Volume 32,Issue 6,2023 Table of Contents

1 Multidisciplinary expert consensus on implantation and management of venous infusion port (2023 edition)

刘鹏 , 吴巍巍

2023, 32(6):799-814. DOI: 10.7659/j.issn.1005-6947.2023.06.001

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The totally implantable venous access device (TIVAD), also known as venous infusion port, is an emerging intravenous access device primarily used for chemotherapy and parenteral nutrition support. Its reliability and effectiveness have been confirmed by recent applications. Currently, the utilization of this technology in domestic settings is mainly concentrated in large medical institutions. However, there are significant differences in implantation surgery and maintenance practices among different regions, resulting in variations in actual outcomes, high incidence of related complications, and differences in patient satisfaction. The expert group, consisting of experienced professionals from various disciplines involved in TIVAD work, has collaborated and extensively discussed the latest research findings and then developed the Multidisciplinary expert consensus on implantation and management of venous infusion port (2023 edition). This consensus applies to healthcare professionals engaged in TIVAD work and covers the entire process of implantation and maintenance of the venous infusion port. The goal is to reduce complications associated with implantation and usage and improve the safety and satisfaction of patients using a TIVAD.

2 Interpretation of the European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines for Antithrombotic Therapy in Vascular Diseases — atherosclerotic lower extremity arterial disease

YANG Pu , SHENG Chang , WANG Wei , HUANG Jianhua

2023, 32(6):815-823. DOI: 10.7659/j.issn.1005-6947.2023.06.002

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The European Society for Vascular Surgery (ESVS) has released the 2023 edition of the "Clinical Practice Guidelines on Antithrombotic Therapy for Vascular Diseases" for the first time. The guidelines provide a detailed introduction and updates on the antithrombotic strategies for atherosclerotic lower extremity arterial disease (LEAD), along with 21 specific recommendations. The prevalence of LEAD and its associated public health costs continue to rise, making antithrombotic therapy a cornerstone in treating LEAD patients. Therefore, the authors interpret the antithrombotic strategies for LEAD, focusing on evidence-based medicine from the guidelines and considering clinical practice, hoping to assist healthcare professionals in better understanding and adhering to the guidelines.

3 First-in-man study of a novel integrated supra-arch branched stent-graft system for aortic arch lesions

SHU Chang , HE Hao , LI Quanming , LUO Mingyao , LI Ming , LI Xin , FANG Kun , WANG Tun , LI Jiehua , LIU Dingxiao

2023, 32(6):824-831. DOI: 10.7659/j.issn.1005-6947.2023.06.003

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Background and Aims Thoracic endovascular aneurysm repair (TEVAR) has been widely used in treating thoracic aortic diseases. However, aortic arch disease remains one of tough parts and research directions of TEVAR due to its treatment difficulties and high risk. In particular, how to reconstruct the three branches of aortic arch in a minimally invasive way is a major challenge for vascular surgery. Although there are new methods for the endovascular treatment of aortic arch diseases, such as hybrid technique, chimney technique, branched stent technique and fenestration technique, these techniques have their limitations. This study was performed to present the results of the first-in-man (FIM) study of applying a novel integrated supra-arch branched stent-graft system (Concave Supra-arch branched stent-graft system, CS system) for the endovascular treatment of aortic arch diseases, to assess its safety and effectiveness. Methods The clinical data of 5 patients with aortic arch disease treated by CS system in the Second Xiangya Hospital of Central South University and Fuwai Hospital of Chinese Academy of Medical Sciences from August 2022 to April 2023 were retrospectively analyzed. The technical success rate, branch patency rate, endo-leak rate and short-term clinical efficacy of the CS system were evaluated. Results The 5 patients included 4 patients with aortic arch aneurysm and 1 patient with Stanford type B aortic dissection. There were 4 males and 1 female, aged from 51 to 79 years. Among them, 2 patients had hypertension, 2 patients had coronary heart disease, 1 patient had diabetes, and 3 patients had abnormal lipid profiles. The CS system was successfully implanted in all 5 patients. There were no serious complications such as vascular rupture and death. The mean interventional time was (72.4±16.9) min, the mean total procedure time was (169.4±19.6) min, and the mean volume of contrast agent used was (79.0±6.5) mL. Intraoperative angiography showed that the aneurysms were completely isolated and the primary dissection tear was completely excluded. No endoleak was observed, and the branch stents were in good shape without stenosis or occlusion. Postoperative ICU stay time was (24.2±3.2) h. There were no serious complications during the perioperative period, and the survival rate was 100%. All 5 patients were discharged from hospital 2 weeks after operation. The CTA examination before discharge showed that the position of the three-branch stent system was satisfactory, there was no endoleak, and there was no stenosis or occlusion of the three-branch vessels in the arch. Five patients were in good general condition during follow-up, with no cardio-cerebral events. The survival rate was 100%, and the longest follow-up period reached 6 months. No stent migration and endoleak were observed or secondary interventions were required during the follow-up period. Conclusion The CS system is an integrated stent system with a concave structure. The design of this system optimates the brain protection strategy of total endovascular repair of aortic arch and can effectively preserve the arch branches while treating aortic arch lesions without sufficient proximal landing zone. The integrated design also provides excellent stability. Using the CS system for endovascular three-branch reconstruction of aortic arch lesions has a high success rate of operation and satisfactory short-term outcome, indicating promising prospects for clinical application.

