Chun-Che Shih

Reduced number and impaired function of circulating endothelial progenitor cells in patients with abdominal aortic aneurysm

AIMnCirculating endothelial progenitor cells (EPCs) are associated with coronary artery disease (CAD) and predict its outcome. Although the pathophysiology of abdominal aortic aneurysm (AAA) is different, it shares some risk factors with CAD. Therefore, the correlation between EPCs and AAA was investigated.nnnMETHODS AND RESULTSnSeventy-eight subjects (age 77.2 ± 7.8 years) with suspected AAA were prospectively enrolled. Cut-off values (men, 3.5-5.5 cm; women, 3-5 cm) were used to define normal aorta, small AAA, and large AAA on thoraco-abdominal computer tomography. Endothelial function was measured by flow-mediated vasodilation (FMD). Flow cytometry and colony-forming units (CFUs) were used to evaluate circulating EPC numbers. Circulating EPCs were defined as mononuclear cells with low CD45 staining and double-positive staining for KDR, CD34, or CD133. Late out-growth EPCs were cultured from six patients with large AAAs and six age- and sex-matched controls to evaluate proliferation, adhesion, migration, tube formation, and senescence. FMD was significantly lower with large (5.26% ± 3.11%) and small AAAs (6.31% ± 3.66%) than in controls (8.88% ± 4.83%, P=0.008). Both CFUs (normal 38.39 ± 12.99, small AAA 21.22 ± 7.14, large AAA 6.98 ± 1.97; P=0.026) and circulating EPCs (CD34(+)/KDR(+) and CD133(+)/KDR(+)) were significantly fewer in AAA patients than in controls. On multivariate analysis, CFUs and circulating EPCs (CD34(+)/KDR(+)) were independently, inversely correlated to AAA diameter. Proliferation, adhesion, migration, tube formation, and senescence of late EPCs were significantly impaired in AAA patients.nnnCONCLUSIONnThe number and function of EPCs were impaired in AAA patients, suggesting their potential role in AAA.

Malignancy After Heart Transplantation

Background: The purpose of this study was to assess the incidence and type of malignancies after heart transplantation at a medical institute in Taiwan. Methods: From January 1987 to December 2008, a total of 66 patients who survived more than 30 days after transplantation were enrolled in this study. Results: Of the 66 heart transplant recipients, 8 (12.1%) post‐transplant malignancies were diagnosed: 5 post‐ transplant lymphoproliferative diseases (PTLD), 1 prostate cancer, 1 lung cancer, and 1 squamous cell carcinoma of the cheek. The clinical presentations were diverse, and the diagnoses were confirmed by biopsy. Only 1 patient died of PTLD and subsequent multiple organ failure. Conclusion: Cancer is a limiting factor for long‐term survival after heart transplantation. The most common type in this study was PTLD. Early detection and aggressive treatment results in good response and preserves the allograft.

Implantation sequence modification averts distal stent graft-induced new entry after endovascular repair of Stanford type B aortic dissection

OBJECTIVEnThis study investigated predisposing factors of distal stent graft-induced new entry (SINE).nnnMETHODSnData from November 2006 to May 2012 were abstracted retrospectively from the records of 73 patients with complicated type B aortic dissection who had received stent graft treatment in our institution. Diameters of the true and false lumen, area and circumference of the true lumen, prestent and poststent oversize, taper, and mismatch ratio were recorded and analyzed to see if there were any significant differences between the SINE (nxa0= 19) and non-SINE (nxa0= 54) population and between those in whom the initial endograft was inserted from the proximal thoracic aorta (nxa0= 49) or the distal thoracic aorta (nxa0= 24).nnnRESULTSnA distal-first sequence of stent graft deployment produced significantly fewer instances of distal SINE. The area oversizing ratio of the distal end of the stent graft was greater in the SINE vs non-SINE groups (3.76xa0± 1.7 vs 2.63xa0± 2.57; Pxa0= .002) and in the proximal-first vs distal-first deployment sequence groups (3.67xa0± 2.57 vs 1.39xa0± 0.90; Pxa0<xa0.001).nnnCONCLUSIONSnMinimizing the preprocedure distal oversizing ratio with a distal small graft-first procedure could reduce the risk of late distal SINE for Stanford type B aortic dissection. Furthermore, the area ratio is a potentially more sensitive modality for size assessment and prediction of distal SINE occurrence.

