Volume 33,2024 Number 6

INTERPRETATION OF GUIDELINES

• Interpretation of the European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms

  KAN Yuanqing, FU Weiguo

  2024,33(6):867-875, DOI: 10.7659/j.issn.1005-6947.2024.06.001

  Abstract: (58) HTML (57) PDF (750.36 KKB)(794)

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  The European Society for Vascular Surgery (ESVS) released the ESVS 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms, providing a comprehensive and detailed overview of diagnostic and treatment strategies for abdominal aortic aneurysms and iliac artery lesions. Based on the best available evidence as of August 2023, the guidelines include 160 recommendations according to the revised European Society of Cardiology grading system. This new edition features 59 additional recommendations compared to the 2019 version. Key topics covered in the guidelines include quality control, epidemiology, and diagnostic screening, management of small abdominal aortic aneurysms, elective repair of abdominal aortic aneurysms, management of ruptured and symptomatic abdominal aortic aneurysms, and management of complex abdominal aortic aneurysms, with evidence-based summaries and graded recommendations provided. These guidelines are of significant value for guiding clinical practice in vascular surgery for abdominal aorto-iliac artery aneurysms in domestic settings. However, it is essential to tailor individualized diagnosis and treatment plans to the specific conditions of local patients. This article interprets relevant sections of the guidelines for academic reference and discussion.

SYMPOSIUM

• Aortic intimal intussusception and intraoperative stent-graft-induced aortic intimal intussusception during TEVAR

  MA Tao, FU Weiguo

  2024,33(6):876-884, DOI: 10.7659/j.issn.1005-6947.2024.06.002

  Abstract: (33) HTML (15) PDF (1.58 MKB)(176)

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  When an acute aortic dissection occurs, the intima tears. If the tear forms a circumferential rupture, the intima distal to the tear detaches from the aortic wall and forms an independent intimal lumen. As this lumen collapses along the direction of blood flow, it creates an antegrade intimal detachment, known as aortic intimal intussusception. Aortic intimal intussusception is rare, with 90% of cases occurring during the natural progression of an aortic dissection, but it can also be a complication of thoracic endovascular aortic repair (TEVAR). With the increasing prevalence and number of TEVAR procedures in recent years, the incidence of surgery-related complications has also risen. However, reports on intraoperative stent graft-induced aortic intimal intussusception (ISAII) during TEVAR are extremely limited. This condition, being a rare type of dissection or complication, is not well-known to most physicians. Therefore, this article aims to introduce the concept, characteristics, diagnosis, classification, treatment principles and methods, and precautions of aortic intimal intussusception and ISAII, providing theoretical support for clinical practice and benefiting more patients. Aortic intimal intussusception occurring during the natural progression of the disease sometimes requires a combination of electrocardiogram-gated computed tomography angiography or cardiac ultrasound for a definitive diagnosis. In most cases, such lesions can be repaired under direct vision during open surgery. However, during TEVAR procedures, intussusception lesions are often only detectable by digital subtraction angiography, and in most cases, endovascular techniques are recommended for repair. If the intussusception lesions are not promptly identified, catastrophic consequences can occur. During TEVAR, if ISAII is detected after routine angiography, it is crucial to first preserve the surgical instruments and access routes. Next, angiography is required to clarify the type of intussusception and to distinguish the structural changes in the aorta, selecting the appropriate treatment strategy based on the classification. ISAII is classified into three types. Type I ISAII lesion is confined to the stent-covered area of the thoracic aorta and do not require additional stent implantation. Type Ⅱ ISAII lesion is located distal to the stent-covered area but are confined to the thoracic aorta. Treatment involves implanting a covered stent in the thoracic aorta to fix the intimal flap and restore true lumen patency. Type Ⅲ ISAII lesion is located in the abdominal aorta, which is the most dangerous and requires the highest level of surgical decision-making and technical skill. In addition to implanting a covered stent in the thoracic aorta, a bare stent is needed in the abdominal aorta to fix the intimal flap and restore true lumen blood supply.

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MONOGRAPHIC STUDY

• Results of the PATENCY clinical trial using the Longuette™ chimney stent-graft in thoracic endovascular aortic repair

  HE Fei, SHU Chang, LUO Mingyao, FANG Kun, HU Jia, ZUO Jian, LI Xiaoqiang, LI Quanming, HE Hao, LI Xin, LI Ming, WAN Zicheng

  2024,33(6):885-893, DOI: 10.7659/j.issn.1005-6947.2024.06.003

  Abstract: (37) HTML (17) PDF (1.06 MKB)(142)

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  Background and Aims The chimney technique is a method for the left subclavian artery (LSA) reconstruction during thoracic endovascular aortic repair (TEVAR), with type Ⅰa endoleak being the main complication. The Longuette? chimney stent-graft is specifically designed for the chimney technique to reduce type Ⅰa endoleak during LSA reconstruction. To evaluate the efficacy of the Longuette? chimney stent-graft combined with TEVAR in the treatment of Stanford type B aortic dissection (TBAD) involving the LSA, we conducted a prospective, multi-center clinical trial (PATENCY clinical trial). This study was to summarize the one-year results and experiences of the PATENCY clinical trial.Methods From October 2018 to March 2022, twenty-six vascular surgery centers nationwide participated in the PATENCY clinical trial, enrolling a total of 150 eligible TBAD patients. All patients underwent LSA reconstruction with the Longuette? chimney stent-graft during TEVAR. The clinical efficacy and adverse events were evaluated during the perioperative period and at 12 months after operation, and the cumulative survival rate, LSA patency rate, and endoleak-free rate at one year after operation were analyzed.Results The patients' ages ranged from 30 to 77 years, with an average age of (54.48±11.12) years. Among them, 138 patients (92.0%) had concomitant hypertension; acute, subacute, and chronic TBAD accounted for 74.7%, 17.3%, and 8.0% of cases, respectively. General anesthesia was used in 124 patients (82.7%). The surgery success rate was 99.33% (149/150), with an average operative time of (91.67±41.47) min, X-ray exposure time of (31.36±16.71) min, and blood loss of (71.55±60.40) mL. The perioperative endoleak incidence was 5.33% (8/150), including type I in 6 cases, type Ⅱ in 1 case, and type Ⅳ and 1 case. One patient (0.67%) experienced acute occlusion of the Longuette? chimney stent, which was recanalized after another endovascular procedure. One patient (0.67%) had an acute cerebral infarction after operation, and two patients (1.33%) developed retrograde Stanford type A aortic dissection, with one death occurring three weeks after operation. Two patients (1.33%) died within postoperative 30 d. A total of 142 patients were closely followed for 11.67 (5-16) months. No displacement of the aortic stent or Longuette? chimney stent-graft was observed. Two type I endoleak patients underwent reintervention with embolization at six months and one year after operation, respectively. Six patients still had minor endoleaks at the one-year follow-up, but their TBAD false lumen remained stable without significant symptoms, and they received conservative treatment. Stenosis and occlusion within the Longuette? chimney stent occurred in one and two patients, respectively, with one case of retrograde Stanford type A aortic dissection. All these patients were asymptomatic and received conservative treatment. No complications such as stroke, paraplegia, or left upper limb ischemia were observed. The cumulative one-year survival rate, LSA patency rate, and endoleak-free rate were 97.96%, 97.96%, and 91.91%, respectively.Conclusion The use of the Longuette? chimney stent in endovascular treatment of TBAD for LSA reconstruction is simple, safe, and effective. It can significantly reduce the incidence of perioperative type Ⅰa endoleak, providing a new treatment option for minimally invasive management of aortic arch lesions.

