Using a Surgeon-modified Iliac Branch Device to Preserve the Internal Iliac Artery during Endovascular Aneurysm Repair: Single-center Experiences and Early Results

Background:

To evaluate the feasibility of a new surgeon-modified iliac branch device (IBD) technique to maintain pelvic perfusion in the management of common iliac artery (CIA) aneurysm during endovascular aneurysm repair (EVAR).

Methods:

From January 2011 to December 2013, a new surgeon-modified IBD technique was performed in department of vascular surgery of Peking Union Medical College Hospital in five patients treated for CIA aneurysm with or without abdominal aortic aneurysm. A stent-graft limb was initially deployed in vitro, anastomosed with vascular graft, creating a modified IBD reloaded into a larger sheath, with or without a guidewire preloaded into the side branch. The reloaded IBD was then placed in the iliac artery, with a covered stent bridging internal iliac artery and the branch. Finally, a bifurcated stent-graft was deployed, and a limb device was used to connect the main body and IBD.

Results:

Technical successes were obtained in all patients. The mean follow-up length was 24 months (range: 6–38 months). All grafts remained patent without any sign of endoleaks. There were no aneurysm ruptures, deaths, or other complications related to pelvic flow.

Conclusions:

Using the surgeon-modified IBD to preserve pelvic flow is a feasible endovascular technique and an appealing solution for personalized treatment of CIA aneurysm during EVAR.     

A coil placement technique to treat intracranial aneurysm with incorporated artery

Background

Endovascular coil embolization is an accepted treatment option for intracranial aneurysms. However, the coiling of aneurysms with an incorporated artery (IA) poses a high risk of IA occlusion. Here we report our experience of endovascular coil placement using a technique that avoids IA occlusion in aneurysms with IAs.

Multidetector CT Evaluation in Arterial Stenting

Background

Multidetector CT (MDCT) represents breakthrough in CT technology, significantly improving CT Angiography applications.

Methods

Twenty one patients with aortoiliac & branch aneurysms or stenosis were evaluated by Digital Subtraction Angiography (DSA) and Multidetector CT (MDCT) before and after endovascular repair.

Results

There were eight cases of aortic & branch aneurysms and 13 with stenosis. Four cases had aortic aneurysms, while one case had left subclavian artery aneurysm, thoracic aneurysm, femoral and popliteal artery pseudoaneurysms. Of the 13 cases with stenotic lesions, iliac stenosis was seen in eight patients. The others included carotid, vertebral, aortic, renal and aortic bifurcation stenotic. MDCT offered accurate information on shape and size of aneurysm, shape and patency of graft, the presence or absence of perigraft thrombosis or endoleaks, while in stenotic lesions it provided useful information on shape of graft, its location, its patency and the presence and quantity of distal flow.

Conclusion

MDCT was found to be a potentially useful modality during initial evaluation and follow up of patient undergoing endovascular repair.Key Words: Multidetector Computed Tomography, Endovascular stents, Arterial disease     

Contrast-enhanced Ultrasound in Detecting Endoleaks with Failed Computed Tomography Angiography Diagnosis after Endovascular Abdominal Aortic Aneurysm Repair

Background:

Endovascular aneurysm repair (EVAR) is one of the first-line therapies of abdominal aortic aneurysms. Postoperative endoleak is the most common complication of EVAR. Computed tomography angiography (CTA), which is routine for follow-up, has side effects (e.g., radiation) and also has a certain percentage of missed diagnosis. Preliminary studies on contrast-enhanced ultrasound (CEUS) have shown that the sensitivity of CEUS for detecting endoleak is no lower than that of CTA. To investigate the advantages of CEUS, we conducted CEUS examinations of post-EVAR cases in which CTA failed to detect endoleak or could not verify the type of endoleak.

Methods:

Post-EVAR patients, who were clinically considered to have endoleak and met the inclusion criteria were enrolled between March 2013 and November 2014. All of the patients underwent color Doppler flow imaging (CDFI) and a CEUS examination. Size, location, microbubble dispersion, and hemodynamic characteristics of leaks were recorded. Comparison between the diagnosis of CEUS and CDFI was conducted using Fisher''s exact test and clinical outcomes of all patients were followed up.