4 Short-term outcomes of endovascular reconstruction of internal iliac artery in the treatment of isolated iliac artery disease

HAN Hui , SHU Chang , LI Xiangyu , FAN Bowen , MA Hao , LUO Mingyao

2023, 32(6):832-839. DOI: 10.7659/j.issn.1005-6947.2023.06.004

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Background and Aims Internal iliac artery lesions can cause various clinical symptoms, and aggressive treatment can significantly improve patients' prognosis and quality of life. Open surgery is the classic method for treating iliac artery lesions, but it requires higher technical demands and carries greater risks for patients. Endovascular techniques for reconstructing the internal iliac artery have been widely applied, with current progress mainly focusing on the treatment of concomitant abdominal aortic aneurysms, and there is limited research specifically targeting the internal iliac artery lesions. Furthermore, due to the complexity of lesion types and anatomical structures, there are no specialized guidelines or expert consensus at home and abroad to guide the diagnosis and treatment of internal iliac artery lesions, and there is a lack of standardized protocols for endovascular treatment techniques. This requires clinicians to develop individualized strategies based on the characteristics of the lesions, anatomical considerations, and personal experience. Currently, the more widely used and technically mature endovascular treatment methods include endovascular angioplasty and stent placement, while for those with concomitant external iliac artery lesions, "sandwich"technique and branch stenting have their advantages and disadvantages. This study was performed to observe the short-term treatment outcomes of employing the aforementioned commonly used endovascular repair methods and selecting different reconstruction strategies based on the individual conditions of patients with internal iliac artery lesions, to explore the feasibility of using personalized endovascular techniques for reconstructing the internal iliac artery.Methods The data of 13 patients with isolated iliac artery lesions who underwent internal iliac artery reconstruction at the National Cardiovascular Center from November 2015 to June 2022 were retrospectively analyzed. The primary endpoints were the incidence of postoperative symptoms of internal iliac artery ischemia such as buttock claudication and erectile dysfunction. The secondary outcome variables included such as the patency of blood flow and the presence of endoleaks, stent displacement, restenosis on aortic CTA at least 1 month after the procedure.Results Among the 13 patients, there were 12 males and 1 female, with a mean age of 62 (46-73) years. Based on preoperative imaging findings and the characteristics of the lesions, appropriate surgical methods were selected. Among them, 8 cases with internal iliac artery stenosis at the ostium were treated with simple balloon angioplasty, 4 cases with iliac artery aneurysm, dissection, or penetrating ulcers were treated with covered stent endovascular exclusion, and 1 case with common iliac artery aneurysm and iliac artery involvement was treated with the "sandwich"technique. All patients successfully underwent unilateral iliac artery revascularization without perioperative complications such as myocardial infarction, major bleeding, limb embolism, or death. The median follow-up time was 3.9 (1-22) months. During the follow-up period, none of the patients experienced ischemic symptoms in the iliac artery supply region. The CTA results showed that the blood flow in the ipsilateral iliac artery and external iliac artery was unobstructed, and the stent morphology and position were normal, with no evidence of endoleaks, embolism, or aneurysm expansion. Two cases with severe stenosis at the internal iliac artery ostium treated with simple balloon angioplasty showed moderate residual stenosis on follow-up at 3 months after operation, but both were relieved compared to the preoperative condition.Conclusion The application of endovascular techniques for treating internal iliac artery lesions is safe and feasible. The specific surgical approach should be selected based on individualized conditions.

5 Application of free flaps combined with vascular reconstruction in the repair of upper limb destructiv wounds with vascular injuries

QIN Fengjun , WANG Cheng , ZHANG Ying , DU Weili , JIA Wei , TIAN Xuan , SHEN Yuming , LIU Jianlong

