Huihua Shi

Clinical Assessment of Endovascular Stenting Compared with Compression Therapy Alone in Post-thrombotic Patients with Iliofemoral Obstruction

OBJECTIVE The study aimed to evaluate the clinical results of stent placement in post-thrombotic patients with iliofemoral obstruction compared with results in those treated with elastic compression stockings (ECS). METHODS A retrospective analysis of post-thrombotic patients with iliofemoral obstruction was conducted in a single institution from January 2007 to December 2012. Duplex ultrasound and selective phlebography were performed in patients with chronic venous disease and previous deep venous thrombosis (DVT). Post-thrombotic syndrome (PTS) with iliofemoral vein obstruction (Villalta score ≥10) was diagnosed in 216 patients. Among these, 122 patients were treated by stent placement, and the remaining 94 patients were treated conservatively with 30-40 mmHg ECS therapy. Technical success, stent patency rates, and complications were recorded after the interventions. Results including Villalta score, pain, edema, ulcer, and popliteal vein reflux were assessed in both groups. RESULTS Percutaneous iliofemoral venous stenting was successful in 116 of 122 patients (95.1%) without major complications. Follow up periods ranged from 3 to 58 months (median 21 months). Cumulative primary, assisted primary, and secondary stent patency rates at 3 years were 68.9%, 79.0%, and 91.6%, respectively. Among patients with severe PTS, the Villalta score decreased significantly with endotreatment, compared to the score of those treated by ECS therapy (16.12 ± 4.91 vs. 10.98 ± 5.89, p < .01). However, there was no significant score improvement between the two therapies in patients with moderate PTS (6.59 ± 2.37 vs. 5.75 ± 3.03, p = .22). There was a significantly higher 24 month recurrence free ulcer healing rate in the endotreatment groups (86.6% vs. 70.6%, p < .01). Both edema and pain improved significantly in the two groups. The popliteal vein reflux rate showed no significant change after endotreatment. CONCLUSIONS Endovascular treatment is a safe, effective, and feasible method to correct the iliofemoral obstruction of PTS. Only post-thrombotic patients with severe PTS as assessed by the Villalta score appear to benefit from the endovascular treatment.

The Effect of Endovenous Laser Ablation of Incompetent Perforating Veins and the Great Saphenous Vein in Patients with Primary Venous Disease

OBJECTIVE/BACKGROUND This study aimed to investigate the clinical results and fate of incompetent perforating veins (IPVs) following treatment of superficial venous insufficiency, with or without endovenous laser ablation (EVLA) of IPVs. METHODS A retrospective analysis of patients with primary venous insufficiency (PVI) was conducted in a single institution from January, 2010 to December, 2011. IPVs were found in 311 patients (376 limbs). Among these, 132 patients (156 limbs) were treated with EVLA of IPVs and varicose vein surgery, and the remaining 179 patients (220 limbs) were treated with varicose vein surgery alone and served as controls. The fate of the IPVs, complications and clinical results were evaluated. RESULTS The technical success rate of EVLA of IPVs was 100%. There was no statistical difference in complications between the two groups. At 1 year follow up, 68 perforators were recanalized and still incompetent in the EVLA treated IPV group compared with 437 incompetent perforators in the untreated IPV group (18.7% vs. 92.6%; p < .001). A faster median ulcer healing time (1.40 months) was found in the EVLA treated IPV group (95% confidence interval [CI] 1.15-1.66 vs. 3.30 months [95% CI 2.50-4.10]; p = .001), even though no statistical difference in the 12 month ulcer healing rate was observed between the two groups (p = .584). There were no significant differences between the two groups for varicose vein recurrence rates or changes in the Venous Clinical Severity Score (VCSS). CONCLUSION EVLA was safe and effective in reducing the number of IPVs in PVI. However, the addition of IPV EVLA had no effect on ulcer healing rate, VCSS or varicose vein recurrence at 1 year follow up.

Glyoxalase-1 Overexpression Reverses Defective Proangiogenic Function of Diabetic Adipose-Derived Stem Cells in Streptozotocin-Induced Diabetic Mice Model of Critical Limb Ischemia