Results:

Sixteen patients were enrolled, and 12 (75%) had endoleaks with verified types by CEUS. Among 12 cases of endoleaks were positive by CEUS, 10 were CDFI-positive, and the four CEUS-negative cases were all negative by CDFI. The diagnostic values of CEUS and CDFI were statistically different (P = 0.008). Six patients with high-pressure endoleaks received endovascular re-intervention guided by CEUS results. One patient with type III endoleak had open surgery when endovascular repair failed.

Conclusions:

CEUS is a new, safe, and effective means for detection of endoleaks post-EVAR. This technique can be used as a supplement for routine CTA follow-up to provide more detailed information on endoleak and its category.     

大脑中动脉瘤的治疗策略(附111例病例分析)

目的探讨大脑中动脉瘤治疗方法的选择和疗效。方法回顾性分析2005年1月至2011年7月间手术夹闭和血管内介入治疗的111例114个大脑中动脉瘤。分析术前分级、动脉瘤大小、部位、治疗结果。结果手术夹闭88例患者90个动脉瘤,术后15 d～48个月(平均12.7个月)造影随访,夹闭动脉瘤89个,瘤颈残留1个,未见复发。血管内介入治疗23例24个动脉瘤。支架辅助栓塞7个,球囊辅助栓塞3个,单纯微弹簧圈栓塞12个,17个动脉瘤术后1～37个月(平均10.6个月)造影随访,5个(29.4%)复发;单纯支架治疗2个(未破裂夹层动脉瘤),术后3个月造影随访,1个动脉瘤消失,1个无变化。Glasgow预后评分5～4分中夹闭72例(81.8%),介入21例(91.3%)。结论窄颈(浆果样)大脑中动脉瘤,手术夹闭和介入栓塞均不易复发。复杂大脑中动脉瘤手术夹闭不易复发,介入栓塞相对容易复发。大脑中动脉瘤合并血肿(血肿量>30 mL),选择手术夹闭动脉瘤并清除血肿。介入栓塞和手术夹闭大脑中动脉瘤均能有效防止动脉瘤再出血。     

Percutaneous Balloon Angioplasty for Severe Native Aortic Coarctation in Young Infants Less Than 6 Months: Medium- to Long-term Follow-up

Background:

Although balloon angioplasty (BA) has been performed for more than 20 years, its use as a treatment for native coarctation of the aorta (CoA) during childhood, especially in young infants, remains controversial. This study aimed to assess the effects and potential role of percutaneous transcatheter BA for native CoA as an alternative therapy to surgical repair in young infants.

Methods:

The 37 patients aged from 6 days to 6 months with severe CoA in congestive heart failure or circulatory shock were admitted for BA. Patient''s weight ranged from 2.4 to 6.1 kg. All 37 patients were experiencing cardiac dysfunction, and eight patients were in cardiac shock with severe metabolic acidosis. Eleven patients had an isolated CoA, whereas the others had a CoA associated with other cardiac malformations. Cardiac catheterization and aortic angiography were performed under general anesthesia with intubation. Transfemoral arterial approaches were used for the BA. The size of the balloon ranged from 3 mm × 20 mm to 8 mm × 20 mm, and a coronary artery balloon catheter was preferred over a regular peripheral vascular balloon catheter.

Results:

The femoral artery was successfully punctured in all but one patient, with that patient undergoing a carotid artery puncture. The systolic peak pressure gradient (PG) across the coarctation was 41.0 ± 16.0 mmHg (range 13–76 mmHg). The mean diameter of the narrowest coarctation site was 1.7 ± 0.6 mm (range 0.5–2.8 mm). All patients had successful dilation; the PG significantly decreased to 13.0 ± 11.0 mmHg (range 0–40 mmHg), and the diameter of coarctation significantly improved to 3.8 ± 0.9 mm (range 2.5–5.3 mm). No intraoperative complications occurred for any patients. However, in one case that underwent a carotid artery puncture, a giant aneurysm formed at the puncture site and required surgical repair. The following observations were made during the follow-up period from 6-month to 7-year: (1) The PG across the coarctation measured by echocardiography further decreased or remained stable in 31 cases. The remaining six patients, whose PGs gradually increased, required a second dilation. No patient required further surgery because of a CoA; (2) in two cases, an aortic aneurysm was found with an angiogram performed immediately postdilatation and disappeared at 18 and 12 months of age, respectively; (3) tricuspid regurgitation and pulmonary hypertension improved in all patients; (4) all patients were doing well and were asymptomatic.