2023, 32(6):840-849. DOI: 10.7659/j.issn.1005-6947.2023.06.005

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Background and Aims Destructive wounds in the extremities often involve damage to major blood vessels. If not properly managed, they can lead to severe consequences such as limb ischemic necrosis and amputation. In order to explore diagnostic and treatment methods for such destructive wounds, this study was performed on the clinical outcomes of using free flaps combined with vascular reconstruction to repair upper limb destructive wounds combined with major vascular injuries to provide reference and guidance for the clinical treatment of such destructive wounds.Methods A retrospective analysis was conducted on 45 patients with upper limb destructive wounds and significant vascular injuries who underwent repair using free flaps combined with vascular reconstruction at Beijing Jishuitan Hospital from December 2017 to December 2022. The evaluation and treatment methods for vascular injuries, types of free flaps used for wound repair, postoperative vascular patency and limb perfusion, flap survival, and wound and donor site healing were summarized. During the last follow-up, hand muscle and nerve repair assessment criteria from the Hand Surgery Society of the Chinese Medical Association were used to evaluate the muscle strength of hand flexion and extension and finger sensory function.Results Among the 45 patients, there were 38 males and 7 females, with a mean age of (39.4±15.1) years. Five cases involved upper arm destructive wounds combined with brachial artery injuries, and 40 cases involved forearm and wrist destructive wounds combined with radial and/or ulnar artery injuries. The reconstruction methods included significant saphenous vein bridge reconstruction of the brachial artery in 3 cases (6.7%), artificial vascular bridge reconstruction of the brachial artery in 2 cases (4.4%), significant saphenous vein bridge reconstruction of the ulnar artery in 1 case (2.2%), significant saphenous vein bridge reconstruction of the radial artery in 35 cases (77.8%), and blood flow bridge flap reconstruction of the radial artery in 4 cases (8.9%). Anterolateral thigh flaps were used in 29 cases (64.4%), paraumbilical perforator flaps in 12 cases (26.7%), groin flaps in 1 case (2.2%), and latissimus dorsi muscle flaps (with an area of 24-10 cm×35-18 cm) in 3 cases (6.7%). The donor site was directly sutured and closed in 24 cases (53.3%), nearby flaps were transferred for coverage in 13 cases (28.9%), and split-thickness skin grafts were used for coverage in 8 cases (17.8%). The survival rate of free flaps was 97.8% (44/45), and the wound healing rate at stage I was 93.3% (42/45). Thirty-eight patients were followed up for 3-36 months, and the flaps and limb perfusion were satisfactory. The patency rate of reconstructed vessels was 92.1% (35/38). The patient's thumb and finger extension function was normal at the last follow-up. The muscle strength assessment of thumb and finger flexion showed grade Ⅴ in 5 cases (13.2%), grade Ⅳ in 13 cases (34.2%), grade Ⅲ in 16 cases (42.1%), and grade Ⅱ in 4 cases (10.5%). The finger sensory function assessment showed grade S4 in 5 cases (13.2%), grade S3 in 10 cases (26.3%), grade S2 in 12 cases (31.6%), grade S1 in 8 cases (21.0%), and grade S0 in 3 cases (7.9%).Conclusion Prompt evaluation and treatment of vascular injuries are necessary for upper limb destructive wounds combined with major vascular injuries. Autogenous or artificial vascular reconstruction should be performed based on the diameter of the injured vessels to prevent limb ischemic necrosis. Reconstructed vessels and destructive wounds should be covered promptly with tissue flaps rich in blood supply. Free flap transplantation should be prioritized whenever possible as it yields better results than distal pedicle flap transplantation.

6 Development of a prediction model for postoperative lower extremity deep venous thrombosis in patients with malignant tumors undergoing general surgery

SHENG Chang , HE Ailan , WAN Lingyan , WANG Wei , HUANG Jianhua , YANG Pu , TANG Hongying

2023, 32(6):850-858. DOI: 10.7659/j.issn.1005-6947.2023.06.006

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Background and Aims Lower extremity deep venous thrombosis (LDVT) is a common postoperative complication in patients with general surgical malignancies, significantly affecting their postoperative recovery. Currently, assessment tools cannot provide a detailed risk stratification for LDVT patients. Therefore, this study aims to explore the influencing factors for LDVT occurrence in patients with general surgical malignancies after surgery and establish a reliable prediction tool to assist in diagnosing and preventing LDVT.Methods The clinical data of patients undergoing inpatient surgery for malignant tumors in the Department of General Surgery, Xiangya Hospital, Central South University from January 1, 2021, to October 31, 2022, were retrospectively collected, and the cases were strictly quality-controlled according to well-designed inclusion and exclusion criteria. Established LDVT influencing factors and important clinical features were used as analysis variables. Univariate and multivariate analyses were performed to evaluate the influencing factors for LDVT and screen predictive factors for the model. A receiver operating characteristic (ROC) curve based on Logistic regression was created using programming software to assess the model's predictive performance. A calibration curve was used to evaluate the goodness of fit between the prediction model and the data. Decision curve analysis was employed to compare the clinical application value of the prediction model with other single indicators.Results A total of 342 patients were included, with 167 cases in the LDVT group and 175 cases in the control group. Univariate analysis revealed that a history of surgical trauma within one month, hypertension, smoking, alcohol consumption, history of radiotherapy, duration of ICU stay, red blood cell (RBC) count, hemoglobin (Hb) level, fibrinogen degradation products (FDP), D-dimer, coagulation time, surgical duration, intraoperative RBC transfusion, intraoperative plasma transfusion, and surgical approach were all related to the occurrence of LDVT (all P<0.05). Multivariate analysis demonstrated that a history of surgical trauma within one month, FDP, coagulation time, surgical duration, intraoperative RBC transfusion, and intraoperative plasma transfusion were independent influencing factors for postoperative LDVT (all P<0.05). A nomogram was constructed by using these independent influencing factors as predictor variables, and the area under the ROC curve (AUC) for predicting LDVT risk at 2 weeks after surgery was 0.830 (95% CI=0.787-0.874, P<0.001). The Hosmer-Lemeshow statistic in the calibration curve was 0.973. Decision curve analysis demonstrated that the model had a better net benefit than single indicators.Conclusion The prediction model developed in this study exhibits good discriminative ability and clinical application value. It can assist clinicians in risk stratification for LDVT in high-risk populations and facilitate the attainment of personalized and effective prevention and treatment measures. Future studies should focus on testing and improving the external validity of the model through multicenter, prospective research designs incorporating intelligent algorithms.