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• First-in-man study of a new femoral endovascular access supra-arch branched stent graft for the treatment of aortic arch disease

  ZUO Jian, LIU Jincheng, YU Shiqiang, YI Wei, ZHANG Jinglong, CHEN Jia, LI Chao, SUN Zilan, LI Zilin

  2024,33(6):894-900, DOI: 10.7659/j.issn.1005-6947.2024.06.004

  Abstract: (32) HTML (35) PDF (1.06 MKB)(116)

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  Background and Aims Currently, conventional total arch replacement remains the main treatment for lesions involving the aortic arch. Conventional total arch replacement requires completion under the open chest and cardiopulmonary bypass, with a surgical duration of over 10 hours, earning it the title of a "bloody, night-long, life-or-death" surgery. Due to the unique anatomical structure of the aortic arch, it has long been considered a "forbidden zone" for endovascular treatment. Although intra-aortic techniques for the aortic arch are advancing rapidly, the bottleneck issue still needs to be solved, making it difficult to be widely applied in clinical practice. Here, the authors report the results of the first-in-man (FIM) study of a new femoral endovascular access supra-arch branched stent graft for treating aortic arch lesions to evaluate its application effectiveness and safety preliminarily.Methods The clinical results of 3 patients with aortic arch lesions treated using the femoral endovascular access supra-arch branched stent graft at the First Affiliated Hospital of Air Force Medical University from October 2023 to December 2023 were analyzed. Patient baseline information, lesion characteristics, intraoperative parameters, postoperative aortic arch repair, and related complications were collected.Results All three patients were male, aged between 50 and 74. All surgeries were successful without short-term postoperative complications or deaths. The three patients included one case of aortic arch coarctation aneurysm and two cases of aortic arch aneurysm with ulceration; two of them presented with chest pain, and one was incidentally found during physical examination. All three patients had concomitant hypertension, and one had diabetes. The lesions in two patients were located in zones 1-3, involving the left common carotid artery, and in one patient, the lesion was located in zones 0-3, involving the innominate artery and the left common carotid artery. The average operative time was 125 min. One patient was admitted to the intensive care unit (ICU) with catheter indwelling, while the remaining two had their catheters removed in the operating room. There was no cerebral ischemia process, and no cardiovascular or cerebrovascular complications occurred during the operation. The stents were all introduced via the femoral artery route, and the implantation was smooth. Intraoperative digital subtraction angiography showed excellent position and shape of the stent graft with good patency, complete isolation of the lesion area, and no adverse events such as endoleak or branch artery stenosis. The average length of ICU stay was 31 h. Postoperative reexamination of aortic vascular imaging showed good positions of the main and branch stents, good isolation of the lesions, and no endoleak or branch vessel stenosis or occlusion. There were no postoperative cardiovascular and cerebrovascular complications.Conclusion Applying this new femoral endovascular access supra-arch branched stent graft to treat aortic arch lesions results in no cerebral ischemia during the operation. Moreover, the delivery system is accessed via the femoral artery route, making the procedure more straightforward and reducing trauma further. The surgery proceeds uneventfully, with good outcomes, and the short-term postoperative efficacy is satisfactory, indicating promising clinical application prospects.

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• Endovascular treatment of type B aortic dissection with the Castor single-branched stent: a single-center retrospective study

  FANG Min, ZHANG Hao, ZHANG Lei, WEI Xiaolong, YUAN Liangxi, SONG Chao, ZHAO Zhiqing, BAO Junmin, LIU Guangqin, LU Qingsheng

  2024,33(6):901-908, DOI: 10.7659/j.issn.1005-6947.2024.06.005

  Abstract: (24) HTML (16) PDF (827.19 KKB)(117)