Conclusions:

Percutaneous BA is a relatively safe and effective treatment for severe native CoA in young infants, and should be considered a valid alternative to surgery because of its good outcome and less trauma and fewer complications than surgery.     

Evaluation of angiography as the sole imaging study for the proximal aortic neck prior to EVAR

Background

Angiographic assessment is an alternative to computerised tomography (CT) prior to endovascular aneurysm repair (EVAR). We evaluated angiography in aortic neck morphology assessment as an alternative investigation.

Methods

Patients admitted for elective or emergency EVAR were assessed by pre-operative CT and intra-operative angiography. The proximal and distal aortic neck diameters, and neck length were measured. Measurements were expressed as median (95% CI).

Results

35 patients (20 male) were assessed from August 2003 to January 2005 for elective (26) and emergency (9) EVAR. In the overall group, the proximal neck diameter was 22.0mm (21.0–23.0) on CT, and 20.7mm (19.3–22.3) on angiography. The distal neck diameter was 23.0mm (22.0–24.0) on CT, and 22.3mm (20.3–24.6) on angiography, while the neck length was only slightly greater on angiography [23.0mm (17.5–28.4)] relative to CT [23.0mm (20.0–28.0)]. The stent-grafts deployed were oversized by 26.8% (± 14.8%) relative to the CT measurements, and 33.7% (± 15.6%) relative to angiographic measurements. Good correlation was found for all three measurements between CT and angiography.

Conclusions

Angiography alone is inadequate for endovascular aneurysm repair. Although it has timesaving potential, the accuracy achieved is not sufficient to use alone.     

Endothelial Injury Preceding Intracranial Aneurysm Formation in Rabbits

Objective:

This study investigates the change of endothelial cell morphology and function at the rabbit basilar bifurcations in response to sustained high blood flow after bilateral common carotid artery ligation.

Methods:

Fifteen adult female New Zealand white rabbits were divided into experimental and sham control groups. The experimental group was subjected to bilateral common carotid artery ligation to increase the compensatory basilar artery flow. Basilar artery flow was monitored by transcranial Doppler after surgery. The endothelial cells at the arterial bifurcations were studied morphologically by electron microscopy and immunohistochemistry using β-catenin antibodies. Basilar artery flow increased significantly following common carotid artery ligation.

Results:

Early-stage basilar artery bifurcation aneurysms were present in all rabbits at three months after ligation. The endothelial cells changed from a fusiform to column shape at the basilar artery bifurcation. Gaps between endothelial cells of the experimental group appeared wider in the electron microscopic photographs compared with those of the control group. The expression of endothelial β-catenin at the arterial bifurcations also decreased.

Conclusion:

This study is the first to present endothelial cell changes of basilar artery bifurcation in response to sustained high blood flow in rabbits. Endothelial cell impairment possibly initiates aneurysm formation.     

Safety and Efficacy of a Novel Technique in the Use of Fractional Flow Reserve in Complex Coronary Artery Lesions

Background:

Fractional flow reserve (FFR) has become an increasingly important index when making decisions with respect to revascularization of coronary artery stenosis. However, the pressure guidewire used in obtaining FFR measurements is difficult to control and manipulate in certain complex coronary artery lesions, resulting in increased fluoroscopy time and contrast dye usage. This study examined a novel (NOV) technique for obtaining FFR measurements in hope of easing the difficulties associated with evaluating and treating complex coronary artery lesions.

Methods:

Fifty-six patients with complex coronary artery lesions were assigned to a conventional (CON) FFR technique group or a NOV FFR technique group. The NOV technique involved the use of a balloon and wire exchange within the coronary artery. The fluoroscopy time, contrast dye usage, and FFR-related complications were assessed after completing the FFR measurement procedure for each patient.

Results:

The median time required for fluoroscopy in the NOV technique group was significantly less than that in the CON technique group; additionally, lesser amounts of contrast dye were used in the NOV technique group (both P < 0.05). The NOV technique was successfully performed in thirty patients, without any FFR-related complications. However, the CON technique failed in three patients, including two who experienced coronary artery spasms (P > 0.05).