7 Cost-effectiveness analysis of AngioJet mechanical thrombectomy compared to catheter-directed thrombolysis for the treatment of lower extremity deep vein thrombosis

LI Guanqiang , SUN Yuan , ZHANG Jingbo , ZHANG Xicheng

2023, 32(6):859-866. DOI: 10.7659/j.issn.1005-6947.2023.06.007

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Background and Aims Lower extremity deep vein thrombosis (DVT) is a common complication in hospitalized patients. The current approach to its treatment focuses on rapid thrombus removal to reduce the occurrence of post-thrombotic syndrome. The main methods include catheter-directed thrombolysis (CDT) and mechanical thrombus removal (PMT). However, there is still some controversy regarding the indications for CDT and PMT, and there needs more relevant research in health economics, making it difficult to assess the benefits of CDT and PMT treatments for patients. This study aims to comprehensively evaluate and compare the benefits of CDT and AngioJet treatments in patients with lower extremity DVT who underwent surgical treatment in order to provide recommendations for clinical doctors in selecting appropriate treatment methods and maximize the benefits for patients in terms of efficacy, quality of life, and economics.Methods Clinical and follow-up data were collected from patients diagnosed with lower extremity DVT and treated with CDT or AngioJet in the Department of Vascular Surgery from December 2018 to August 2020. The analysis included efficacy (syndrome scores), cost-effectiveness, follow-up color Doppler ultrasound results, Villalta scores, and CIVIQ-2 scores.Results A total of 79 patients with lower extremity DVT were included, with 47 patients treated with AngioJet (AngioJet group) and 32 patients treated with CDT (CDT group). There were no significant differences in general characteristics and consumable usage between the two groups of patients (all P>0.05). Symptoms significantly improved in both groups after treatment, with a higher recovery rate in the AngioJet group compared to the CDT group (34.04% vs. 12.50%, P<0.05). There was no significant difference in the length of hospital stay between the two groups (P>0.05). The treatment cost was significantly higher in the AngioJet group compared to the CDT group (77 498.11 CNY vs. 66 092.58 CNY, P<0.05). However, the cost per 1% recovery rate was lower in the AngioJet group compared to the CDT group (2 579.83 CNY vs. 5 287.41 CNY). There was no statistically significant difference in the postoperative follow-up color Doppler ultrasound scores between the two groups (P>0.05), but both the Villalta scores and CIVIQ-2 scores indicated that the treatment efficacy in the AngioJet group was superior to that in the CDT group (both P<0.01).Conclusion AngioJet and CDT are effective in treating lower extremity DVT, but AngioJet is a more cost-effective treatment option for patients with lower extremity DVT while providing better quality of life. In economically feasible situations, the AngioJet treatment option may be considered.

8 Effect of resistance exercise on deep vein thrombotic angiogenesis in mice

WU Caijiao , LI Xiaorong , XU Jiaao , LI Xiaoyan , WEI Jiani , ZHAO Huihan , YING Yanping

2023, 32(6):867-877. DOI: 10.7659/j.issn.1005-6947.2023.06.008

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Background and Aims Evidence supports the early mobilization of patients with acute deep vein thrombosis (DVT) on adequate anticoagulation, which does not increase the risk of pulmonary embolism and can improve patient symptoms. However, there is limited research on the effects of resistance exercise on DVT angiogenesis. This study explores whether resistance exercise can promote angiogenesis in DVT and facilitate venous thrombus recanalization.Methods Seventy-two adult male C57BL/6J mice were used to construct a DVT model through inferior vena cava stenosis. They were randomly divided into a model group and a resistance exercise group. The resistance exercise group underwent resistance exercise intervention using tail loading, while no intervention was performed on the model group. Partial mice from both groups were sacrificed at 7, 14, and 28 d after modeling, and the venous thrombus was observed using ultrasound before sacrificing. HE staining was used to observe the mice's venous thrombus and lung tissue pathology. The thrombus recanalization rate was calculated. ELISA was used to measure the expression levels of vascular endothelial growth factor (VEGF) in the serum of mice in each group. Immunohistochemical staining was performed to detect the expression of vascular endothelial growth factor A (VEGF-A), vascular endothelial growth factor receptor 2 (VEGFR-2), and platelet endothelial cell adhesion molecule (CD31) in the venous thrombus of mice, and the number of CD31-positive blood vessels was calculated. qRT-PCR was used to detect the mRNA expression of VEGF and VEGFR-2 in the venous tissue containing the thrombus.Results Ultrasound revealed a gradual reduction in thrombus size in both groups of mice after surgery. Compared to the model group, the resistance exercise group exhibited significantly smaller thrombus size and lumen diameter in mice at 28 d after surgery. The lung tissue structure was generally normal at different time points after surgery in both groups. At 7 d after surgery, there were no significant differences between the two groups in terms of thrombus recanalization rate, serum VEGF concentration, expression levels of VEGF-A and VEGFR-2 in the thrombus, number of CD31-positive blood vessels, and mRNA expression of VEGF and VEGFR-2 in the venous tissue containing the thrombus (all P>0.05). However, at 14 and 28 d after surgery, the resistance exercise group showed significantly higher thrombus recanalization rate, serum VEGF concentration, expression levels of VEGF-A and VEGFR-2 in the thrombus, number of CD31-positive blood vessels, and mRNA expression of VEGF and VEGFR-2 in the venous tissue containing the thrombus compared to the model group (all P<0.05).Conclusion Resistance exercise can increase the expressions of VEGF and VEGFR-2 in mice with DVT, thereby promoting angiogenesis and venous thrombus recanalization in DVT.