The Impact of Distal Stent Graft–Induced New Entry on Aortic Remodeling of Chronic Type B Dissection

BACKGROUNDnIn chronic type B aortic dissection, late distal stent graft-induced new entry (SINE) has a possible negative role in long-term aortic remodeling. This study aimed to investigate the impact of SINE occurrence on survival by evaluating true and false lumen remodeling in thoracic and abdominal segments at midterm surveillance.nnnMETHODSnThis study enrolled 65 patients with chronic type B aortic dissection (DeBakey type IIIb), who had received hybrid thoracic endovascular aortic repair (TEVAR) and had completed surveillance for at least 3 years. The 3-year survival rate was 84.7%. The patients were classified into non-SINE (nxa0= 47) and SINE (nxa0= 18) groups. Serial computed tomography scans were used to analyze volumetric change, true and false lumens, and thrombus volume from arch to aortic bifurcation level.nnnRESULTSnThe SINE event occurred at a median of 22.5 months. In the SINE group, there was a significant interruption of the abdominal true lumen expansion in the second year (median 0.01 [interquartile range (IQR), -0.03 to 0.12] in the non-SINE group versus median -0.04 [IQR, -0.12 to 0.04] in the SINE group; pxa0= 0.014). There was a significantly worse thoracic false lumen remodeling in the SINE group compared with the non-SINE group in the third year after the SINE event occurred (median 0 [IQR, -0.09 to 0.05] in the non-SINE group versus median 0.06 [IQR, 0 to 0.13] in the SINE group; pxa0= 0.038).nnnCONCLUSIONSnFor chronic aortic dissection, late occurrence of distal SINE could influence abdominal true lumen expansion and thoracic false lumen shrinkage. Early reintervention for distal SINE could improve aortic remodeling in chronic aortic dissection.

Initial experience with percutaneous edge-to-edge transcatheter mitral valve repair in a tertiary medical center in Taiwan

Background: The transcatheter edge‐to‐edge mitral valve repair, using MitraClip, has been a safe and effective treatment for severe mitral regurgitation (SMR) in the westerners. However, the therapeutic results of the MitralClip in Taiwan remained elucidated. Methods: Patients with symptomatic SMR were evaluated by the heart team. For those with high or prohibitive surgical risks, transcatheter mitral valve repair was performed in hybrid operation room. During procedure, continuous hemodynamic monitoring was conducted. Transthoracic echocardiography (TTE), blood tests, and six‐minute walk test (6MWT) were performed before and 1‐month after surgery. Results: A total of 20 patients (73.4 ± 11.1 years, 85% male) with a mean Euroscore II of 13.2 ± 17.7% and a mean STS score of 8.7 ± 9.0% for mortality were enrolled. After a mean procedural time of 239 ± 95 min, an average of 1.8 ± 0.7 clips were used in each procedure. The procedural successful rate was 95% to achieve mild residual mitral regurgitation. Cardiac output was increased from 3.6 ± 0.9 to 4.6 ± 1.4 (p = 0.008) and V‐wave of left atrial pressure declined from 24.4 ± 9.8 to 19.3 ± 7.1 (p = 0.030) immediately during the index procedure. There was no peri‐procedural death, myocardial infarction, stroke or any events requiring emergent cardiac surgery. All patients experienced significant improvement in heart failure symptoms. The 6‐min walk distance increased from 219.6 ± 118.4 m to 279.1 ± 111.6 (p = 0.04) at 1 month. The echocardiogram further showed significant improvements of mitral regurgitation, pulmonary artery systolic pressure, and the left ventricular end‐diastolic volume. Conclusion: Trans‐catheter edge‐to‐edge mitral valve repairs are safe and effective in Asians with symptomatic SMR, regarding the improvements of clinical symptoms and exercise capacities. MitraClips is also associated with reverse remodeling of pulmonary hypertension and left ventricular size in patients with SMR.