Conclusions:

Compared to the CON technique used for measuring FFR, the new technique reduced the fluoroscopy time and amount of contrast dye used when evaluating complex coronary artery lesions. The new technique did not increase the risk of operation or decrease the success rate.     

A Preliminary Study of the Therapeutic Role of Human Early Fetal Aorta-derived Endothelial Progenitor Cells in Inhibiting Carotid Artery Neointimal Hyperplasia

Background:

Endothelial cell damage is an important pathophysiological step of restenosis after angioplasty and stenting. Cell transplantation has great therapeutic potential for endothelial recovery. We investigated the effect of transplanting endothelial progenitor cells (EPCs) derived from human early fetal aortas in rat injured arteries.

Methods:

The carotid arterial endothelium of Sprague-Dawley rats was damaged by dilatation with a 1.5 F balloon catheter, and then EPCs derived from human early fetal aortas (<14 weeks) were injected into the lumen of the injured artery in transplanted rats, with an equal volume of normal saline injected into control rats. Rats were sacrificed at 2 and 4 weeks after treatment and transplanted cells were identified by immunohistochemical staining with anti-human CD31 and anti-human mitochondria antibodies. Arterial cross-sections were analyzed by pathology, immunohistochemistry, and morphometry.

Results:

Green fluorescence-labeled EPCs could be seen in the endovascular surface of balloon-injured vessels after transplantation. The intimal area and intimal/medial area ratio were significantly smaller in the transplanted group than in the control (P < 0.05) and the residual lumen area was larger (P < 0.05). After EPC transplantation, a complete vascular endothelial layer was formed, which was positive for human von Willebrand factor after immunohistochemical staining, and immunohistochemical staining revealed many CD31- and mitochondria-positive cells in the re-endothelialized endothelium with EPC transplantation but not control treatment.

Conclusion:

EPCs derived from human early fetal aorta were successfully transplanted into injured vessels and might inhibit neointimal hyperplasia after vascular injury.     

破裂椎动脉夹层动脉瘤早期介入栓塞治疗

目的:探讨破裂椎动脉夹层动脉瘤早期栓塞治疗方法及疗效。方法:22例破裂椎动脉夹层动脉瘤根据夹层动脉瘤形态以及与同侧小脑后下动脉(PICA)的关系,分别采用支架结合弹簧圈栓塞5例(其中2个以上支架叠加4例),单纯双支架治疗1例;弹簧圈闭塞近端椎动脉1例,动脉瘤及载瘤动脉闭塞15例。术后腰大池引流血性脑脊液,预防脑血管的痉挛。结果:本组22例患者中17例实施急诊手术(术中均未见出血和梗塞),5例限期手术;支架置入术6例,其中1例术后早期出现非动脉瘤性出血,但术后均恢复良好。单纯弹簧圈闭塞术16例,术后2例出现后组颅神经麻痹症状,1例高龄Ⅳ级患者放弃治疗出院。随访3个月-18个月,期间无再出血及脑梗塞发生,1例遗有后组颅神经麻痹症状;影像学随访14例,其中3例多支架结合弹簧圈栓塞治疗的载瘤动脉通畅、动脉瘤消失,11例动脉瘤及载瘤动脉闭塞的无再通,对侧椎动脉造影显示动脉瘤不显影。结论:破裂椎动脉夹层动脉瘤应尽早介入栓塞治疗。根据具体情况选择不同介入方法安全有效,双支架结合弹簧圈栓塞治疗方法应首先考虑。     

The Treatment of Mid-shaft Clavicle Fractures

Objective:

Through reviewing the relevant literature from the past decades, to summarize the assessment and management of fractures of the clavicle, and provide an overview of the clinical results of a range of treatment options.

Data Sources:

The data analyzed in this review are mainly from articles included in PubMed and EMBASE, published from 1960 to 2015.

Study Selection:

Studies involving assessment of fractures of the clavicle were reviewed. Further literatures were gathered regarding the conservative and surgical treatment of these fractures, including the methods of fixation and the surgical approaches used. Both conservative and surgical treatments were then compared and contrasted.