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  Background and Aims With the advancement of endovascular therapy, the treatment strategies for Stanford type B aortic dissection involving the left subclavian artery (LSA) have gradually matured. However, due to the complex anatomical structure of this area and the limitations of the devices themselves, complications such as endoleak, landing zone injury, and retrograde dissection still exist. This study explores the effectiveness of the Castor single-branched stent in treating Stanford type B aortic dissection through a single-center retrospective study.Methods Patients with Stanford type B aortic dissection who underwent endovascular surgery using the Castor single-branched stent in the Department of Vascular Surgery of the First Affiliated Hospital of Naval Medical University from December 2018 to October 2021 were included. Preoperative Dicom format full aortic CTA images, detailed intraoperative information, and follow-up outcomes of the included patients were collected. EndoSize software was used to measure variables such as the arterial diameter of the proximal and distal landing zones of the dissection, the length of the lesion, and the relationship between the LSA opening and the dissection. The stent enlargement rate was calculated based on the grafts used during surgery. The success rate of the surgery and the incidence rates of short- and long-term complications were observed and recorded.Results A total of 107 cases of Stanford type B aortic dissection were included, all of which were treated with endovascular surgery, achieving technical success in all cases. The distance from the main tear in the proximal dissection to the LSA was (42.7±17.3) mm; the distance from the proximal edge of the dissection to the LSA was (7.7±13.2) mm; the diameter of the proximal landing zone of the aorta was (31.5±3.0) mm; and the distance from the distal opening of the left common carotid artery to the proximal opening of the LSA was (8.5±2.6) mm. The proximal diameter of the main body of the Castor stent was (32.5±3.3) mm, the distal diameter was (26.6±3.3) mm, and the diameter of the branched stent was (10.7±3.5) mm. The proximal oversize of the main body stent was (3.2±3.5)%, and the distal oversize was (0.1±9.5)%. During the perioperative period and follow-up, 9 patients died. Among them, 1 patient died from multi-organ failure due to severe hypotension before surgery and low perfusion after operation; 1 patient died from retrograde dissection rupture 4 d after operation; 1 patient died from respiratory failure 1 month after operation; 1 patient died from pulmonary infection 4 months after operation; 2 patients died from heart failure 6 months after operation; 2 patients died from cerebral hemorrhage at 9 months and 14 months after operation respectively; and 1 patient died from an unknown cause 11 months after operation. Six patients experienced adverse events related to aortic dissection: 1 case of retrograde dissection and 3 cases of cerebral infarction occurred during the perioperative period; during follow-up, there was 1 case of type Ib endoleak and 1 case of branched stent occlusion.Conclusion Stanford type B aortic dissection often involves the LSA. Endovascular surgery requires anchoring the stent in a healthy landing zone while preserving the LSA to prevent complications such as cerebral infarction and paraplegia. The Castor single-branched stent is well-suited for endovascular treatment of Stanford type B aortic dissection involving the LSA and has certain advantages in treating those in the acute period.

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• Feasibility and efficacy of using Castor stent for reconstruction of the left common carotid artery in aortic arch lesions

  SUN Wenchao, LIU Tao, PEI Chang'an, SUN Bo, CAO Guangxin, ZHANG Jiefeng

  2024,33(6):909-917, DOI: 10.7659/j.issn.1005-6947.2024.06.006

  Abstract: (22) HTML (14) PDF (1.06 MKB)(128)

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  Background and Aims Thoracic endovascular aortic repair (TEVAR) has become the preferred method for treating aortic arch lesions. One of the challenges and research directions in TEVAR is reconstructing the supra-aortic branches. The Castor single-branched stent graft is widely used to reconstruct the left subclavian artery during TEVAR. However, its application in reconstructing the left common carotid artery (LCCA) is rarely reported. Therefore, this study investigated the feasibility and efficacy of using the Castor single-branch stent graft to reconstruct the LCCA during TEVAR.Methods Five patients with aortic arch lesions involving Zone 2 treated in the Department of Vascular Surgery of Weifang People's Hospital from October 2021 to September 2022 were reviewed. All patients were males, aged between 39 and 77 years, with an average age of (59.2±14.08) years. Among them, three had acute Stanford type B aortic dissection, and two had aortic arch aneurysms. Under DSA guidance, all patients underwent TEVAR with the reconstruction of the LCCA using the Castor-integrated branched aortic-covered stent. The surgical-related variables, the incidence of postoperative adverse events, and the occurrence of adverse events and aortic remodeling within a six-month follow-up after the operation were analyzed.Results All five patients successfully underwent the surgery. The operative time ranged from 168 to 233 min, with an average of (191±19.06) min, and no conversions to thoracotomy were necessary. The LCCA was successfully reconstructed using the Castor single-branched stent in all patients. During the postoperative hospital stay, one patient experienced a stroke but recovered full right upper limb muscle strength (Grade V) with clear consciousness two months after the operation. The other four patients did not experience any all-cause death, stroke, stent migration, dissection recurrence, endoleak, paraplegia, or left upper limb ischemia during hospitalization and follow-up. Six months after surgery, aortic CTA re-examination showed that the Castor single-branched stent was well-positioned, with a significant reduction in the mean aortic diameter at the aortic isthmus and pulmonary artery bifurcation levels compared to preoperative measurements (35.8 mm vs. 41.9 mm, P=0.035; 31.1 mm vs. 36.7 mm, P=0.048). The patency rate of the aortic and branch stents was 100%, with no endoleak, and thrombus formation was observed in the aneurysmal/false lumen.Conclusion Under strict adherence to indications, the use of the Castor single-branched stent for LCCA reconstruction during TEVAR is safe and feasible. However, its efficacy requires longer follow-up and validation with more cases.

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• Treatment strategies and risk factors for iliac limb occlusion after endovascular repair of abdominal aortic aneurysm

  QI Youfei, WANG Huixuan, LIU Sahua, CHEN Hao, ZHANG Wenbo, WU Hongfei, LIU Zhendong, XU Yuyang, XIAO Zhanxiang, LI Zhenzhen

  2024,33(6):918-925, DOI: 10.7659/j.issn.1005-6947.2024.06.007

  Abstract: (29) HTML (14) PDF (1.09 MKB)(157)

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  Background and Aims Endovascular aneurysm repair (EVAR) has become the preferred treatment for abdominal aortic aneurysm (AAA) due to its minimally invasive nature and quick postoperative recovery. Iliac limb occlusion (ILO) is a common complication after EVAR, but its management poses many challenges. Therefore, this study was performed to explore the treatment strategies and risk factors for ILO following EVAR.Methods The clinical data of 14 cases of ILO that occurred after EVAR admitted to Department of Vascular Surgery, Hainan General Hospital/Hainan Affiliated Hospital of Hainan Medical University between August 2013 and August 2022 were retrospectively analyzed, and 435 EVAR cases without ILO during the same period served as a control to analyze the risk factors for developing ILO after EVAR.Results The average operative time for the 14 patients undergoing endovascular or hybrid surgery was (183.9±32.6) min, with intraoperative blood loss of (187.1±70.2) mL. Thrombus removal and restoration of intravascular blood flow were achieved through hybrid surgery in 10 cases. In two cases where hybrid surgery failed, bilateral femoral artery bypass grafting was performed. Another two cases underwent percutaneous mechanical thrombectomy using an aspiration catheter to restore intravascular blood flow. After thrombus removal from the iliac limb, balloon dilation and stent angioplasty were performed on the iliac limb and distal external iliac artery (EIA) for residual stenotic lesions. After the operation, ischemic symptoms in the lower limbs were relieved entirely in all patients. During the follow-up period, no recurrence of ischemic symptoms was observed. Univariate analysis indicated that factors such as the diameter of the proximal EIA (P=0.045), iliac artery tortuosity≥60°(P=0.003), iliac artery stenosis ≥50% (P=0.007), the distal portion of the iliac limb graft anchoring to the EIA (P=0.015), and the oversize rate of the distal iliac limb graft ≥15% (P=0.028) were associated with the occurrence of ILO after EVAR.Conclusion Endovascular or hybrid surgery is the preferred treatment for ILO following EVAR. Attention should be paid to the risk factors for ILO, and proactive prevention should be undertaken during EVAR planning and operation.

