Volume 32,Issue 12,2023 Table of Contents

1 Research progress in the prevention and treatment of stroke after endovascular aortic arch repair

GAO Jiangping , GUO Wei

2023, 32(12):1819-1828. DOI: 10.7659/j.issn.1005-6947.2023.12.001

[Abstract](319) [HTML](353) [PDF 855.04 K](895)

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Conventional open repair of the aortic arch is associated with a higher risk of perioperative complications and mortality. Endovascular aortic arch repair (EAAR) offers a minimally invasive treatment option for patients deemed high risk for open surgery. However, compared to conventional open surgery, EAAR still carries an elevated risk of stroke. Branch TEVAR represent one of the most promising techniques for the endovascular treatment of aortic arch diseases. Although the early stroke risk is slightly higher than that of conventional open surgery, such risks are considered acceptable for high-risk patients. The primary causes of postoperative stroke include solid embolism, gas embolism, and cerebral hypoperfusion. Key strategies for preventing stroke following EAAR include preoperative assessment, perioperative monitoring, pharmacological prevention, and optimization of intraoperative procedures. For patients who have already developed a stroke, prompt diagnosis and assessment, pharmacological treatment, and appropriate surgical interventions form the cornerstone of treatment, and effective multidisciplinary collaboration is particularly crucial for improving the patient's condition and prognosis. Currently, there is still considerable research space in the prevention and treatment of stroke associated with EAAR. Therefore, the authors address the incidence, mechanisms, risk factors, as well as prevention and treatment strategies for early postoperative stroke following EAAR, to provide insights for clinical work.

2 Interpretation of the European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on the Management of Atherosclerotic Carotid and Vertebral Artery Disease

MA Bo , YE Zhidong , LIU Peng

2023, 32(12):1829-1841. DOI: 10.7659/j.issn.1005-6947.2023.12.002

[Abstract](337) [HTML](501) [PDF 991.66 K](1702)

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The European Society for Vascular Surgery (ESVS) has released the 2023 edition of "Clinical Practice Guidelines on the Management of Atherosclerotic Carotid and Vertebral Artery Disease", providing a comprehensive and detailed descriptions of diagnostic and therapeutic strategies for carotid and vertebral artery disorders. The guidelines consist of a total of 133 recommendations, among which 11 recommendations have been revised in terms of evidence grades or recommendation strengths, and 38 are newly introduced recommendations. Atherosclerotic carotid and vertebral artery stenosis are critical contributors to ischemic stroke, and a rational management and treatment strategies can reduce the risk of stroke. Therefore, the authors, based on the information from evidence-based medicine in the guidelines and considering the clinical practices in our country, interpret the content of the guidelines with the aim of assisting healthcare professionals in better managing patients with atherosclerotic carotid and vertebral artery diseases.

3 Interpretation on the updated points of the 2023 Society for Vascular Surgery, American Venous Forum, and American Vein and Lymphatic Society clinical practice guidelines for the management of varicose veins of the lower extremities

LI Long

2023, 32(12):1842-1853. DOI: 10.7659/j.issn.1005-6947.2023.12.003

[Abstract](444) [HTML](811) [PDF 882.85 K](4677)

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The Society for Vascular Surgery, the American Venous Forum, and the American Vein and Lymphatic Society recently released the 2023 clinical practice guidelines for the management of varicose veins of the lower extremities, and provided new evidence-based recommendations on key issues affecting the management of patients with lower extremity varicose veins (CEAP class 2 diseases). The main content of the guidelines includes evidence-based recommendations for patients with lower extremity varicose veins in terms of clinical evaluation, compression therapy, medications and nutritional supplements, endovenous ablation versus high ligation and stripping for saphenous vein reflux, evaluation and treatment of varicose tributaries and incompetent perforators, management of thrombotic complications, and management and treatment of bleeding varicose veins and superficial vein aneurysms. This article summarizes and interprets the key updates in the new guidelines, integrating the latest advances in evidence-based medicine, aiming to serve as a reference for the clinical practice of domestic counterparts.