Results:

Through retrieving and reading the abstract, a total of 42 representative articles were selected, which covered all aspects of the conservative treatment and surgical treatment, and compared the advantages and disadvantages of different treatment options.

Conclusions:

Although the majority of recent data suggest that surgery may be more appropriate as it improves functional outcome and reduces the risk of complications, we recommend that the treatment should be individually assessed.     

Coronary anatomy,anatomic variations and anomalies: a retrospective coronary angiography study

INTRODUCTION

The incidence of coronary artery anomalies (CAAs) varies from 0.2% to 8.4%. Knowledge of such anatomical variations is important as coronary procedures are regularly performed these days. We aimed to find the coronary dominance pattern, intermediate artery (IMA) frequency and CAA incidence in our clinic, and compare them to those in the literature.

METHODS

The medical reports of 5,548 patients who had undergone coronary angiography (CAG) between 2005 and 2009 were retrospectively investigated. Dominance pattern and presence of IMA and CAA were recorded. CAAs were described using two different classifications: Angelini and Khatami’s classification, and a new modified classification that was derived from Angelini and Khatami’s classification. Some procedural details and clinical features of the patients with CAA were also investigated.

RESULTS

Coronary dominance pattern was: 81.6% right coronary artery, 12.2% circumflex artery and 6.2% co-dominant. IMA was present in 613 (11.0%) patients. The incidences of overall anomaly were 2.7% and 1.4%, according to the different classifications. Absent left main coronary artery, which was the most common anomaly in the present study, was found in 51 (0.9%) patients. Incidences of myocardial bridge, coronary arteriovenous fistulae and aneurysms were 1.1%, 0.2% and 0.3%, respectively.

CONCLUSION

CAAs are generally asymptomatic, isolated lesions. Some may lead to anginal symptoms, myocardial infarction or sudden death. We found that CAA was associated with increased radiation and contrast exposure in patients who underwent CAG. This risk could be reduced if appropriate catheters were designed and training programmes on ostial cannulation were developed.     

High-resolution Magnetic Resonance Imaging of Moyamoya Disease

Objective:

To introduce the imaging characteristics of moyamoya disease (MMD) using high-resolution magnetic resonance imaging (HR-MRI) and to discuss the role of HR-MRI in differentiating MMD from other intracranial artery diseases, especially intracranial atherosclerotic disease (ICAD).

Data Sources:

This review was based on the data in articles published between 2005 and 2015, which were obtained from PubMed. The keywords included HR-MRI, MMD, ICAD, and intracranial artery diseases.

Study Selection:

Articles related to HR-MRI for MMD or other intracranial artery diseases were selected for review.

Results:

There are differences between the characteristic patterns of HR-MRI in MMD and ICAD. MMD is associated with inward remodeling, smaller outer diameters, concentric occlusive lesions and homogeneous signal intensity, while ICAD is more likely to be associated with outward remodeling, normal outer diameters, eccentric occlusive lesions, and heterogeneous signal intensity. Other intracranial artery diseases, such as dissection and vasculitis, also have distinctive characteristics in HR-MRI. HR-MRI may become a useful tool for the differential diagnosis of MMD in the future.

Conclusions:

HR-MRI of MMD provides a more in-depth understanding of MMD, and it is helpful in evaluating pathological changes in the vessel wall and in differentiating MMD from other intracranial artery steno-occlusive diseases, particularly ICAD.     

Study of Relationship Between the Blood Supply of the Extrahepatic Bile Duct and Duct Supply Branches from Gastroduodenal Artery on Imaging and Anatomy

Background:Liver transplantation has become the treatment of choice for patients with end-stage acute or chronic hepatic disease.Bile duct complications are common events after liver transplantation.Th...     

Revisiting the Boyne procedure

Background

The technique involving the free grafting of the mandibular condyle with a vertical ramus osteotomy was described by Philip Boyne in 1987 along with a series of 15 cases where a patient presented with a markedly displaced fracture dislocation of the mandibular condyle.

Method

Twenty-one cases (25 condylar fractures) were treated with a modified Boyne technique.

Results

Results showed that we had a complication rate of 12% (8% resorption, 4% fracture of the plate).