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CLINICAL RESEARCH

• Efficacy and safety of mechanical thrombectomy devices in the treatment of acute superior mesenteric artery embolism

  WU Senyan, CHENG Guobing, WANG Sheng, LU Wei, XU Youyao

  2024,33(6):926-934, DOI: 10.7659/j.issn.1005-6947.2024.06.008

  Abstract: (27) HTML (10) PDF (1012.14 KKB)(148)

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  Background and Aims In recent years, the Acostream and Angiojet mechanical thrombectomy devices have been widely used to treat various thromboembolic diseases. However, few reports have been on their use in treating acute superior mesenteric artery embolism (ASMAE), and no comparative studies on their efficacy in ASMAE treatment have been published. Therefore, this study was performed to summarize and compare the cases of ASMAE treated with Acostream or Angiojet in the authors' institution to provide a reference for clinical treatment selection.Methods The clinical data of 23 ASMAE patients treated with mechanical thrombectomy devices in Department of Vascular Surgery, Quzhou People's Hospital between January 2019 and January 2023 were retrospectively analyzed. Of the patients, 10 cases were treated with the Acostream thrombus suction device (Acostream group), and 13 cases received treatment with the Angiojet mechanical thrombus fragmentation device (Angiojet group). The basic patient data (sex, age, onset time, signs of peritonitis, embolism location, concomitant embolism in other areas, and past medical history), intraoperative observation indicators (intraoperative blood loss, usage of balloon and stent), complications (incidence of target vessel dissection, incidence of distal arterial embolism, and incidence of bleeding events), and postoperative intestinal necrosis and perioperative mortality were compared between the two groups. The pre-and postoperative NRS pain scores, white blood cell (WBC) counts, D-dimer levels, hemoglobin levels, and the rate of abdominal pain relief, thrombus recurrence rate, and lumen restenosis during follow-up were also analyzed.Results The two groups had no statistically significant differences in the basic data (all P>0.05). The incidence of intraoperative target vessel dissection was lower in the Acostream group compared to the Angiojet group (10.0% vs. 53.8%, P<0.05). The two groups had no significant differences regarding intraoperative blood loss, distal arterial embolism, stent, and balloon usage rate, the incidence of bleeding events, and perioperative mortality (all P>0.05). Among the 5 patients with signs of peritonitis, two cases (one from each group) did not experience pain relief after endovascular surgery and underwent bowel resection after laparoscopy confirmed intestinal necrosis. There were no significant changes in hemoglobin levels before and after surgery in either group (both P>0.05). However, postoperative NRS pain scores, WBC counts, and D-dimer levels decreased compared to preoperative levels (some P<0.05), with similar trends observed between the two groups. During postoperative follow-up, all patients experienced complete relief of abdominal pain symptoms. One patient in the Acostream group was readmitted due to acute cerebral infarction. Upon re-examination with abdominal aorta CTA or enhanced whole abdominal CT, no patients had recurrent thrombosis or severe stenosis in the superior mesenteric artery trunk, and no patients died.Conclusions Both Acostream and Angiojet thrombectomy devices are safe and effective for treating ASMAE. However, attention should be given to the formation of target vessel dissection when using the Angiojet mechanical thrombectomy device. Clinical decisions should be based on the patient's overall condition when selecting an individualized surgical plan.

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• Comparison of the efficacy of great saphenous vein arterialization surgery and endovascular surgery in the treatment of thromboangiitis obliterans

  ZAIYING·Yeerbao, DI Tao, LI Hu, TIAN Ye

  2024,33(6):935-942, DOI: 10.7659/j.issn.1005-6947.2024.06.009

  Abstract: (34) HTML (17) PDF (1.16 MKB)(136)

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  Background and Aims Thromboangiitis obliterans (TAO) is an organic disease affecting small and medium-sized arteries and veins in the extremities. Its cause is unknown, and treatment options are limited. With advances in medical technology, the most commonly used methods are great saphenous vein arterialization surgery and endovascular surgery. However, there is no consensus on the superiority of these two procedures. Therefore, this study was performed to compare the clinical efficacy of great saphenous vein arterialization surgery and endovascular surgery in treating TAO, aiming to provide a reference for clinical treatment.Methods The clinical and follow-up data of 183 patients diagnosed with TAO at the First Affiliated Hospital of Xinjiang Medical University from January 2015 to April 2023 were retrospectively analyzed. Among them, 40 patients underwent great saphenous vein arterialization (great saphenous vein arterialization group), and 143 patients underwent endovascular treatment (endovascular treatment group). The patients were matched 1:1 based on age (±5 years) and TASC classification of the lesion segment, resulting in 36 pairs of patients, all male. Relevant clinical indicators were compared between the two groups.Results There were no statistically significant differences in the baseline data between the two groups after matching (all P>0.05). The great saphenous vein arterialization group showed better postoperative patency rates and ankle-brachial index than the endovascular treatment group and a lower rate of secondary surgical interventions (all P<0.05). The endovascular treatment group had better outcomes regarding postoperative pain visual analogue scale scores, intermittent claudication, and length of hospital stay, than the great saphenous vein arterialization group (all P<0.05). The two groups had no significant differences regarding postoperative foot coldness/numbness, gangrene, amputation rates, and postoperative infection (all P>0.05). Kaplan-Meier curve analysis indicated that the long-term prognosis was better in the great saphenous vein arterialization group (P<0.05).Conclusion Compared to endovascular treatment, great saphenous vein arterialization surgery is more effective in treating TAO, offering higher patency rates and lower secondary surgical intervention rates, lower costs, and better mid-to-long-term efficacy. For patients with financial difficulties, great saphenous vein arterialization surgery may be a choice to improve mid-to-long-term outcomes. Although endovascular treatment provides better short-term clinical efficacy, such as relief from resting pain, its long-term prognosis is less favorable than great saphenous vein arterialization surgery. Therefore, without suitable vascular grafts, endovascular surgery is optional to reduce postoperative pain and improve the patient's quality of life.