4 Endovascular management strategies for aortic intimal intussusception during repair of Stanford type B aortic dissection

LOU Yanbo , ZHU Qianqian , ZHANG Hongkun

2023, 32(12):1854-1863. DOI: 10.7659/j.issn.1005-6947.2023.12.004

[Abstract](335) [HTML](218) [PDF 1.45 M](957)

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Intraoperative aortic intimal intussusception (AII) is an uncommon but life-threatening complication during thoracic endovascular aortic repair (TEVAR). Remedial intervention is difficult, and it is prone to misdiagnosis, underdiagnosis, and misjudgment. Accurately identifying intraoperative AII and promptly providing effective treatment pose a significant challenge. Intraoperative AII is considered a secondary condition, and the specific etiology remains unclear, potentially associated with surgical factors and underlying aortic pathologies. This article, based on relevant literature and clinical experiences, introduces and discusses the causes, classifications, key points in diagnosis and evaluation, and emergency intravascular management of intraoperative AII in patients undergoing TEVAR for aortic dissection. The authors first propose a refined classification based on visceral blood flow perfusion, adding an assessment of the severity of visceral branch ischemia to the existing classification. This new classification divides intraoperative AII into two subtypes (a and b) based on intraoperative DSA depicting visceral branch perfusion. The advantage of the new classification lies in its ability not only to differentiate the severity of visceral ischemia but also to guide endovascular emergency management strategies. Secondly, for patients suspected of intraoperative AII, detailed intraoperative angiography is necessary to determine the classification. The authors recommend a three-step process involving proximal and distal stent graft imaging and endoluminal imaging of the abdominal aortic true lumen. This aids in clarifying the stability of the proximal landing zone and the type of intraoperative AII, determining the poorly perfused visceral branches, severity, and type of ischemic obstruction, and is crucial for the subsequent remedial measures. Finally, intraluminal remedial stenting is preferred for its excellent therapeutic effects, minimal trauma, and rapid postoperative recovery. The procedure should proceed smoothly in a proximal-to-distal and main trunk-to-branch manner. Concerning the reconstruction of blood supply in the distal thoracoabdominal aorta, existing mainstream approaches have certain limitations. The authors recommend a "two-step" approach to rebuild the blood supply of the true lumen of the aorta. This approach can prevent further detachment of the intimal layer toward the distal end.

5 Customized fenestrated aortic stent-graft for aortic arch aneurysm: report of first case in China (with video)

PAN Baihong , OUYANG Yang , LING Jin , WU Kemin , YANG Pu , HUANG Jianhua , WANG Wei

2023, 32(12):1864-1871. DOI: 10.7659/j.issn.1005-6947.2023.12.005

[Abstract](511) [HTML](278) [PDF 1.37 M](917)

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Background and Aims Thoracic endovascular aortic repair (TEVAR) has gradually become a the first-line therapeutic option for thoracic diseases. However, hindered by the complex anatomical structure of the aortic arch, effectively reconstructing supra-arch arteries during lesion treatment is a common challenge when using current standardized products. Given this, our team, collaborating with a stent manufacturer, had developed the Castor customized fenestrated thoracic stent-graft (hereafter referred to as Castor customized fenestrated stent) and successfully performed the first case of Castor customized fenestrated stent implantation in China. This article provides a report on this.Methods The clinical data, stent customization details, and surgical procedure for the first case of Castor customized fenestrated stent implantation in China were described, and an analysis of the advantages and disadvantages of the Castor customized fenestrated stent and review of relevant literature were also conducted.Results The patient, a 59-year-old male who underwent TEVAR 14 years ago, developed an aortic arch aneurysm involving the left subclavian artery (LSA) and left common carotid artery (LCCA). With the patient's and family's consent, we utilized the Castor fenestrated stent to seal the aneurysm. The surgical plan involved using the Castor customized fenestrated stent to occlude the aneurysm and placing the Castor stent branch into the LCCA. Preoperatively, fenestrations were customized to separately reconstruct the innominate artery (IA) and LSA. Successful implantation of the Castor single branch stent was achieved during surgery, effectively reconstructing the three supra-arch arteries. Postoperative imaging confirmed satisfactory aneurysm occlusion with no endoleak, patent flow in the three branch arteries, and no occurrence of adverse events related to the aorta.Conclusion The performance of the Castor individualized fenestrated stent is excellent, fitting the patient's anatomical characteristics, completely isolating the aneurysm, and enabling precise fenestration for reconstruction of the supra-arch arteries. Importantly, it avoids compromising stent integrity, providing a means for precise clinical interventions.

6 Complications following closure of internal iliac artery during endovascular repair of abdominal aortic aneurysm and their association with collateral formation

LIU Xinghua , ZHU Longtu , LI Tao , SONG Chao , WEI Xiaolong , ZHANG Lei , YUAN Liangxi , BAO Junmin , ZHAO Zhiqing , LU Qingsheng

2023, 32(12):1872-1881. DOI: 10.7659/j.issn.1005-6947.2023.12.006

[Abstract](566) [HTML](326) [PDF 995.66 K](1019)