Conclusion

The Boyne procedure should be thought of as a mainstream treatment method for the displaced fractured mandibular condyle.Key Words: Boyne procedure     

Evolution of mycotic aortic aneurysm treatment by endovascular repair

Introduction

Endovascular intervention for mycotic aortic aneurysms is now an alternative treatment option.

Case report

An 83-year-old male presented with confusion and pyrexia of unknown origin. Acute deterioration and subsequent computed tomography scan of the abdomen revealed a contained rupture of a mycotic aortic aneurysm for which the patient had a successful endovascular repair.

Conclusion

Endovascular management of aortic mycotic aneurysms provides an alternate and potentially safer method of intervention, particularly in patients deemed unsuitable for open repair.     

Clinical Relevance of Coronary Fractional Flow Reserve: Art-of-state

Objective:

The objective was to delineate the current knowledge of fractional flow reserve (FFR) in terms of definition, features, clinical applications, and pitfalls of measurement of FFR.

Data Sources:

We searched database for primary studies published in English. The database of National Library of Medicine (NLM), MEDLINE, and PubMed up to July 2014 was used to conduct a search using the keyword term “FFR”.

Study Selection:

The articles about the definition, features, clinical application, and pitfalls of measurement of FFR were identified, retrieved, and reviewed.

Results:

Coronary pressure-derived FFR rapidly assesses the hemodynamic significance of individual coronary artery lesions and can readily be performed in the catheterization laboratory. The use of FFR has been shown to effectively guide coronary revascularization procedures leading to improved patient outcomes.

Conclusions:

FFR is a valuable tool to determine the functional significance of coronary stenosis. It combines physiological and anatomical information, and can be followed immediately by percutaneous coronary intervention (PCI) if necessary. The technique of FFR measurement can be performed easily, rapidly, and safely in the catheterization laboratory. By systematic use of FFR in dubious stenosis and multi-vessel disease, PCI can be made an even more effective and better treatment than it is currently. The current clinical evidence for FFR should encourage cardiologists to use this tool in the catheterization laboratory.     

Open and Endovascular Treatment of Trans-Atlantic Inter-Society Consensus II D Aortoiliac Occlusive Lesions: What Determines the Rate of Restenosis?

Background:

Open surgery is the preferred approach for the treatment of type D lesions according to the Trans-Atlantic Inter-Society Consensus (TASC) II guideline, but endovascular solutions also appear to be a valid option in selected patients. The study aimed to identify the risk factors of restenosis after open and endovascular reconstruction of symptomatic TASC II D aortoiliac occlusive lesions (AIOLs).

Methods:

Fifty-six patients (82 limbs) who underwent open repair and endovascular treatment (ET) for symptomatic TASC ΙΙ D AIOLs between March 2005 and December 2012 were retrospectively reviewed. Baseline characteristics, preoperative and postoperative imaging, and operation procedure reports were reviewed and analyzed. Restenosis after revascularization was assessed by duplex ultrasound or computed tomography angiogram. Kaplan-Meier survival analysis, Log-rank test, and multivariate Cox regression were used to evaluate the relevance between risk factors and patency.

Results:

The mean duration of follow-up was 42.8 ± 23.5 months (ranging from 3 to 90 months). Primary patency rates at 1-, 3-, 5-, and 7-year were 93.6%, 89.3%, 87.0%, and 70.3%, respectively. Restenosis after revascularization occurred in 11 limbs. Kaplan-Meier survival analysis and the Log-rank test revealed that diabetes, Rutherford classification ≥5^th and concurrent femoropopliteal TASC II type C/D lesions were significantly related to the duration of primary patency. According to the result of Cox regression, diabetes and femoropopliteal TASC ΙΙ type C/D lesions were identified as the risk factors for restenosis after revascularization.

Conclusion:

This study demonstrated that diabetes and femoropopliteal TASC ΙΙ type C/D lesions are risk factors associated with restenosis after open and ET of TASC II D AIOLs.     

Bronchial Artery Embolization for Hemoptysis: A Retrospective Observational Study of 344 Patients

Background:Hemoptysis is a significant clinical entity with high morbidity and potential mortality.Both medical management (in terms of resuscitation and bronchoscopic interventions) and surgery have s...