Hengxi Yu

Endovascular Stenting vs. Extrathoracic Surgical Bypass for Symptomatic Subclavian Steal Syndrome

Purpose To analyze the immediate and long-term outcomes of endovascular stenting vs. extrathoracic surgical bypass for subclavian steal syndrome. Methods From 1989 to 2010, 252 consecutive patients (173 men; mean age 62 years) with vertebrobasilar and upper extremity symptoms of subclavian steal were treated with balloon-expandable stents (n = 148) or extrathoracic surgical bypasses (n = 104: 71 axilloaxillary and 33 carotid-subclavian) using polytetrafluoroethylene grafts. Results The technical success rate was 97.3% in the stent group vs. 99.0% for the bypass group (p=0.605). There was no perioperative mortality or any permanent neurological deficit in either group. The overall perioperative complication rate was 6.1% in the stent group vs. 9.6% in the bypass group (p=0.295). The 10-year target vessel revascularization rate was 46.6% for stenting vs. 5.8% for bypass (p<0.001). The cumulative primary patency rates at 1, 3, 5, and 10 years were 91%, 78%, 67%, and 49% for the stent group vs. 99%, 97%, 95%, and 89% for the bypass group (p<0.001). The cumulative secondary patency rates were 95%, 91%, 86%, and 64%, respectively, for the stent group vs. 99%, 99%, 98%, and 94% for the bypass group (p=0.001). No difference was detected in overall survival curves between the groups (p=0.527). Conclusion Both endovascular stenting and extrathoracic surgical bypass are safe and effective treatments for subclavian steal syndrome in the short and medium term; however, extrathoracic surgical bypasses are more durable in the long term.

Drug-eluting vs. bare metal stents for symptomatic vertebral artery stenosis.

Purpose To evaluate the immediate and long-term outcomes of drug-eluting stent (DES) vs. bare metal stent (BMS) for symptomatic vertebral artery stenosis (VAS). Methods From 2003 to 2010, 206 consecutive patients (158 men; mean age 66.8 years) underwent DES (sirolimus-eluting or paclitaxel-eluting) or BMS placement for symptomatic extracranial and intracranial stenoses in 219 vertebral arteries. The technical success, clinical success, periprocedural complications, target vessel revascularization (TVR), and overall survival were compared between the DES and BMS groups. Results The technical success rate was 98.3% (119/121) for the DES group vs. 100% for the BMS group (p=0.503). The clinical success rate was 95.5% (107/112) for the DES group vs. 97.9% (92/94) for the BMS group (p=0.592). No periprocedural death or stroke occurred. The overall periprocedural complication rate was 2.7% (3/112) in the DES group vs. 4.3% (4/94) in BMS group (p=0.813). The median follow-up was 43 months (range 3–95) for the DES group and 46 months (range 6–89) for BMS. At last follow-up, the TVR rate was 6.3% (7/112) for the DES group vs. 20.2% (19/94) for the BMS group (p=0.003); 4 (3.6%) patients in the DES group and 8 (8.5%) patients in the BMS group experienced a VBS stroke (p=0.132). By life-table analysis, the 5-year TVR rate was 4.5% (5/112) for the DES group vs. 19.1% (18/94) for the BMS group (p=0.001). No difference was detected in the overall survival curves between the groups (p=0.500). Conclusion Both DES and BMS are feasible, safe, and effective for symptomatic VAS. However, DES can significantly decrease the TVR rate in the long term compared with BMS.

Angioplasty for pediatric renovascular hypertension: a 13-year experience.

PURPOSE We aimed to evaluate the long-term outcome and efficacy of percutaneous transluminal renal angioplasty (PTRA) for pediatric renal artery stenosis (RAS), which is an important cause of medication-refractory pediatric hypertension. MATERIALS AND METHODS We retrospectively evaluated 22 hypertensive children (age range, 3-17 years) who underwent PTRA from February 2000 to July 2012. Sixteen patients had Takayasu arteritis and six fibromuscular dysplasia. Five were not included in the statistical analysis due to loss to follow-up. RESULTS Technical success was achieved in 32 of 34 procedures (94.1%). The stenosis rate decreased from 84.5% before PTRA to 20.1% after PTRA. Treatment was effective in 72.7% (16/22) of patients, including complete cure in 27.3% (6/22) and improvement in 45.5% (10/22). Systolic and diastolic blood pressures decreased from 153 ± 19.1 to 131.7 ± 21.4 mmHg and from 97.9 ± 14.2 to 83.6 ± 19.3 mmHg, respectively (P <0.01). Number of antihypertensive agents decreased from 2.7 to 0.5 per patient. Restenosis was detected in 40.9% (9/22) of patients, with a restenotic interval of 11.8 months (range, 3-47 months). Lesion length was strongly correlated with clinical success (cure and improvement) (independent-sample t test, P <0.001; binary logistic regression, P = 0.040). CONCLUSION Lesion length is an important determination of clinical success with PTRA for pediatric RAS. PTRA is an appropriate treatment option for pediatric renovascular hypertension due to Takayasu arteritis and fibromuscular dysplasia.