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Background and Aims Endovascular aneurysm repair (EVAR) has gradually become the first-line treatment for abdominal aortic aneurysm due to its safety and effectiveness. Although various minimally invasive intravascular devices and intervention techniques are currently utilized for preserving the internal iliac arteries (IIA), cases requiring the occlusion of IIA are still not uncommon in clinical practice. Once IIA is closed, especially in patients undergoing bilateral IIA embolization, complications such as gluteal muscle ischemia, intestinal ischemia, and sexual dysfunction may arise. Additionally, some patients with well-established collateral branches of the IIA show no significant occurrence of closure-related complications after bilateral IIA closure. Therefore, the present study was performed to investigate and analyze complications such as gluteal, intestinal, and genital ischemia after the closure of unilateral or bilateral IIA in EVAR and their relationship with collateral compensation.Methods Baseline data and preoperative, intraoperative, and postoperative imaging data of 1 902 patients who underwent EVAR in Changhai Hospital from July 2011 to July 2021 were retrospectively collected and analyzed. Among them, 426 patients undergoing IIA closure were selected (62 cases of bilateral IIA closure, and 264 cases of unilateral IIA closure), and complications were assessed through telephone follow-ups. Complications such as gluteal muscle ischemia, intestinal ischemia, and sexual dysfunction during the perioperative and follow-up periods were recorded. Collateral circulation was observed based on intraoperative and postoperative imaging, and the relationship between collateral establishment and complications was analyzed.Results Of the 426 patients, 73 (17.1%) exhibited symptoms of gluteal muscle ischemia, 7 (1.6%) had symptoms of intestinal ischemic necrosis, and 3 (0.7%) developed sexual dysfunction. On follow-up CTA conducted 1-12 months postoperatively, 321 patients (75.4%) had unilateral or bilateral IIA collateral vessels. Among them, 143 cases (33.6%) had formation of collaterals from the deep femoral artery to the IIA, 79 cases (18.5%) had collaterals originating from the internal iliac artery, 90 cases (21.1%) had collaterals from the mesenteric artery to the IIA visceral branch, 7 cases (1.6%) had collaterals from the superficial femoral artery to the IIA, 7 cases (1.6%) had collaterals from the splenic artery to the IIA, 13 cases (3.1%) had collaterals from the external iliac artery to the IIA, and 76 cases (17.8%) had collaterals from the contralateral IIA. In the entire patient group, the incidence of complications in patients with collateral establishment was significantly lower than in those without collateral vessels (OR=4.68, 95% CI=2.84-7.71, P<0.05), and this was primarily associated with the establishment of collateral circulation from the contralateral IIA (OR=6.30, 95% CI=2.21-17.94, P<0.05). In patients with bilateral IIA closure, those with collateral formation had a significantly lower complication rate than those without collateral vessels (OR=5.79, 95% CI=2.65-12.67, P<0.05), and this was mainly related to the formation of collateral vessels from the deep femoral artery (OR=2.91, 95% CI=1.35-6.29, P<0.05).Conclusion IIA closure of during EVAR results in varying degrees of ischemic symptoms in the gluteal muscle, bowel, and genitalia. The occurrence of complications is closely related to postoperative collateral circulation. For patients requiring bilateral IIA treatment during EVAR, a thorough assessment of the corresponding collateral sources should be conducted before operation, and preservation should be considered during the operation.

7 Analysis of clinical efficacy of fenestration/branched stent-graft for dilatation of the thoracoabdominal aorta

HE Mengwei , HUO Weixue , ZHANG Heng , LU Ye , TIAN Wen , FENG Jiaxuan , ZENG Zhaoxiang , FENG Rui

2023, 32(12):1882-1891. DOI: 10.7659/j.issn.1005-6947.2023.12.007

[Abstract](304) [HTML](222) [PDF 1.36 M](723)