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• Association of serum IL-8 and VEGF levels with in-stent restenosis in lower limb arteriosclerosis obliterans patients within 1 year after stent implantation

  HU Weilong, WANG Gaoshang, ZHANG Xiaobing, ZHANG Tongqing

  2024,33(6):943-951, DOI: 10.7659/j.issn.1005-6947.2024.06.010

  Abstract: (21) HTML (11) PDF (796.90 KKB)(116)

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  Background and Aims Stent implantation is one of the main treatments for lower extremity arteriosclerosis obliterans (ASO). It effectively restores vascular patency and improves clinical symptoms, but some patients experience in-stent restenosis within one year after surgery. In-stent restenosis can lead to poor prognosis for patients, making it crucial to understand the pathological mechanisms influencing restenosis after surgery for ASO. Serum interleukin 8 (IL-8) and vascular endothelial growth factor (VEGF) are indicators of inflammation and endothelial function, respectively, and are closely related to the occurrence of ASO. However, it is unclear whether they are associated with in-stent restenosis after stent implantation for ASO. Therefore, this study was conducted to investigate the association of IL-8 and VEGF levels with in-stent restenosis in ASO patients within one year after stent implantation, and establish a nomogram model to predict in-stent restenosis within after stent implantation.Methods A total of 100 ASO patients who received stent implantation at Department of Vascular Surgery, Nanyang First People's Hospital between January 2020 and October 2022 were selected for the study. Patients were followed up for one year after-surgery and divided into restenosis and non-restenosis groups based on follow-up results. Demographic characteristics, postoperative serum IL-8 and VEGF levels, and other relevant variables were collected. Univariate and Logistic regression analyses were used to identify risk factors for in-stent restenosis within one year after stent implantation. A nomogram model was constructed based on these risk factors to predict the risk of in-stent restenosis within one year after stent implantation, and the predictive model was validated.Results Four patients were lost to follow-up, resulting in a loss rate of 4.00% (4/100). Among the 96 patients, 29 experienced in-stent restenosis, with an in-stent restenosis rate of 30.21% (29/96). Logistic regression analysis revealed that age ≥60 years (OR=4.191), Fontaine stage Ⅳ (OR=2.863), complete occlusion (OR=2.445), lower extremity vascular lesion length ≥7.15 cm (OR=3.343), postoperative IL-8 ≥1.02 ng/mL (OR=6.482), and postoperative VEGF ≥158.37 pg/mL (OR=10.402) were independent risk factors for in-stent restenosis within one year after stent implantation (all P<0.05). Validation of the nomogram prediction model constructed based on these factors showed that the calibration curve was close to the ideal curve; the C-index was 0.857 (95% CI=0.785-0.952). The ROC curve results showed that the area under the ROC curve for predicting in-stent restenosis within one year after stent implantation was 0.852 (95% CI=0.631-0.979), with sensitivity and specificity of 92.50% and 78.40%, respectively.Conclusion Postoperative serum IL-8 and VEGF levels are closely related to the incidence of in-stent restenosis in ASO patients. Higher postoperative serum IL-8 and VEGF levels indicate a higher risk of in-stent restenosis. The nomogram model based on these findings can assist clinicians in providing better treatment and follow-up plans for ASO patients.

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• Clinical observation of platelet-rich plasma in the treatment of ischemic non-healing wounds in the lower limbs

  DIAO Yongpeng, ZHANG Bang, WU Zhiyuan, LIU Ping, DU Mengmeng, LAN Yong, XU Zhengxi, ZHOU Tao, LI Yongjun

  2024,33(6):952-960, DOI: 10.7659/j.issn.1005-6947.2024.06.011

  Abstract: (21) HTML (10) PDF (1.01 MKB)(136)

  Abstract:

  Background and Aims After undergoing active endovascular intervention or open surgery to reconstruct limb blood flow, patients with ischemic non-healing wounds in the lower limbs still face long hospital stays, high treatment difficulty, high costs, and poor wound healing outcomes. Platelet-rich plasma (PRP) is advantageous due to its simple preparation, abundant sources, relative safety, and lack of side effects. It can be directly applied to wounds to enhance the healing process and has been widely used in the field of non-healing wound repair. However, there are few reports on its use for ischemic non-healing wounds in the lower limbs. This study was performed to explore the clinical efficacy and safety of PRP in the treatment of ischemic non-healing wounds in the lower limbs, so as to provide a reference for clinical treatment of such refractory wounds.Methods From January 2021 to December 2022, patients with ischemic non-healing wounds in the lower limbs admitted to the Vascular Surgery Department of Beijing Hospital and the Peripheral Vascular Department of the First Affiliated Hospital of Henan University of Traditional Chinese Medicine were selected. Patients had an ankle-brachial index (ABI) of >0.5 to <0.9, wound bed tissue in the red phase (granulation tissue phase), wound area >1 to <20 cm2, and non-healing wounds without dead space or poor drainage. Autologous venous blood (50 mL) was drawn from patients and centrifuged using a density gradient centrifugation method to prepare PRP and PRP gel. On the basis of systemic treatments including smoking cessation, lipid-lowering, anticoagulation, antiplatelet therapy, circulation improvement, blood pressure reduction, and blood sugar control, debridement was performed, followed by direct PRP injection into the wound base and external application of PRP gel to the wound, with dressing changes every 7 d. After 14 d, wound area (clinical efficacy was determined according to wound area reduction), granulation score, exudate score, and wound depth score, as well as inflammatory markers (CRP, WBC, ESR), pain score, and adverse reactions were observed.Results After 14 days of PRP treatment, the wound area significantly reduced compared to that before treatment [(10.16±4.07) cm² vs. (5.107±3.38) cm², P=0.000]. Among the patients, 8 cases (12.7%) were fully healed, 25 cases (39.7%) showed significant improvement, 24 cases (38.1%) were effective, and 6 cases (9.5%) were ineffective, with a total effectiveness rate of 90.5%. The local wound depth, granulation tissue, and exudate scores significantly improved compared to those before treatment (all P<0.05). No antibiotics were used after treatment, and inflammatory markers (WBC, CRP, ESR) were decreased, and patients' self-reported pain score was reduced (all P<0.05). No significant adverse reactions were observed during the treatment process.Conclusion The combined method of direct PRP injection into the wound base and topical application of PRP gel can promote granulation growth, epithelial crawling, accelerate wound healing, inhibit wound inflammatory response, and reduce patient pain, proving to be a safe and effective treatment for ischemic non-healing wounds in the lower limbs.

