and the result showed that there was no consistency between two examinations (κ=0.072, P=0.000).Conclusion Preoperative gastroscopy in patients without digestive system symptoms can help early detection of digestive diseases, and preoperative digestive system symptoms may be the basis for changing surgical procedure.

Abstract:Background and Aims Over the past few years, bariatric and metabolic surgery has developed rapidly, as evidenced by the continuous emergence of new procedures and constant renewal of concepts. Meanwhile, the large amount of literature generated in this field has laid the foundation for further scientific research. Therefore, this study was conducted to analyze the research progress and hotspots in the field of bariatric and metabolic surgery through a bibliometric and visualized analysis of the English literature concerning this subject published in 2021, so as to provide a guidance for future clinical and basic science research.Methods The English literature of studies in the field of bariatric and metabolic surgery in 2021 included in the Web of Science database were retrieved, and the literature number, source of institutions, publication journals and specific key words were analyzed based on bibliometrics methods.Results A total of 5 335 papers were finally included for analysis. The top three countries with the largest number of relevant papers were the United States, China, and Italy. Harvard Medical School, University of Michigan, and the University of Sao Paulo occupied the top three positions of the most prolific institutions. The top three journals with the most publications were Obesity Surgery (n=510), Surgery for Obesity and Related Diseases (n=221), and Nutrition Metabolism and Cardiovascular Diseases (n=157). The United States was the country with the most extensive foreign co-operation. China ranked second in the world in terms of the number of published papers, but only ranked the twelfth in terms of foreign co-operation. Harvard Medical School (90 times), Mayo Clinic (70 times), University of Michigan (41 times) were the top 3 institutions with the most extensive foreign co-operation. In addition to focusing on surgery, bariatric surgery research in 2021 also included the fields such as cardiovascular medicine, nutrition, and oncology. "Once-weekly semaglutide in adults with overweight or obesity" was found to be the highest cited paper in citation network in the field of bariatric surgery in the 2021 (202 times). "Bariatric surgery versus intensive medical therapy for diabetes-5-year outcomes" was the most cited paper in co-citation network (179 times). Obesity Surgery (1 526 times, 510 papers), the New England Journal of Medicine (1 355 times, 2 papers), Surgery for Obesity and Related Diseases (1 246 times, 221 papers) were found to be the most cited journals in this field. In the key word co-occurrence network, “Gut Microbiota” and “Glucose” presented the current and future popular research direction and trend in this field. Sj?str?m L (277 times), Schauer PR (274 times), Buchwald H (223 times) in the co-cited network, were the most highly cited authors in this field.Conclusion In terms of publication volume in 2021, the United States still ranks the first in the world, and China ranks the second, but exhibits limited co-operation with other countries. In addition to focusing on surgery, cardiovascular medicine, nutrition and oncology are also the research priorities in this field. The association of intestinal flora with obesity and related metabolic diseases, as well as the effect of bariatric surgery on blood sugar improvement and its action mechanism, remain the current and future hot research topics.