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Background and Aims With the advancement of endovascular techniques, the safety and effectiveness of total endovascular treatment for abdominal aortic diseases have been widely validated. However, in thoracoabdominal aortic diseases, the anatomical conditions are more complex, making endovascular treatment challenging, and its safety and effectiveness require further determination. This study was performed to summarize the single-center experience of the authors' team in using fenestration/branched stent-graft for the treatment of dilatation of the thoracoabdominal aorta and introduce the team's innovative double-trunk technique for complex thoracoabdominal aortic diseases, aiming to provide reference and insights for fellow professionals.Methods The data of 37 patients with dilatation of the thoracoabdominal aorta who underwent fenestration/branched stent-graft treatment and had at least two reconstructed branch arteries from October 2021 to July 2023 in the Shanghai General Hospital were retrospectively collected. Among the 37 patients, there were 20 cases of distal aneurysmal dilatation after dissection and 17 cases of thoracoabdominal aortic aneurysms. After comprehensive preoperative CTA and evaluation, single-trunk endovascular treatment was performed in 26 cases, and double-trunk technique was used in 11 cases. Relevant clinical data (baseline information, preoperative anatomical parameters, perioperative indicators, and follow-up outcome variables) were collected to analyze the overall treatment effects and the safety and efficacy of the double-trunk technique.Results A total of 162 branch arteries were reconstructed successfully with a technique success rate of 100%. During the perioperative period, there were 3 deaths (8.11%), 3 cases of graft implantation syndrome (8.11%), and 1 case of type Ⅲ endoleak (2.70%). The median follow-up time was 13.73 (2.33-26.74) months, and the overall survival rate was 91.9% (34/37). During the follow-up period, type Ⅲ endoleak occurred in 2 cases (5.41%), stent restenosis or occlusion occurred in 3 cases of (8.11%), and dissection progression occurred in 1 case (2.70%); 5 patients (13.51%) underwent re-intervention. There were significant differences between the single-trunk group and the double-trunk group in terms of reconstruction methods, the ratio of 4-branch reconstruction, and the average number of stents used (all P<0.05), while other indicators showed no statistically significant differences between the two groups (all P>0.05).Conclusion Fenestration/branched stenting for dilatation of the thoracoabdominal aorta is a safe and effective strategy. For anatomically complex lesions where traditional single-trunk combined with fenestration/branched stent-graft is difficult to reconstruct all branches, the double-trunk technique is a feasible choice. However, the results of this study still need more cases and longer follow-up time for validation.

8 Efficacy of in situ fenestration versus in vitro pre-fenestration for reconstruction of left subclavian artery in the treatment of aortic arch lesions with unfavorable proximal landing zone

ZHOU Baoning , HUA Zhaohui , ZHANG Shuai , MA Ke , LI Zhen

2023, 32(12):1892-1900. DOI: 10.7659/j.issn.1005-6947.2023.12.008

[Abstract](249) [HTML](225) [PDF 1.44 M](734)

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Background and Aims Currently, the fenestration technique has been widely applied in the treatment of various thoracic aortic diseases. Fenestration techniques can be categorized into in situ fenestration and in vitro pre-fenestration, each with its own characteristics, advantages and disadvantages. This study was conducted to compare and analyze the short- and mid-term efficacy of in situ fenestration and in vitro pre-fenestration techniques in the reconstruction of left subclavian artery (LSA) for aortic arch lesions with unfavorable proximal landing zone (either short or unhealthy), and also summarize the experience in selecting fenestration approaches.Methods The clinical data of 215 patients with aortic arch diseases treated with LSA reconstruction using in situ fenestration or in vitro pre-fenestration technique in the First Affiliated Hospital of Zhengzhou University from March 2019 to March 2022 were retrospectively analyzed. Among them, 114 cases underwent in situ fenestration (in situ fenestration group), and 101 cases were treated with in vitro pre-fenestration (in vitro pre-fenestration group). The technical success rates, perioperative and follow-up adverse events, and mortality rates were compared between the two groups.Results The technical success rate in the in situ fenestration group was 93.9% (3 cases of fenestration failure, 3 cases of type Ia endoleak, and 1 case of access vessel injury); one patient developed bilateral multiple acute cerebral infarctions 4 d after operation, and the patient recovered well with conservative treatment; there were 3 aorta-related deaths within 30 d, with 2 deaths occurring on postoperative day 10 and day 25 due to visceral artery involvement causing multi-organ failure, and 1 death on postoperative day 2 due to rupture of the abdominal aorta dissection. The technical success rate in the in vitro pre-fenestration group was 94.1% (1 case of LSA coverage due to stent displacement, 3 cases of type Ⅲ endoleak, 2 cases of type Ia endoleak); one patient experienced right-sided acute cerebral infarction 1 d after operation and recovered well with medical treatment; there were no aorta-related deaths in this group. The median follow-up time was 26 (10-46) months in the in situ fenestration group and 19 (10-44) months in the in vitro pre-fenestration group. During the follow-up period, branch stent occlusion occurred in 1 case at 6 months after operation and type Ia endoleak occurred in 2 cases at 3 months in the in situ fenestration group; 1 case developed proximal dissecting aneurysm at 3 months after operation and 2 cases developed type Ia endoleak at 3 months after operation in the in vitro pre-fenestration group. There were no aorta-related deaths in either group. There were no statistically significant differences in technical success rates, perioperative and follow-up adverse event rates, and mortality rates between the two groups (all P>0.05).Conclusion Both in situ fenestration and in vitro pre-fenestration techniques for LSA reconstruction in the treatment of aortic arch diseases demonstrate good safety and efficacy. Individualized procedural selection based on patient anatomical conditions and disease characteristics can improve technical success rates and reduce complications.