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• Evaluation of the application of enhanced recovery after surgery principles in perioperative management for patients undergoing non-interventional retrieval of inferior vena cava filters

  LIANG Taoyuan, WANG Mengmeng, MA Lin, WANG Xizhu, LU Xuemei, TIAN Xuan

  2024,33(6):961-969, DOI: 10.7659/j.issn.1005-6947.2024.06.012

  Abstract: (25) HTML (8) PDF (916.29 KKB)(121)

  Abstract:

  Background and Aims The enhanced recovery after surgery (ERAS) concept involves integrating and optimizing perioperative interventions based on evidence-based medical principles and multidisciplinary collaboration. It has been implemented across various surgical fields and has gained widespread recognition. Permanent retention of an inferior vena cava filter (IVCF) can lead to various complications. Guidelines recommend retrieving the filter when the risk of deep vein thrombosis decreases. However, retrieval can be challenging or unsuccessful due to complications such as filter tilt, adherence, perforation, or migration. In such cases, non-interventional surgical methods like laparoscopic or open IVCF retrieval may be employed, though these methods are associated with significant surgical trauma and postoperative complications. There are no reports on the application of ERAS in non-interventional IVCF retrieval. Therefore, this study explores the effectiveness of ERAS-guided perioperative management in patients undergoing non-interventional IVCF retrieval.Methods The clinical data from 34 patients who underwent non-interventional IVCF retrieval were retrospectively analyzed. Among them, 20 patients (from January 2022 to June 2023) received perioperative management based on ERAS principles (observation group), while 14 patients (from July 2020 to December 2021) received traditional perioperative management (control group). Baseline characteristics and intraoperative and postoperative indicators were compared between the two groups.Results The observation group had a higher average age than the control group (51.2 years vs. 39.5 years, P<0.05). Other factors, including sex, body mass index, preoperative hemoglobin level, medical history, IVCF placement reasons, IVCF location, IVCF type, number of interventional retrieval attempts, IVCF indwelling time, and retrieval methods, showed no significant differences between the groups (all P>0.05). The observation group had lower intraoperative blood loss, shorter operative time, fewer ICU admissions, shorter nasogastric tube retention time, shorter length of postoperative hospital stays, and lower pain visual analogue scale scores 6 h after operation (all P<0.05). The overall incidence of complications was lower in the observation group, though the difference was not statistically significant (25.0% vs. 50.0%, P>0.05). Additionally, the observation group had a higher score on the comfort scale (88.5 vs. 82.3, P<0.05) and lower total hospital costs (44 000 yuan vs. 54 000 yuan, P<0.05).Conclusion The implementation of ERAS management measures in non-interventional IVCF retrieved patients during the perioperative period has a good effect, and the intraoperative measures are safe and effective and have positive effects in promoting patient recovery, alleviating pain, and improving patient treatment experience.

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• Removal of inferior vena cava filter by open surgery after failure of endovenous retrieval: a report of 36 cases

  WANG Mengmeng, TIAN Xuan, LIANG Taoyuan, MA Lin, WANG Xizhu, LIU Jianlong, JIA Wei, JIANG Peng

  2024,33(6):970-978, DOI: 10.7659/j.issn.1005-6947.2024.06.013

  Abstract: (24) HTML (11) PDF (1.53 MKB)(116)

  Abstract:

  Background and Aims Inferior vena cava filters (IVCF) effectively prevent fatal pulmonary embolism (PE) and are widely used in clinical practice. They are suitable for patients with recurrent PE and those with lower extremity deep vein thrombosis (DVT) who have contraindications to anticoagulation during the perioperative period requiring mechanical thrombectomy or catheter-directed thrombolysis. Once the thrombus has resolved or stabilized and the PE risk has decreased, experts widely accept that the IVCF should be retrieved. Most retrievable IVCFs can be removed through endovascular surgery. However, retrieval becomes problematic when the retrieval hook of a conical filter penetrates the inferior vena cava (IVC) wall or when the spindle filter exceeds the retrieval time window. Forcibly retrieving the filter endovascularly may damage the IVC, posing a life-threatening risk to the patient. Leaving the filter in place permanently can result in complications such as filter fracture, perforation, IVC obstruction, and the need for long-term anticoagulation, leading to patient anxiety. These patients may opt for open abdominal surgery to retrieve the filter, which has shown satisfactory results. This study was performed to further explore the methods, safety, efficacy, and short- to mid-term outcomes of open surgery for retrieving IVCFs that are difficult to remove through the endovascular procedure.Methods The data of 36 patients who underwent open surgery to retrieve IVCFs that were difficult to remove through endovascular procedures between January 2020 and December 2023 were retrospectively collected. The types of filters, retrieval success rate, and postoperative complications, as well as the changes in blood parameters and anxiety status after surgery were analyzed.Results Among the 36 patients, 30 cases (83.3%) involved spindle-shaped filters, and 6 cases (16.7%) involved conical filters; two filters (5.6%) were located in the suprarenal IVC, while 34 filters (94.4%) were located in the infrarenal IVC. The median retention time for the filters was 15 (5-41) months. All 36 filters were successfully retrieved, with a retrieval rate of 100%, and no perioperative deaths occurred. Compared to preoperative levels, postoperative hemoglobin levels decreased, while D-dimer and aspartate aminotransferase levels increased (all P<0.05), but no safety risks were observed. Both the positive rate of anxiety and the Hamilton Anxiety Rating Scale scores were significantly reduced after surgery (both P<0.05). There was one case (2.8%) of respiratory failure and one case (2.8%) of pericaval hematoma, with no cases of symptomatic PE. During the 3-6 month follow-up, no recurrence or worsening of lower extremity DVT was observed, IVC occlusion occurred in one case (2.8%), incisional hernia occurred in two cases (5.6%), and three cases (8.3%) had minor residual filter fragments, with no cases of symptomatic PE.Conclusions For the retrieval of IVCFs that are difficult to remove through the endovascular method, open surgery is safe and allows for successful filter retrieval without symptomatic PE or new lower extremity DVT. Additionally, it significantly improves patients' anxiety.