Factors Affecting Optimal Aortic Remodeling After Thoracic Endovascular Aortic Repair of Type B (IIIb) Aortic Dissection

PurposeThe purpose of this study was to determine factors associated with entire aortic remodeling after thoracic endovascular aortic repair (TEVAR) in patients with type B dissection.Materials and MethodsThe patients with type B (IIIb) dissections who underwent TEVAR from 2006 to 2013 with minimum of 2xa0years of follow-up computed tomography data were retrospectively reviewed. Based on the status of false lumen remodeling of entire aorta, patients were divided into three groups: complete regression, total thrombosis, and inadequate regression with patent abdominal false lumen.ResultsA total of 90 patients (72 males, 18 females; mean age 56.6xa0±xa016.4xa0years) were included and divided into the complete regression (nxa0=xa022), total thrombosis (nxa0=xa018), and inadequate regression (nxa0=xa050) groups. Multivariate logistic regression analysis indicated that dissection extension to iliac arteries, increased preoperative number of dissection tear over abdominal aorta, and decreased preoperative abdominal aorta bifurcation true lumen ratio, as compared between the inadequate and complete regression groups, were associated with a persistent false lumen (odds ratioxa0=xa033.33, 2.304, and 0.021; all, pxa0≤xa00.012). Comparison of 6, 12, and 24xa0months postoperative data revealed no significant differences at any level, suggesting that the true lumen area ratio might not change after 6xa0months postoperatively.ConclusionsIncreased preoperative numbers of dissection tear around the abdominal visceral branches, dissection extension to the iliac arteries, and decreased preoperative true lumen area ratio of abdominal aorta are predictive of entire aortic remodeling after TEVAR in patients with type B dissection.Level of EvidenceIII.

The Impact of Aortic Tortuosity on Delayed Type I or III Endoleak after Endovascular Aortic Repair

BACKGROUNDnEndovascular aneurysm repair (EVAR) becomes the treatment of choice for patients with abdominal aortic aneurysm (AAA). Type I or III endoleak is related to high risk of rupture and reintervention, but little is known about the delayed presentation of these. We sought to evaluate the delayed type I or III endoleak after EVAR and assess the early morphological portending factors.nnnMETHODSnWe retrospectively reviewed a database of 249 patients who underwent endovascular repair with a Zenith AAA stent graft (Cook Medical, Bloomington, IN) in a single institute from October 2005 to December 2013. Age, aneurysm size, angulation, tortuosity index (TI), and follow-up evaluations were recorded and analyzed. Patients having <1xa0year of follow-up were excluded.nnnRESULTSnOne hundred eighteen patients were included in this study. There was no delayed type Ia endoleak. Ten patients (9.3%) were found to have a delayed type Ib or III endoleak. The mean diagnosis time was 49.1xa0months (range, 22-91xa0months) after EVAR. All of them were treated with endovascular repair except one had combined open revision. Three of the patients (30%) with delayed endoleaks presented with a ruptured aneurysm, and two of them (20%) died after reintervention. Postoperative TI was found to be the most significant morphological factor associated with increased risk of type Ib or III endoleak.nnnCONCLUSIONSnDelayed type Ib or III endoleak was not rare in our study population and was found to have a high risk of rupture and mortality. Aneurysm tortuosity is associated with increased risk of endoleaks, and postoperative TI can be an indicator in the early period of follow-up.

Edge Stenosis After Covered Stenting for Long Superficial Femoral Artery Occlusive Disease: Risk Factor Analysis and Prevention With Drug-Coated Balloon Angioplasty:

Purpose: To report a retrospective analysis of risk factors for edge restenosis after Viabahn stent-graft treatment of superficial femoral artery (SFA) occlusive disease and determine any protective effect of drug-coated balloons (DCBs) used at the time of stent-graft implantation. Methods: Between October 2011 and July 2016, 110 patients (mean age 73.3±7.6 years; 78 men) were treated with the Viabahn stent-graft for long SFA occlusions. Thirty-eight (34.5%) patients had DCB reinforcement at the distal edge of the stent-graft. For analysis, the population was divided into groups of no edge stenosis patients (n=88; mean lesion length 22.4±4.2 cm) and edge stenosis patients (n=22; mean lesion length 23.5±5.7 cm). The clinical outcomes, ankle-brachial indices, computed tomography angiography findings, and patency were compared at a minimum of 12 months. Logistic regression analysis was employed to determine risk factors for edge stenosis; the results are presented as the odds ratio (OR) and 95% confidence interval. Results: No differences in clinical or procedural characteristics were identified except the higher incidence of diabetes (p=0.008) and greater need for retrograde access (p=0.033) in the edge stenosis group. DCB reinforcement reduced the incidence of edge stenosis (p=0.021) and target lesion revascularization (TLR; p=0.010) and resulted in a significantly higher 1-year primary patency rate (92.1% vs 76.4%, p=0.042). However, multivariate analysis revealed only poor distal runoff (OR 0.31, 95% CI 0.11 to 0.83, p=0.020) as a predictor of edge stenosis. Conclusion: The risk of edge stenosis after Viabahn implantation was higher in patients with poor distal runoff. DCB reinforcement over the distal edge reduced edge stenosis, decreased 1-year TLR, and improved 1-year primary patency.

Establishing stable innominate access by inserting a body floss wire from the brachial artery to the femoral artery facilitates right carotid artery stenting in Type III arch anatomy

OBJECTIVESnIn patients with severe carotid artery stenosis, the anatomy of their Type III aortic arch increases the difficulty and complication rates during carotid artery stenting because of its tortuosity and sharp angulation for cannulation as well as the unstable support of the guidewire for shuttle sheath delivery.nnnMETHODSnWe demonstrate a novel technique to overcome these challenges, namely the creation of stable innominate artery access by inserting a through-and-through body floss wire from the right brachial artery to the femoral artery.nnnRESULTSnWe successfully performed right carotid artery stenting in 3 patients with Type III arch anatomy. All patients received regular outpatient follow-up uneventfully for more than 1u2009year.nnnCONCLUSIONSnThis facilitates the procedure of the right carotid artery stenting in patients with Type III aortic arch.

Endovascular stenting for end-stage lung cancer patients with superior vena cava syndrome post first-line treatments – A single-center experience and literature review

Background Superior vena cava (SVC) syndrome is a major complication that occurs when a growing lung malignancy compresses the SVC extrinsically. Current treatment options include radiotherapy or chemotherapy to shrink the tumor or endovascular stenting of the SVC to restore flow. Herein, we report a case series treated in a single institution to demonstrate the safety, effectiveness, and outcomes of salvage and primary stenting for malignant SVC obstruction. Methods A total of 12 male patients with malignant superior vena cava obstruction caused by lung cancer underwent SVC stenting from October 2009 to May 2015. Data were reviewed retrospectively, including demographic and clinical characteristics, procedural details, and outcomes. Results Seven patients had received radiotherapy prior to SVC stenting, while the other five patients received stenting as first‐line therapy for SVC syndrome. Only one patient experienced initial symptomatic improvement after radiotherapy, and symptoms of SVC syndrome recurred one year later. Wallstents® (Boston Scientific, Natick MA, USA) were used in all patients. Preoperatively, the mean narrowest SVC diameter measured by CT was 2.16 mm (0–5.5 mm). Technical success was achieved in all patients without complications such as pulmonary embolism, rupture or bleeding. Postoperative mean narrowest SVC diameter measured by CT during follow‐up was 11.17 mm (8–13.5 mm). Symptoms of SVC syndrome such as arm and face swelling and dyspnea improved within 1–5 days in all patients. After median follow‐up duration of 11.5 months, only one patient presented recurrent SVC syndrome due to in‐stent thrombosis two months after stenting. Conclusion Salvage SVC stenting remains a safe and effective treatment for patients with SVC obstruction after failure of radiotherapy and chemotherapy. Primary stenting may be considered at initial presentation of SVC syndrome to improve patients’ quality of life.