9 Analysis of factors for abdominal aortic remodeling after endovascular repair of Debakey type Ⅲb aortic dissection

LU Fanzhen , WENG Xiang , ZHANG Teng , LI Xian'gui , ZHAO Wenpeng , ZHANG Wenwen , ZHOU Weimin

2023, 32(12):1901-1907. DOI: 10.7659/j.issn.1005-6947.2023.12.009

[Abstract](511) [HTML](351) [PDF 721.98 K](828)

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Background and Aims Thoracic endovascular aortic repair (TEVAR) has become the preferred treatment for complex aortic dissections and has been widely applied in recent years. TEVAR usually needs to cover the primary tear alone, leaving the distal tear uncovered. However, long-term follow-up has revealed that leaving the distal tear untreated can lead to a series of complications, such as aneurysmal dilatation at the distal end of stent-graft, inadequate perfusion causing visceral ischemia, and the development of new dissections at the distal end of the covered stent. Additionally, recent studies have demonstrated that the remodeling effect in the thoracic aortic segment with stent coverage is favorable after TEVAR, but the remodeling effect in the abdominal aortic segment without stent coverage is less satisfactory, potentially leading to aortic dilation or the development of dissecting aneurysms, requiring further intervention. Given the close relationship between poor abdominal aortic remodeling after TEVAR and the prognosis of patients, this study was performed to investigate the abdominal aortic remodeling following TEVAR in patients with acute or subacute Debakey IIIb aortic dissection and the potential influencing factor, so as to provide a reference for clinical practice.Methods The preoperative and one-year postoperative information as well as imaging data of patients with Debakey IIIb aortic dissection undergoing TEVAR surgery in the Second Affiliated Hospital of Nanchang University from May 2017 to May 2023 were retrospectively collected. Patients were categorized into non-remodeling and remodeling groups according to the arterial diameter of the maximum diameter plane of the abdominal aorta and the changes in the true and false lumens. Factors influencing abdominal aortic remodeling after TEVAR were analyzed.Results Based on inclusion and exclusion criteria, 105 patients were finally selected, with 44 in the non-remodeling group and 61 in the remodeling group. Results of univariate analysis showed that there were no statistically significant differences between the two groups in terms of sex, time from symptom onset to surgery, and medical history (all P>0.05); there were significant differences between the non-remodeling and remodeling groups in terms of median age (62.50 years vs. 55.00 years), average number of the distal tears (2.98 vs. 2.26), and the proportion of cases with left renal artery involvement (38.64% vs. 19.67%) (all P<0.05). Results of Multivariate Logistic regression analysis revealed that the number of distal tears was an independent risk factor for abdominal aortic remodeling after TEVAR (OR=0.589, 95% CI=0.406~0.855, P=0.005).Conclusion Following TEVAR, some patients exhibit inadequate remodeling of the abdominal aorta, and the primary factor influencing this is the number of distal tears. For those with a higher number of distal tears, close follow-up and observation of aortic remodeling are recommended, and surgical intervention may be necessary if needed.

10 Metabolomic analysis of the mechanisms for human umbilical cord mesenchymal stem cells improving lower limb ischemia in mice

ZHOU Mengdie , WANG Zan , ZHANG Min , LI Zhihong , XIE Xiaoyun , ZHU Jianhua

2023, 32(12):1908-1918. DOI: 10.7659/j.issn.1005-6947.2023.12.010

[Abstract](602) [HTML](206) [PDF 1.68 M](777)