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BASIC RESEARCH

• Regulation of biological behavior in breast cancer cells by karyopherin α2 through the ERK signaling pathway

  RAN Ran, LIU Caiyang, WANG Hao, HE Xing, KOU Lingna

  2024,33(6):979-987, DOI: 10.7659/j.issn.1005-6947.2024.06.014

  Abstract: (19) HTML (17) PDF (1.76 MKB)(119)

  Abstract:

  Background and Aims Abnormal expression of nuclear transport protein α2 (KPNA2) can enhance the migration and invasion abilities of breast cancer cells, leading to an increased risk of lung metastasis and is associated with poor prognosis in breast cancer patients. This study was conducted further to analyze the expression of KPNA2 in breast cancer cells and explore the related mechanism for it affecting the biological behavior of breast cancer cells.Methods The KPNA2 expressions in cancer tissues and adjacent tissues from 62 breast cancer patients were detected by immunohistochemical staining. Two human breast cancer cell lines (MDA-MB-453 and MCF-7) were divided into the negative control group (transfected with blank plasmid), KPNA2 knockdown group (transfected with KPNA2 siRNA), ERK inhibitor group (treated with ERK inhibitor U0126), and combined group (transfected with KPNA2 siRNA combined with U0126 treatment). After 48 h of treatment, KPNA2 mRNA and protein expressions were detected by qRT-PCR and Western blot, respectively. Changes in cell proliferation, apoptosis and invasion ability, ERK1/2 pathway, and apoptosis-related protein expressions were detected using MTT assay, flow cytometry, Transwell assay, and Western blot analysis, respectively.Results Immunohistochemistry results showed that the expression level of KPNA2 protein in breast cancer tissue was higher than in adjacent tissue (2.48±0.39 vs. 1.28±0.22, P<0.05). qRT-PCR and Western blot results showed no significant difference in KPNA2 mRNA and protein expressions between the negative control and ERK inhibitor groups in both breast cancer cell lines (all P>0.05). In contrast, the KPNA2 knockdown and combined groups showed downregulation of KPNA2 mRNA and protein expressions (all P<0.05). Functional experiments showed that, compared to their respective negative control groups, the ERK inhibitor group, KPNA2 knockdown group, and combined group exhibited decreased cell proliferation rates, increased apoptosis rates, and reduced cell invasion abilities, with the combined group showing the most significant changes (all P<0.05). Western blot results indicated that, compared to their respective negative control groups, the ERK inhibitor group, KPNA2 knockdown group, and the combined group had downregulated expressions of phosphorylated ERK1/2 and cleaved caspase-3 proteins, with the combined group showing the most pronounced downregulation (all P<0.05).Conclusion The expression level of KPNA2 is elevated in breast cancer tissues. Its role in enhancing breast cancer cells' migration and invasion abilities may be related to the activation of the ERK signaling pathway. KPNA2 holds promise as a new target for drug development in breast cancer.

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REVIEW

• Research progress on the mechanism of ferroptosis in organ ischemia reperfusion injury

  LI Heng, MAO Yilun, ZHAO Yikun, GUO Yuanyuan

  2024,33(6):988-995, DOI: 10.7659/j.issn.1005-6947.2024.06.015

  Abstract: (17) HTML (26) PDF (1.08 MKB)(136)

  Abstract:

  Ischemia-reperfusion injury (IRI) is one of the key factors leading to organ dysfunction and transplant failure. Its mechanism is complex and not yet fully elucidated, with limited treatment options. During IRI, various forms of cell death are activated, including apoptosis, pyroptosis, autophagy, and programmed necrosis. Ferroptosis, a novel form of programmed cell death characterized by iron-dependent reactive oxygen species (ROS) and lipid peroxidation accumulation, has been shown to play a significant role in IRI. By regulating iron, glucose, amino acid, and lipid metabolism, as well as signaling pathways, ferroptosis exacerbates organ IRI. Inhibiting ferroptosis has been proven to reduce IRI damage in multiple organs effectively, but compared to other forms of programmed cell death, the mechanisms of ferroptosis in IRI are still less studied. IRI is closely related to ROS production, which induces lipid peroxidation reactions and damages cell membrane structures, thereby being tightly linked to ferroptosis. This paper discusses the multifaceted roles of ferroptosis in organ IRI by examining the regulatory pathways of iron metabolism, lipid peroxidation, antioxidant systems, and other factors involved in cellular ferroptosis, aiming to provide references for IRI-related experiments and clinical treatments.

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• Review of research progress on mechanism of resistance to anti-EGFR therapy in metastatic colorectal cancer

  XU Kunming, XU Yunhua, CHEN Xiguang, FU Guang, HUANG Qiulin, XIAO Shuai

  2024,33(6):996-1011, DOI: 10.7659/j.issn.1005-6947.2024.06.016

  Abstract: (21) HTML (20) PDF (1.17 MKB)(189)

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  Metastatic colorectal cancer (mCRC) represents the advanced stage of colorectal cancer progression. Treatment options are diverse, but patient prognosis is generally poor. The epidermal growth factor receptor (EGFR) signaling pathway plays a central role in the development of mCRC, involving multiple key molecules. Abnormal activation of EGFR is closely related to tumor growth, metastasis, and treatment resistance. Therefore, EGFR-targeted therapy is crucial for mCRC, but treatment resistance often leads to therapy failure, and the molecular mechanisms are complex. Here, the authors review the molecular mechanisms related to anti-EGFR treatment resistance in mCRC and the progress in intervention studies, providing a reference for a deeper understanding of the mechanisms of anti-EGFR resistance and the optimization of treatment strategies.