9 Experimental study of stromal cell-derived factor 1α inducing migration of adipose-derived stem cells to promote muscle repair in diabetic ischemic lower limbs

HUANG Donglin , LIANG Zhijie , ZHU Dandan , JIANG Hongmian , NING Yan , LI Hongmian

2023, 32(6):878-887. DOI: 10.7659/j.issn.1005-6947.2023.06.009

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Background and Aims Stromal cell-derived factor-1α (SDF-1α) is a chemotactic factor that directs cell migration. Studies have shown that mesenchymal stem cells (MSCs) can migrate along the SDF-1 gradient to the site of tissue injury and participate in tissue repair. However, there is currently a lack of in vivo studies on the tissue repair of diabetic ischemic lower limbs using SDF-1α-induced adipose-derived stem cells (ASCs). Therefore, this study was conducted to investigate the effect of SDF-1α on the migration of rat adipose-derived stem cells (rASCs) to the muscle tissue of diabetic ischemic rat lower limbs and its impact on tissue repair.Methods The rASCs were isolated and cultured from the adipose tissue of SD rats. Cell morphology was observed, and the differentiation capacity towards adipocytes, chondrocytes, and neurons was evaluated. Then, the rASCs were transfected and labeled with green fluorescent protein (GFP) using adenovirus. Diabetes was induced in rats using the streptozotocin (STZ) method, and the right femoral artery of the rats was ligated to induce lower limb ischemia. The rats were randomly divided into two groups and injected with rASCs via the tail vein. The SDF-1α protein was injected into the midsection of the affected limb muscle in one group (SDF-1α+rASCs group), while the other group was injected with an equal amount of phosphate-buffered saline (rASCs group). Blood flow measurements of the rat lower limbs were conducted at weeks 1 and 2 after treatment, and the ischemic limb-to-contralateral limb blood flow ratio was calculated and compared. At week 4, the rats were euthanized, and muscle tissue from the ischemic region was subjected to HE staining to observe the arrangement of muscle tissue in different treatment groups. Immunofluorescent staining using factor Ⅷ (FⅧ) as a marker for microvessels was performed to observe the distribution of FⅧ and GFP in the tissues under a fluorescence microscope.Results The cultured cells exhibited spindle or multiangular growth and had the ability to differentiate into adipocytes, chondrocytes, and neurons, confirming their identity as rASCs. The blood flow measurements of the diabetic ischemic rat lower limbs showed that the ischemic limb-to-contralateral limb blood flow ratio was significantly higher in the SDF-1α+rASCs group than in the rASCs group at week 1 (0.33±0.03 vs. 0.26±0.02, P=0.016), and this difference further increased at week 2 (0.60±0.02 vs. 0.47±0.01, P=0.050). HE staining revealed a more orderly arrangement of muscle tissue in the SDF-1α+rASCs group at week 4. Immunofluorescent staining showed that the number of rASCs in the skeletal muscle tissue of the SDF-1α+rASCs group was significantly higher than that in the rASCs group at week 4 (P<0.05), and overlapping red fluorescence (FⅧ) and green fluorescence (rASCs) were observed.Conclusion Increasing the concentration of SDF-1α at the site of ischemia can effectively increase the number of rASCs migrating to the affected area, resulting in optimized blood flow perfusion and significant improvement in muscle tissue repair. In addition, the differentiation of rASCs into endothelial cells may be one of the key mechanisms.

10 Efficacy comparison of CHIVA versus obliteration therapy in the treatment of non-saphenous varicose veins of the lower limbs

XU Hongbo , WANG Zheng , LI Jiale , TANG Yulin , WANG Zhichao , XUE Bichen , NIE Wanpin , YAO Kai

2023, 32(6):888-898. DOI: 10.7659/j.issn.1005-6947.2023.06.010

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Background and Aims The hemodynamic types of lower limb varicose veins arising from non-saphenous tributaries are complex, and traditional treatment methods such as saphenous vein main trunk closure or stripping may miss reflux point, resulting in a high recurrence rate. Currently, commonly used treatment methods mainly include radiofrequency ablation (RFA), laser therapy, and foam sclerotherapy, but there has yet to be a consensus. This study aims to evaluate the safety and effectiveness of conservative hemodynamic correction of venous insufficiency (CHIVA) and RFA combined with ultrasound-guided foam sclerotherapy (UGFS) obliteration for non-saphenous varicose veins of the lower limbs.Methods A total of 95 patients with lower limb varicose veins originating from non-saphenous sources, who were consecutively admitted to Xiangya Third Hospital of Central South University and followed up regularly from July 2019 to December 2021, were selected. Among them, 41 patients underwent CHIVA treatment (CHIVA group), and 54 underwent RFA combined with UGFS obliteration (closure group). The data that included demographic characteristics, reflux vein types, shunt types, perioperative conditions, postoperative efficacy, complications, and Venous Clinical Severity Score (VCSS) were collected.Results The CHIVA group had a significantly shorter average operative time than that of the closure group (61.36 min vs. 78.15 min, P=0.000 5), significantly less average intraoperative blood loss than that of the closure group (4.07 mL vs. 8.52 mL, P<0.000 1), a and significantly fewer incisions during the operation than that of the closure group (1.58 vs. 3.65, P<0.000 1); there was no significant difference in average hospital stay between the two groups (P>0.05). The incidence rates of pigmentation, thrombophlebitis, and hematoma in the CHIVA group were significantly lower than those in the closure group (4.9% vs. 24.1%; 2.4% vs. 14.8%; 0 vs. 11.1%, all P<0.05). Six months after the operation, the varicose vein regression rate in the closure group was significantly higher than that in the CHIVA group (90.7% vs. 70.7%, P<0.05). The reintervention rate in the CHIVA group was significantly higher than that in the closure group (29.3% vs. 9.3%, P<0.05). There was no significant difference between the two groups regarding newly developed varicose veins 12 months after operation (P>0.05). Both groups showed significant improvement in VCSS at 6 and 12 months after operation compared to preoperative scores, but at 6 months after operation, the CHIVA group showed a more significant decrease compared with the closure group (1.89 vs. 2.50, P<0.05); there was no statistically significant difference in VCSS between the two groups at 12 months after operation (P>0.05).Conclusion Compared to obliteration therapy, CHIVA has similar outcomes in varicose vein regression and quality of life at postoperative 1 year, with better perioperative variables and fewer complications, but a higher demand for reintervention at postoperative 6 months. Both methods have comparable safety and effectiveness, and the specific choice should be based on the center's technical equipment, the surgeon's experience, and the patient's preferences.