Endovascular Revascularization for Carotid Artery Occlusion in Patients with Takayasu Arteritis

OBJECTIVES Type I Takayasu arteritis is a progressive inflammatory disease involving the aortic arch and its main branches. If untreated, patients may develop a variety of serious conditions ranging from hemiplegia to death. Whilst there is a relatively strong evidence base for the outcome of surgical techniques, few reports have focused on revascularization using an endovascular technique in patients with Takayasu arteritis. METHODS From May 2007 to March 2013, 11 consecutive patients with Takayasu arteritis presenting with severe cerebral ischemia symptoms caused by occlusive lesion in carotid artery underwent elective revascularization, 10 on the left carotid artery and 1 on the right. All patients received immunosuppressive treatment pre-and post-operation. Contraindications to open surgery included: ESR >40 mm/h; ipsilateral cerebral infarction of <2 weeks duration and sufficient poor health whereby the patient cannot tolerate general anesthesia. Quality of life was analyzed using the EQ-5D questionnaire before and after surgery. RESULTS Patients were followed for a mean of 31.6±27.4 months. Seven cases of total occlusion and 2 cases of severe stenosis were recanalized successfully and experienced clinical remission. Recanalization failed in 2 patients, both of whom had occlusion of a long segment of the artery. Initial endovascularization comprised small diameter, low pressure dilatation only to allow time for the reopened arteries to respond. If clinically indicated, repeat angioplasty with a larger diameter balloon was performed 1-3 months later. Major complications occurred in 2 patients. Eight of the recanalized carotid arteries were patent at the end of follow-up and patients had satisfactory quality of life CONCLUSIONS In patients with Takayasu arteritis, carotid artery recanalization via endovascular surgery combined with immunosuppressive therapy is effective and can be performed safely and repeatedly. The improvement in carotid artery blood flow supplying the central nervous system relieves symptoms of cerebral ischemia and is associated with an improved quality of life.

A rare case of giant popliteal artery aneurysm in a young adult

Popliteal artery aneurysms (PAAs) are rare in the general population, but are the most common peripheral aneurysms. PAAs are often bilateral and are associated with abdominal aortic aneurysms. They usually affect older men with established cardiovascular disease caused by atherosclerosis. Whenever they occur in younger men, other more unusual etiologies such as trauma, mycotic aneurysm, inflammatory arteritis or popliteal entrapment are responsible. The authors report a rare case of giant congenital PAA, revealed by acute limb ischemia in a 23-year-old patient. The evolution after resection of the popliteal aneurysm and end-to-end anastomosis with synthetic graft was favorable.

A new self-convertible inferior vena cava filter: experimental in-vitro and in-vivo evaluation.

PURPOSE To evaluate using in-vitro and in-vivo models the feasibility and capture efficiency of a new self-convertible inferior vena cava filter (SCF), equipped with a biodegradable self-converting switch. MATERIALS AND METHODS Capture rates were tested in an in-vitro flow model for simulated supine and upright positions with clot diameters of 3 mm and 5 mm and tube diameters of 22 mm, 25 mm, and 28 mm. In the in-vivo study, five filters were implanted in five adult dogs. Venography was performed after the procedure every 2 weeks until filter conversion. RESULTS All filters were successfully implanted and completely converted with a mean trapping efficiency of 75.5% in the in-vivo study. The SCF was most efficient at 92% in the upright orientation with 5-mm clots and a 22-mm caval diameter. All five filters exhibited successful delivery and conversion in vitro. The SCFs were manually manufactured without barbs or hooks, and because of this feature, migration occurred. CONCLUSIONS The SCF is feasible and highly efficient and converts itself successfully. Evaluation is planned of future prototypes with appropriate modifications for risk of migration of the filter.