• Factors influencing the efficacy of thyrotropin suppression therapy after surgery for differentiated thyroid cancer: a review of research progress

  ZHANG Miao, XU Danqing, ZHOU Li, DING Jinwang, PENG You

  2024,33(6):1012-1017, DOI: 10.7659/j.issn.1005-6947.2024.06.017

  Abstract: (20) HTML (14) PDF (648.03 KKB)(152)

  Abstract:

  Differentiated thyroid cancer (DTC) is the most common type of thyroid cancer, accounting for over 94% of cases. Currently, the main treatments include radical surgical resection, selective radioiodine (¹³¹I) therapy, and thyroid-stimulating hormone (TSH) suppression therapy, with generally good overall prognosis. TSH can bind to TSH receptors expressed by DTC cells, stimulating their growth. Therefore, TSH suppression therapy is a crucial step in reducing the risk of tumor recurrence in DTC patients after surgery, and it has been clearly recommended by multiple guidelines both at home and abroad. However, in clinical practice, some patients still find it difficult to achieve the TSH suppression therapy goals, requiring repeated adjustments of the treatment dose to reach the desired targets. During the treatment process, patients may experience discomfort such as fatigue, drowsiness, or palpitations. This article mainly summarizes the factors influencing the efficacy of TSH suppression therapy after DTC surgery, aiming to help clinicians provide better postoperative TSH suppression treatment and follow-up management for DTC patients, thereby improving their quality of life, extending long-term survival, and reducing postoperative recurrence rates of DTC.

BRIEF ARTICLES

• China Journal of General Surgery, 2024, 33(6):1018-1022.

  2024,33(6):1018-1022, DOI: 10.7659/j.issn.1005-6947.2024.06.018

  Abstract: (21) HTML (12) PDF (1.30 MKB)(112)

  Abstract:

  背景与目的 真性脾动脉瘤结肠瘘是一类罕见且凶险的疾病，笔者报告1例特殊的真性脾动脉瘤结肠瘘患者的诊治过程，以期提高对该病的认识和诊治水平。方法 对1例真性脾动脉瘤结肠瘘患者的临床表现、影像学特点、介入治疗及腹腔镜手术治疗过程及预后进行回顾性分析，并结合国内外文献，总结真性脾动脉瘤结肠瘘的临床和影像学特点、诊断及治疗方法。结果 2020年10月31日北京大学第一医院急诊科收治了1例首发症状为暗红色血便的40岁女性患者，通过腹盆部增强CT、肠镜和脾动脉造影检查发现患者真性脾动脉瘤破裂至结肠脾曲导致下消化道出血，经介入下弹簧圈栓塞治疗后康复出院，出院后无再发便血等不适。2023年8月7日患者排便时从肛门排出金属丝，自行剪断后出现左上腹痛，再次就诊于我院急诊科，通过腹盆部平扫CT发现患者脾动脉瘤栓塞所用的一部分弹簧圈钢丝经脾动脉瘤结肠瘘进入结肠并从肛门脱出，于2023年8月14日行全麻腹腔镜探查+脾切除+脾动脉瘤切除+结肠部分切除+结肠异物取出术，手术过程顺利，术后病理符合真性脾动脉瘤诊断。出院后随访3个月，患者无腹痛便血等不适。真性脾动脉瘤结肠瘘经介入栓塞，腹腔镜手术切除后痊愈，检索国内外近30年文献未见报道。结论 真性脾动脉瘤结肠瘘尽早行增强CT或数字减影血管造影可明确诊断，对于血流动力学稳定患者首选腹腔镜手术切除，血流动力学不稳定患者可先介入弹簧圈栓塞动脉瘤，待血流动力学稳定后再评估腹腔镜手术，能获得较好的预后。

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• China Journal of General Surgery, 2024, 33(6):1023-1028.

  2024,33(6):1023-1028, DOI: 10.7659/j.issn.1005-6947.2024.06.019

  Abstract: (29) HTML (21) PDF (629.29 KKB)(129)

  Abstract:

  背景与目的 腹股沟疝手术是儿童常见的外科手术之一，单侧腹股沟疝手术后发生异时性对侧腹股沟疝（MCIH）的概率为2.4%~29.0%，因此一些外科医生建议将对侧未闭的鞘状突进行预防性修复，不仅避免嵌顿疝的发生，同时减少全身麻醉的风险以及二次住院的费用；但是有学者认为，需要4~21次不必要的手术才能预防1次对侧腹股沟疝的发生，这将存在过度医疗，同时增加术中睾丸和输精管相关副损伤的危险。因此，本研究主要探讨儿童单侧腹股沟疝术后发生MCIH的影响因素，为单侧腹股沟疝儿童术后MCIH的预防和干预提供依据。方法 回顾性分析2019年1月─2023年9月蚌埠医科大学第二附属医院普通外科102例儿童单侧腹股沟疝患者的临床资料。结果 102例儿童单侧腹股沟疝术后出现MCIH患者共14例（13.7%）。MCIH组和非MCIH组在首次发病年龄、是否为低体质量儿、是否为早产儿方面差异有统计学意义（均P<0.05）。ROC曲线分析结果显示，MCIH首发年龄的截断值为3.5岁。单因素与多因素Logistic回归分析显示，首次发病年龄≤3岁（OR=10.382，95% CI=1.591~67.736，P=0.014）及出生时低体质量（OR=16.480，95% CI=2.714~100.056，P=0.002）是发生MCIH的独立危险因素。结论 首次发病年龄≤3岁及出生时低体质量是儿童单侧腹股沟疝术后MCIH发病的独立危险因素。对于首次发病年龄≤3岁及出生时低体质量，手术方式应选用腹腔镜疝囊高位结扎术以观察对侧是否存在鞘状突未闭，对于未闭的鞘状突进行预防性的结扎，预防MCIH的发生。

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  HERNIA AND ABDOMINAL WALL SURGERY

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  GUIDELINE AND CONSENSUS

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  BARIATRIC METABOLIC SURGERY