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Background and Aims Peripheral arterial disease (PAD) is a condition characterized by insufficient blood flow due to various reasons, and some patients are not suitable for surgery. In recent years, stem cell transplantation has been used in the treatment of PAD, showing promising results. However, the metabolic mechanisms involved in its therapeutic effects remain unclear. This study was conducted to investigate the metabolic pathways and molecules involved in the repair of lower limb ischemic tissue by human umbilical cord mesenchymal stem cells (HUCMSCs) using liquid chromatography-mass spectrometry (LC-MS) metabolomics, with a specific focus on changes in the acid sphingomyelinase (ASM)-ceramide (Cer) metabolic pathway.Methods HUCMSCs were isolated from human umbilical cord tissue, expanded in culture, and characterized using flow cytometry for surface molecular markers. A mouse model of lower limb ischemia was created by ligating and excising the left femoral artery and vein in 8-week-old male C57BL/6J mice. Then, the mice were randomly divided into two groups, with one group receiving local injection of HUCMSCs suspension (HUCMSCs group) and the other receiving PBS (control group). Muscle tissues from the ischemic limb were collected at 3, 7, and 14 d after surgery. HE staining and Masson staining were performed to observe morphological changes. LC-MS analysis was conducted in combination with KEGG database analysis to compare the metabolomic differences between the two groups.Results HUCMSCs expressed high levels of CD105, CD90, and CD73, and low levels of HLA-DR, CD14, CD19, and CD34. Morphological observations revealed a significant improvement in muscle atrophy and fibrosis in the HUCMSCs group compared to the control group at 7 and 14 d after surgery. Non-targeted metabolomic analysis identified 687 metabolites in the gastrocnemius muscle samples, with lipids representing the largest proportion (34.088%). Differential metabolites included 37 in negative ion mode (25 upregulated, 12 downregulated) and 17 in positive ion mode (11 upregulated, 6 downregulated). Cer was significantly downregulated (FC=0.43), and the phosphatidylcholine product of the ASM/Cer pathway also decreased (FC=0.68) compared to the control group. KEGG pathway analysis of combined positive and negative ion mode data from gastrocnemius muscle samples at 3 and 7 d after surgery revealed involvement in pathways such as γ-aminobutyric acid-ergic synapse, arginine/proline metabolism, mineral absorption, oxidative phosphorylation, protein metabolism, glycerophospholipid metabolism, and regulation of the actin cytoskeleton.Conclusion Changes in lipid metabolism play a crucial role in the repair of lower limb ischemic injury promoted by HUCMSCs, with some mechanisms potentially associated with the inhibition of the ASM/Cer pathway.

11 Analysis of the short-term efficacy of radiofrequency ablation for lower extremity varicose veins combined with iliac vein compression

WANG Xueqing , LIU Jiantong , LIN Chao , ZHANG Fuxian , LI Xiangtao

2023, 32(12):1919-1926. DOI: 10.7659/j.issn.1005-6947.2023.12.011

[Abstract](282) [HTML](343) [PDF 895.39 K](847)

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Background and Aims Currently, the indications for iliac vein compression (IVC) stent implantation remain unclear. In addition, for patients with combined IVC and lower extremity varicose veins, some scholars believe that if there is low pressure difference across the narrow segment of the iliac vein (<2 mmHg), simply treating lower extremity varicose veins can effectively improve lower limb symptoms. Therefore, this study was performed to analyze the short-term clinical outcomes of performing radiofrequency closure surgery for lower extremity varicose veins alone in such patients.Methods The data of patients who underwent endovenous radiofrequency ablation for lower extremity varicose veins in Beijing Shijitan Hospital of Capital Medical University from June 2020 to June 2022 were retrospectively analyzed. According to iliac vein ultrasound, CTV, and lower extremity venography examinations, patients with IVC and collateral circulation formation with a pressure difference <2 mmHg (IVC + varicose veins group) were selected. Propensity score matching was then employed at a 1:3 ratio to match patients with lower extremity varicose veins only (varicose veins group). The primary endpoints were the occlusion rates of the saphenous vein trunk at 1 week and 3, 6, and 12 months after operation. Secondary endpoints included venous clinical severity score (VCSS) and Chronic Venous Insufficiency Quality of Life Questionnaire (CIVIQ-20) scores at 6 and 12 months after operation.Results A total of 29 patients were identified in the IVC + varicose veins group, matched with 87 patients in the varicose veins group. There were no statistically significant differences in baseline characteristics between the two groups (all P>0.05). After the first postoperative ultrasound examination, the occlusion rates of the saphenous vein trunk were 100.0% in both groups. At 3, 6, and 12 months of follow-up, the occlusion rates in the varicose veins group vs. IVC + varicose veins group were 100.0% vs. 100.0%, 97.7% vs. 100.0%, and 98.8% vs. 100.0%, respectively, with no statistically significant differences (all P>0.05). VCSS and CIVIQ-20 scores significantly decreased in both groups compared to preoperative values (all P<0.05), but there were no statistically significant differences between the two groups (all P>0.05). Both groups had no severe adverse events such as deep vein thrombosis, and the overall incidence rates of complications after operation showed no statistically significant difference between the varicose veins group and the IVC + varicose veins group (20.7% vs. 24.1%, P=0.69).Conclusion For patients with combined IVC and lower extremity varicose veins showing low pressure difference across the narrow segment of the iliac vein, endovenous radiofrequency ablation as a minimally invasive treatment can achieve favorable short-term outcomes. However, further examination is needed to assess its long-term effectiveness.