Management of Complex Patients with Budd–Chiari Syndrome

Therapy for patients with Budd-Chiari syndrome is well established. For those with commonly seen localized lesions, percutaneous transluminal angioplasty or stenting is the first-line treatment. Treatment methods for severely ill patients in whom intervention has failed, or those in a poor general condition, are worth exploring. From February 2002 to July 2008, 31 patients were referred to us. Eighteen patients had a failed intervention, 4 had undergone surgery, and 10 had conservative therapy. All had intractable ascites or/and hematemesis. The procedures carried out in this series included mesocavoatrial shunt in 10 patients, radical correction in 9, mesocavojugular shunt in 7 (including 2 mesojugular shunts), mesocaval shunt in 2, cavoatrial shunt in 2 (including a revision of cavoatrial shunt), and cavojugular shunt in 1. Surgical mortality and postoperative complications were both 3.2%. Twenty-eight patients had a mean follow-up of 40 months. Outcome of follow-up was measured as excellent, good, fair, poor, and death (28.6%, 53.6%, 10.7%, 3.6%, and 3.6%, respectively). The total mortality of the group is 6.5%. After appropriate preoperative evaluation and preparation, active and cautious treatment individualized to the underlying disease may help severely ill patients with Budd-Chiari syndrome.

Simultaneous Kissing Stent Technique with Stent Grafts for Subclavian Artery Aneurysm: A Case Report

Treatment of subclavian artery aneurysm is typically performed as an open procedure. In recent years, the use of an endovascular approach has been reported. We experienced a case of subclavian artery aneurysm treated by simultaneous kissing stent technique. With fewer complications, this is a promising technique.

Aortobilateral Axillary Bypass to Treat Severe Cerebral Ischemia Due to Takayasu's Arteritis

Cerebral ischemia resulting from four cervical arterial occlusions due to Takayasus arteritis is a rare condition. Ascending aortounilateral/-bilateral internal carotid arterial bypass is a means for relieving it. However, postoperative reperfusion syndrome remains an unsolved severe, even fatal complication. The following case report reveals new findings. The patient presented massive cerebral infarction in the left cerebral hemisphere, four cervical arterial lesions, and bilateral subclavian steal syndrome. An ascending aorta to bilateral axillary bypass resumed the vertebral blood flow, and as a result the patient had a marvelous improvement. Unlike ascending aorta-carotid bypass, which directly increases brain perfusion, our procedure does so indirectly via axillary arteries. Therefore, there is strong reason to recommend ascending aorta to biaxillary bypass for patients with cerebral ischemia due to four cervical arterial lesions accompanying a bilateral subclavian steal phenomenon that has reversed vertebral flow.

A comparative study of percutaneous atherectomy for femoropopliteal arterial occlusive disease

BACKGROUND SilverHawk™ directional atherectomy has been used to treat more than 300 thousand cases of lower extremity atherosclerotic occlusive disease in the world since it was approved by FDA in 2003. This study aimed to analyze the safety and effectiveness of symptomatic femoral popliteal atherosclerotic disease treated by directional atherectomy (DA). METHODS Clinical data of all consecutive patients treated with percutaneous atherectomy utilizing the SilverHawk™ plaque excision was retrospectively analyzed. The anatomic criteria of the atherosclerotic lesions were divided into four types: type I stenosis; type II occlusion; type III in-stent restenosis; type IV stent occlusion. RESULTS There were 160 patients treated during the study period. Intermittent claudication in 75 patients (47%), rest pain in 55 patients (34.5%) and tissue loss in 30 patients (18.5%). The number of patients was 72, 15, 49 and 24 in type I, II, III and IV lesions, respectively. Technical success rate was 98.6%, 93.3%, 97.9% and 91.7% in type I, II, III and IV lesions, respectively. Debris of intimal plaque was captured by protection device in 92 patients (71.3%). The mean follow-up period was 23.5±10.4 months. Restenosis rate of type I to IV lesions was 21%, 36%, 36% and 40% respectively. Restenosis rate in type I lesion was significantly lower than that in type III and IV lesions (P<0.05). Patients with tissue loss responded to revascularization as follow: type I, 11/13 healed or reduced (84.6%), type II, 3/3 patients improved (100%), type III, 5/6 patients improved (83.3%) and type IV 4/4 healed (100%). In type IV group, four patients had in-stent thrombosis found by postoperative Duplex ultrasonography. They all underwent DA after catheter-directed thrombolysis with good angiographic results. CONCLUSIONS Percutaneous DA is safe and effective for both de-novo atherosclerotic and in-stent stenotic or occlusive lesions. Thrombolysis before plaque excision is recommended in case of in-stenting thrombosis.