11 Comparison of the efficacy of radiofrequency ablation and high ligation with stripping in the treatment of lower limb varicose veins

WANG Shuo , YANG Yaoguo , TANG Xiaobin , KOU Lei , WU Zhangmin , WANG Sheng , HE Nan , ZHANG Zheng , ZHANG Tengfei , CHEN Zhong

2023, 32(6):899-908. DOI: 10.7659/j.issn.1005-6947.2023.06.011

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Background and Aims High ligation and stripping (HLS) of the great saphenous vein is a classic procedure for the treatment of varicose veins of the lower limbs. However, it has drawbacks such as significant trauma, longer recovery time, and unsightly incision scars. With the advancement of medical technology, minimally invasive treatment techniques, represented by endovenous thermal ablation, have flourished. This study aims to compare the clinical efficacy of radiofrequency ablation (RFA) with traditional HLS for the treatment of lower extremity varicose veins.Methods The clinical and follow-up data of 272 patients (298 limbs) who underwent surgical treatment for primary lower extremity varicose veins at Beijing Anzhen Hospital, Capital Medical University, from May 2021 to June 2022 were retrospectively analyzed. Of the patients, 96 cases (100 limbs) underwent RFA treatment (RFA group), and 176 cases (198 limbs) underwent HLS treatment (HSL group). The preoperative clinical characteristics, surgical details, complications, changes in clinical-etiological-anatomical-pathophysiological (CEAP) classification, venous clinical severity score (VCSS), and Chronic Venous Insufficiency Questionnaire-14 items (CIVIQ-14) scores were compared between the two groups.Results The technical success rate was 100% in both groups, and ultrasound examinations on postoperative day 3 showed a 100% absence/closure rate of the main trunk of the great saphenous vein. A total of 265 patients (290 limbs) completed the follow-up, with a mean follow-up time of (13.2±3.8) months. During the follow-up period, the absence/closure rate of the main trunk of the great saphenous vein was 100% as indicated by ultrasound in both groups. There were no significant differences in the basic clinical characteristics between the two groups (all P>0.05). Compared to the HSL group, the RFA group had significantly lower intraoperative blood loss (21.3 mL vs. 46.8 mL), postoperative day 1 pain scores (3.1 vs. 3.3), overall incidence of complications (25.5% vs. 38.0%), and incidence of abnormal skin sensations (5.1% vs. 24.0%) (all P<0.05). The RFA group had a higher incidence of deep vein thrombosis (5.1% vs. 0, P<0.05). After the procedure, all patients in both groups showed a downgrade in CEAP classification compared to that before the procedure. In the RFA group, 81.7% of limbs were downgraded to C0-C1 level, while in the HSL group, 83.9% of limbs were downgraded to C0-C1 level. VCSS and CIVIQ-14 scores of all patients improved compared to those before the procedure, and the improvement in VCSS score was greater in the HSL group than that in the RFA group (all P<0.05).Conclusions RFA has comparable short-term efficacy to HSL and offers advantages of smaller trauma, less pain, and lower complication rate compared to HSL. It is an effective treatment option for lower extremity varicose veins.

12 Analysis of high-risk factors for ulcer recurrence in patients with venous leg ulcers

OU Juanjuan , CAI Qiuni , HONG Shichai

2023, 32(6):909-914. DOI: 10.7659/j.issn.1005-6947.2023.06.012

[Abstract](515) [HTML](378) [PDF 710.92 K](1239)

Abstract:
Background and Aims Venous leg ulcers are severe complications of chronic venous insufficiency, characterized by high recurrence rates. They can result in prolonged hospitalization, increased financial burden on patients, reduced work capacity, and increased disability. Therefore, this study was performed to identify high-risk factors for the recurrence of venous leg ulcers, providing clinical evidence for effective prevention of ulcer recurrence.Methods The clinical data of patients with venous leg ulcers treated at Zhongshan Hospital, Xiamen University, from January 2021 to September 2022 were retrospectively analyzed. Univariate and multivariate logistic analyses were performed to identify high-risk factors for ulcer recurrence.Results A total of 182 patients with venous leg ulcers were included, all of whom received standardized dressing treatment in the chronic wound outpatient department. The recurrence rate of venous leg ulcers was 47.2%. Univariate analysis revealed a significant association between ulcer recurrence and the following factors: surgical intervention (χ²=19.206, P=0.000), use of elastic compression stocking (χ²=23.590, P=0.000), heavy physical activity (χ²=29.495, P=0.000), and heavy smoking (χ²=9.173, P=0.002). Multivariate Logistic analysis showed that age >60 years, BMI >24 kg/m², female gender, surgical intervention, use of elastic compression stocking, heavy physical activity, and heavy smoking were independent risk factors for the recurrence of venous leg ulcers (all P<0.05).Conclusion The recurrence rate of venous leg ulcers is high. Smoking cessation and reducing heavy physical labor are effective measures to reduce the recurrence of venous ulcers. Early surgical intervention in clinical practice can decrease ulcer recurrence in patients.