12 Analysis of the safety and hospitalization cost composition of retrieval of inferior vena cava filters in a day surgery setting

WU Song , WEI Guodong , SONG Ze , XIE Xu , WANG Lei , ZHANG Zhen , XIA Yutong , QI Ming

2023, 32(12):1927-1935. DOI: 10.7659/j.issn.1005-6947.2023.12.012

[Abstract](389) [HTML](480) [PDF 926.65 K](817)

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Background and Aims In February 2022, the General Office of the National Health Commission issued a notice regarding the publication of the Recommended Catalog for for Day Surgery (2022 edition), in which the procedure for the retrieval of the inferior vena cava filters was not included. This study was conducted to analyze clinical characteristics, mid-term outcomes, and hospitalization cost composition of day surgery retrieval and conventional inpatient retrieval of inferior vena cava filters at the authors' hospital, to assess the safety and feasibility of performing this procedure this procedure in day surgery mode.Methods The data of 229 patients who underwent inferior vena cava filter retrieval in the First Affiliated Hospital of Dalian Medical University from May 2017 to August 2022 were retrospectively analyzed. Among them, 91 patients underwent day surgery retrieval (day surgery group), while 138 patients underwent conventional inpatient retrieval (conventional inpatient group). The general information, complications, follow-up results, and cost details were compared between the two groups of patients, and cost details were analyzed using the structural change analysis method.Results There were significant differences in anticoagulant and alanine aminotransferase levels between the two groups (both P<0.05), but the means were within the normal range, and other baseline characteristics showed no significant differences (all P>0.05). There were no significant differences in the success rate and operative time between the two groups (both P>0.05). However, there were significant differences in hospitalization duration and costs (both P<0.05). All patients in the day surgery group were discharged within 48 h, with a median hospital stay of 1.6 d, while the conventional inpatient group had a maximum hospital stay of 15 d, with a median stay of 6.0 d. The average standard amount per capita for hospitalization in the day surgery group was 22 547.1 yuan, a reduction of 8 153.1 yuan compared to the conventional inpatient group. The contribution rate of structure variation for material costs were 30.57%, with a decrease of 11.4%; for drug costs was 25.81%, with a decrease of 62.7%; for treatment costs, the contribution rate was 19.4%, with a decrease of 9.7%. Compared to conventional inpatient care, the proportion of drug costs in the day surgery mode decreased by 6.9 percentage points (7.16% vs. 14.10%, P<0.001). There was no statistically significant difference in the incidence of perioperative complications between the two groups (P<0.05). The median follow-up time was 23 (1-64) months, and there were no statistically significant differences in outcome events (recurrence of symptomatic pulmonary embolism, recurrence or exacerbation of deep vein thrombosis in the lower limbs, and all-cause mortality) between the two groups (all P>0.05).Conclusion The retrieval of inferior vena cava filters in a day surgery setting is safe and feasible. Moreover, compared to the traditional inpatient mode, it significantly reduces drug costs and the percentage of drug expenses. This approach can play a positive role in the appraisal system of public hospitals.

13 Research progress on surgical instrument automatic recognition and tracking for endovascular interventional robotics

WU Shangzhi , LU Qingsheng

2023, 32(12):1936-1943. DOI: 10.7659/j.issn.1005-6947.2023.12.013

[Abstract](187) [HTML](329) [PDF 702.30 K](1293)

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In the field of vascular surgery, vascular intervention surgery is an efficient minimally invasive treatment method. However, traditional intervention procedures require doctors to wear lead aprons for an extended period of time, and there is also a risk of radiation exposure. This not only poses health hazards for the medical professionals but also has the potential to adversely affect surgical efficiency. With the development and application of endovascular interventional robotics (EIR), it is possible to reduce doctor's radiation exposure while providing higher operational precision and stability over traditional methods. Two key technologies, automatic instrument recognition and real-time tracking, enable EIR to control and assess the orientation of instruments in complex intervention surgeries, ensuring the quality and safety of treatments. Current research predominantly focuses on using intervention imaging to enable EIR to accurately detect and locate instruments in blood vessels in real-time, essentially allowing the robot to perform surgery based on observed image information. Simultaneously, the collaborative work of instrument recognition technology with EIR have significant potential value. This requires robots not only to execute commands precisely but also to understand and predict the operator's intentions. The development of artificial intelligence technology, is expected to support robots in more accurately identifying and tracking instruments and correcting positioning errors, ultimately achieving true collaborative surgery. Here, the authors analyze the application of the two major technologies, automatic instrument recognition and real-time tracking, in the field of EIR, and comprehensively discuss their prospects for clinical applications, along with of the development of relevant technologies both domestically and abroad.