13 Vascular interventional surgery robot and its force feedback technology

TONG Jing , CHU Chengchen , LI Bin

2023, 32(6):915-922. DOI: 10.7659/j.issn.1005-6947.2023.06.013

[Abstract](976) [HTML](872) [PDF 810.25 K](3123)

Abstract:
Vascular interventional surgery is a surgical method that uses instruments such as catheters and guide wires to enter the blood vessels through a minimally invasive skin puncture under visual image guidance and performs diagnosis and treatment on the lesion site. It has the advantages of small trauma, fast recovery, and few complications, and it has become the preferred treatment method for various diseases, such as cardiovascular and cerebrovascular diseases. However, due to the narrow and complex nature of blood vessels, manipulating catheters inside them becomes challenging, increasing the cognitive load on doctors, prolonging surgery time, and raising fatigue levels and surgical risks for operators and patients. On the other hand, vascular interventional surgery requires the high proficiency of doctors, and the number of doctors who can carry out many operations is limited. These greatly limit the broad application of vascular interventional surgery. Robot-assisted vascular interventional surgery has been expected to solve these problems for its accuracy, flexibility, and convenience. Realizing vascular interventional surgery's remoteization, intelligentization, and digitalization is essential. However, compared with other key technologies, such as image navigation and mechanical arm structure of vascular interventional surgery robots, force feedback technology still has a large gap. The lack of force feedback limits its application in complex and challenging, calcified, and chronic occlusive lesions. Therefore, this paper analyzes the fundamental problems, implementation methods, and technical requirements of force feedback technology for vascular interventional surgery robots and discusses the development direction of force feedback technology in combination with domestic and foreign research progress, providing theoretical reference and practical guidance for the research of force feedback technology for vascular interventional surgery robots. From the perspective of engineering design, the fundamental problems faced by force feedback technology are explained from two aspects: the problem of manual force perception and the problem of force compensation force loss, and the process of manual force perception, the range of perceived force, the causes of force loss and the method of force compensation are briefly described. Domestic and foreign research on force feedback technology for vascular interventional surgery robots is still in its infancy, mainly focusing on experimental verification and system development based on mechanical action, electrorheological fluid, and magnetorheological fluid. Although these methods can achieve a certain degree of force feedback effect, they also have some limitations and shortcomings: mechanical force feedback is difficult to overcome inertia; noise interference and large volume limit application scenarios; electrorheological fluid force feedback working voltage greatly exceeds human body safety threshold; magnetorheological fluid force feedback is accompanied by a large amount of heat and friction from the passive viscosity that interferes with accurate force presentation. Therefore, exploring more efficient, sensitive, stable, and suitable remote operation force feedback technology is necessary. In addition, "local force feedback" and "perceptual substitution" are two promising force feedback methods worth exploring. For the technical requirements of force feedback implementation, this paper analyzes in depth from sensor, force detection, and force feedback based on the force transmission process and elaborates on the latest research results at home and abroad. With the development of other interdisciplinary disciplines such as artificial intelligence, big data, the Internet of Things, wireless communication, materials science, and physics, more possibilities and innovations can be provided for force feedback technology for vascular interventional surgery robots. At the same time, establishing a monitoring platform based on information fusion technology, improving relevant laws and regulations, reducing costs, conducting clinical trials and validations, and integrating 5G and virtual reality technologies can enable broader applications of robot-assisted vascular intervention surgery.

14 Progress of endovascular repair of lesions involving aortic root/ascending segment

MAO Yilun , WU Guangmin , SHAN Zhiyuan , ZHANG Zizheng , GUO Yuanyuan

2023, 32(6):923-928. DOI: 10.7659/j.issn.1005-6947.2023.06.014

[Abstract](607) [HTML](676) [PDF 1.02 M](1107)

Abstract:
Aortic root/ascending segment, due to its complex anatomical structure and hemodynamic turbulence characteristics, requires consideration of several factors such as "aortic valve, bilateral coronary artery openings, aortic sinus dilation, and innominate artery opening" when designing endovascular grafts. Therefore, it is regarded as the final "forbidden zone" for endovascular repair, and to this day, there is still no ideal intraluminal graft available for treating lesions in this segment, becoming a forefront issue focused on by major vascular surgery centers worldwide. Current research strategies include the Endo-Bentall procedure, Endo-Wheat procedure, and "Jing's valved-fenestrated endografting" animal experiments, but significant challenges remain unresolved, such as individualization limitations, unclear long-term patency of coronary stents, and graft infections. Currently, there are no perfect endografts or endovascular surgical approaches to address lesions in the aortic root-ascending aorta segment. Given the limitations of the current technology and limited clinical experience, this technique should be reserved for high-risk patients, especially those who refuse open interventions. Here, the authors provide an overview of the currently available endovascular repair options involving the aortic root and ascending aorta lesions.

15 Research progress on the fibrous structure of aortic wall

QI Youfei

2023, 32(6):929-935. DOI: 10.7659/j.issn.1005-6947.2023.06.015

[Abstract](600) [HTML](510) [PDF 658.68 K](1344)

Abstract:
The aortic wall comprises three layers: the intima, the media, and the adventitia. Among them, the media layer is the most complex in tissue structure, carrying the most functions, and is also the primary cause and site of aortic diseases. The main structural components of the aortic media layer are the extracellular matrix (ECM), composed of elastic fibers (EF) and collagen fibers (CF). EF and CF contribute to the local microenvironment of the arterial wall and play a crucial role in maintaining the normal morphology and mechanical characteristics of the aortic wall. EF is associated with the good compliance of the vessel wall, while CF is associated with the ultimate strength of the wall. The interweaving of these two components allows the aortic wall to possess both elasticity and toughness. In this article, the author provides an overview of the composition of the fibrous structure in the aortic wall and the synthesis, expression, and functions of each component.

16 Research advances in diagnosis and treatment of in-stent restenosis after superior mesenteric artery stent implantation

HU Songjie , YIN Xiaoliang , LANG Dehai

2023, 32(6):936-942. DOI: 10.7659/j.issn.1005-6947.2023.06.016

[Abstract](576) [HTML](665) [PDF 671.54 K](1238)

Abstract:
Intestinal ischemia and hypoxia can occur when the superior mesenteric artery (SMA) becomes narrowed or occluded, leading to insufficient blood perfusion. This condition can result in mucosal damage and ischemic necrosis of the intestinal tissue. Restoring blood flow and relieving luminal stenosis is crucial for preventing intestinal necrosis. In recent years, endovascular stent implantation has become one of the primary treatment modalities for SMA stenosis due to its minimally invasive nature compared to open surgical revascularization. It offers advantages such as shorter hospitalization, reduced risk of complications, and lower mortality rates. The procedure has demonstrated favorable short-term clinical outcomes and is consistently recommended in guidelines. However, as stent implantation has become more widely used, in-stent restenosis (ISR) has gained attention after SMA stent implantation. Studies have indicated that patients with SMA stenosis treated with stents are more likely to develop ISR than those who undergo open surgical revascularization. Therefore, managing patients after SMA stent implantation is essential, including maintaining medication therapy to achieve long-term stent patency, early identification and diagnosis of ISR through ultrasound and imaging examinations, and selecting appropriate timing for reintervention. Dual-function ultrasound (DUS) and computed tomography angiography (CTA) demonstrate high sensitivity and specificity for ISR diagnosis and have replaced digital subtraction angiography (DSA) as the preferred preoperative diagnostic and screening tools. Due to the severe consequences of SMA ischemic lesions, such as intestinal necrosis, timely intervention is crucial. Therefore, patients presenting with relevant clinical symptoms of ISR should undergo secondary surgery as soon as possible. The surgical approach can involve repeating endovascular angioplasty and/or stent implantation. For patients with recurring lesions or anatomical constraints that make repeat endovascular repair difficult, traditional open surgical procedures, such as SMA bypass surgery, can be considered a more durable option, particularly in high-risk patients. Here, the authors conduct a literature review on ISR following SMA stent implantation, aiming to summarize and consolidate the current knowledge on preventive strategies, diagnostic approaches, and treatment advancements for ISR.

17 Research progress related to thromboinflammation and post-thrombotic syndrome following deep vein thrombosis

YAO Sicheng , CI Hongbo

2023, 32(6):943-949. DOI: 10.7659/j.issn.1005-6947.2023.06.017

[Abstract](863) [HTML](614) [PDF 688.30 K](1276)

Abstract:
Post-thrombotic syndrome (PTS) is a long-term complication secondary to deep vein thrombosis (DVT), characterized by symptoms such as heaviness, pain, swelling, and ulcers in the affected limb. Due to the irreversible fibrosis of the venous wall in PTS, along with luminal occlusion leading to intractable ulcer formation, the treatment options are limited and their effectiveness is uncertain. Previous perspectives suggested that venous obstruction and dilation, as well as thrombus recanalization and valvular dysfunction, resulting from the progression of thrombosis, are the main pathogenic mechanisms leading to PTS. In recent years, it has been discovered that aseptic inflammatory thrombosis, primarily driven by neutrophils, is abnormally activated in a venous stasis environment. This activation can initiate a cascade of coagulation reactions, leading to intensified thrombus formation, known as the waterfall effect. During the phase of thrombus resolution, macrophages can promote neovascularization within the thrombus by secreting various inflammatory factors, thereby accelerating thrombus dissolution. However, they can also affect the venous wall, reducing compliance, inducing luminal fibrosis, and promoting unfavorable remodeling, ultimately contributing to the development of PTS. This article primarily focuses on the role of thromboinflammation in different stages of venous thrombosis formation, lysis, and venous wall fibrosis, and provides a comprehensive review regarding inflammatory markers and relevant anti-inflammatory target medications.

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Volume 32,Issue 6,2023 Table of Contents

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