14 Inflammatory response of neutrophils in the pathogenesis of abdominal aortic aneurysm

LI Shiyi , WANG Lixin , FU Weiguo

2023, 32(12):1944-1951. DOI: 10.7659/j.issn.1005-6947.2023.12.014

[Abstract](277) [HTML](254) [PDF 793.70 K](886)

Abstract:
Abdominal aortic aneurysm (AAA) is a significant cause of death in adults due to aortic rupture. The pathogenesis of AAA is not fully understood, and there is a lack of reliable and effective pharmacological treatment options. Neutrophils, constituting 70% of circulating white blood cells, serve as the primary defense line of the innate immune system. Neutrophils can participate in the inflammatory response through mechanisms such as phagocytosis, degranulation, the generation of reactive oxygen species, and the formation of neutrophil extracellular traps (NETs). Multiple studies indicate that neutrophils are involved in sterile inflammation and thrombosis, and over-activated neutrophils can also inflict damage on normal tissues and cells, leading to the occurrence of diseases, and this is closely associated with the onset and progression of AAA. This article, integrating the three major pathological features of AAA: extracellular matrix degradation, inflammatory infiltration, and loss of vascular smooth muscle cell function, delves into the multiple roles of neutrophils in the course of AAA. Neutrophils are recruited to the lesion site through mechanisms such as inflammatory factors, causing inflammatory infiltration. Once activated, they release proteolytic enzymes, matrix metalloproteinases, and other molecules, promoting the development of AAA. Neutrophils participate in intraluminal thrombus formation within the AAA by cellular deposition and accumulation of related inflammatory molecules, exacerbating disease progression. The formation of NETs, a recently discovered neutrophil killing mechanism, has been reported to synergistically intensify inflammation from multiple aspects. They may also contribute to intraluminal thrombus formation by activating the coagulation cascade and promoting platelet aggregation, leading to the worsening of AAA lesions. This process plays a crucial role in the progression of this disease. Due to the early stage of related research and the superficial nature of most research conclusions, this article emphasizes the need for a more in-depth understanding within the academic community regarding the complex interactions of neutrophils in the mechanism of AAA, and highlights the significance of elucidating the role of neutrophils in the inflammatory microenvironment of this disease. By providing a comprehensive overview and analysis at the organ, tissue, and cellular levels, this article provides an in-depth reference for experimental research related to AAA. Additionally, it summarizes and discusses potential future research directions, offering insights into the discovery of effective diagnostic and therapeutic targets for AAA.

15 Progress in bioresorbable stents for the treatment of lower extremity artery disease

CAO Zhongze , SHU Chang

2023, 32(12):1952-1958. DOI: 10.7659/j.issn.1005-6947.2023.12.015

[Abstract](257) [HTML](224) [PDF 709.51 K](805)

Abstract:
Lower extremity arterial disease (LEAD) refers to the stenosis or occlusion of lower limb arteries caused by atherosclerotic plaque formation. It is estimated that approximately 237 million people worldwide, aged 25 and above, suffer from LEAD. In China, there are around 45.3 million LEAD patients, imposing a significant disease burden. Endovascular revascularization is the preferred treatment method for alleviating lower limb ischemic symptoms in LEAD patients with poor response to conservative therapy. However, due to reactions such as intimal hyperplasia after stent implantation, the mid- to long-term primary patency rates of endovascular revascularization remain inferior to open surgery, with a higher rate of reintervention. As a novel alternative treatment for the permanent metallic stent implantation, bioresorbable stents (BRS) are stents made from polymers or metal materials that can gradually decompose, degrade and eventually be completely eliminated from the body. After BRS implantation, temporary wall support is provided to the narrowed vascular segment, ideally degrading completely after vascular remodeling to restore physiological vasomotor activity and endothelial function. BRS holds the potential to avoid long-term complications such as in-stent restenosis, thereby further improving the efficacy of endovascular revascularization for LEAD. Currently, BRS such as REMEDY, ABSORB, and AMS have been used in the treatment of LEAD. REMEDY stent treatment for occlusive lesions of lower limb arteries shows suboptimal efficacy, with no apparent advantage over endarterectomy and nitinol stent implantation in treating stenotic lesions. ABSORB demonstrates a high 1-year patency rate for infrapopliteal lesions and a lower rate of target lesion reintervention. In comparison to percutaneous balloon angioplasty, AMS stent implantation has a significantly lower primary patency rate at six months and fails to meet efficacy evaluation criteria. Moreover, there is currently no high-quality recommendations of evidence-based medicine to guide anti-thrombotic treatment after BRS implantation in LEAD patients. In the future, efforts should be directed towards developing the next generation of BRS with superior material properties and optimal structural design. These advancements should be integrated with various endovascular treatment modalities for LEAD to effectively improve the quality of medical care for LEAD patients.

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Volume 32,Issue 12,2023 Table of Contents

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