Adipose‐derived stem cell (ADSC)‐based therapy is promising for critical limb ischemia (CLI) treatment, especially in patients with diabetes. However, the therapeutic effects of diabetic ADSCs (D‐ADSCs) are impaired by the diabetes, possibly through intracellular reactive oxygen species (ROS) accumulation. The objective of the present study was to detect whether overexpression of methylglyoxal‐metabolizing enzyme glyoxalase‐1 (GLO1), which reduces ROS in D‐ADSCs, can restore their proangiogenic function in a streptozotocin‐induced diabetic mice model of CLI. GLO1 overexpression in D‐ADSCs (G‐D‐ADSCs) was achieved using the lentivirus method. G‐D‐ADSCs showed a significant decrease in intracellular ROS accumulation, increase in cell viability, and resistance to apoptosis under high‐glucose conditions compared with D‐ADSCs. G‐D‐ADSCs also performed better in terms of migration, differentiation, and proangiogenic capacity than D‐ADSCs in a high‐glucose environment. Notably, these properties were restored to the same level as that of nondiabetic ADSCs under high‐glucose conditions. G‐D‐ADSC transplantation induced improved reperfusion and an increased limb salvage rate compared D‐ADSCs in a diabetic mice model of CLI. Histological analysis revealed higher microvessel densities and more G‐D‐ADSC‐incorporated microvessels in the G‐D‐ADSC group than in the D‐ADSC group, which was comparable to the nondiabetic ADSC group. Higher expression of vascular endothelial growth factor A and stromal cell‐derived factor‐1α and lower expression of hypoxia‐induced factor‐1α were also detected in the ischemic muscles from the G‐D‐ADSC group than that of the D‐ADSC group. The results of the present study have demonstrated that protection from ROS accumulation by GLO1 overexpression is effective in reversing the impaired biological function of D‐ADSCs in promoting neovascularization of diabetic CLI mice model and warrants the future clinical application of D‐ADSC‐based therapy in diabetic patients. Stem Cells Translational Medicine 2017;6:261–271

In Situ Laser Fenestration Is a Feasible Method for Revascularization of Aortic Arch During Thoracic Endovascular Aortic Repair

Background Reconstruction of the aortic major branches during thoracic endovascular aortic repair is complicated because of the complex anatomic configuration and variation of the aortic arch. In situ laser fenestration has shown great potential for the revascularization of aortic branches. This study aims to evaluate the feasibility, effectiveness, and safety of in situ laser fenestration on the three branches of the aortic arch during thoracic endovascular aortic repair. Methods and Results Before clinical application, the polytetrafluoroethylene and Dacron grafts were fenestrated by an 810‐nm laser system ex vivo, which did not damage the bare metal portion of the endografts and created a clean fenestration while maintaining the integrity of the endografts. In vivo, 6 anesthetized female swine survived after this operation, including stent‐graft implantation in the aortic arches, laser fenestration, and conduit implantation through the innominate arteries and the left carotid arteries. Based on the animal experiments, in situ laser fenestration during thoracic endovascular aortic repair was successively performed on 24 patients (aged 33–86 years) with aortic artery diseases (dissection type A: n=4, type B: n=7, aneurysm: n=2, mural thrombus: n=7). Fenestration of 3 aortic branches was performed in 2 (8.3%) patients. Both the left carotid artery and the left subclavian artery were fenestrated in 6 (25%) patients. Only left subclavian artery fenestration surgery was done in 16 (66.7%) patients. Among these patients, 1 fenestration was abandoned secondary to an acute takeoff of the innominate artery in a type III aortic arch. The average operative time was 137±15 minutes. The technical success rate was 95.8% (n=23). No fenestration‐related complications or neurological morbidity occurred after this operation. During a mean postoperative 10‐month follow‐up (range: 2–17 months), 1 patient died of severe pneumonia, and all the left subclavian artery and carotid artery stents were patent with no fenestration‐related endoleaks upon computed tomography angiography images. Conclusions In situ laser fenestration is a feasible, effective, rapid, repeatable, and safe option for the reconstruction of aortic arch during thoracic endovascular aortic repair, which might be available to revascularize the 3 branches. However, follow‐up periods should be extended to evaluate the robustness of this technique.

Endovascular repair of aortic arch intramural hematoma and penetrating ulcers with 810 nm in situ laser-assisted fenestration: Preliminary results of a single-center: IN SITU LASER FENESTRATION IN AORTIC ARCH DISEASES

The aim of the present study was to report the clinical outcomes of the use of 810 nm in situ laser‐generated fenestration (ISLF) for the treatment of aortic aneurysms (AAs) and intramural hematomas (IMHs) located in the aortic arch.

Comparison of Direct Iliofemoral Stenting Following AngioJet Rheolytic Thrombectomy vs Staged Stenting After AngioJet Rheolytic Thrombectomy Plus Catheter-Directed Thrombolysis in Patients With Acute Deep Vein Thrombosis:

Purpose: To compare the treatment outcomes in patients with acute proximal deep vein thrombosis (DVT) and iliofemoral stenosis who underwent either direct stenting after AngioJet rheolytic thrombectomy or staged stenting after AngioJet thrombectomy plus catheter-directed thrombolysis with urokinase. Methods: From June 2014 to February 2016, 91 DVT patients underwent 2 treatments for duplex-verified iliofemoral stenosis: direct stenting (n = 46; mean age 54.8 years; 32 men) or staged stenting (n = 45; mean age 56.5 years; 27 men). The degree of patency after thrombectomy or thrombolysis was evaluated using the Venous Registry Index (VRI), while the risk of postthrombotic syndrome (PTS) was evaluated according to the Villalta scale. Patients were followed with periodic duplex ultrasound scans up to 1 year. Results: The technical success rates were 100% in both groups; there was no 30-day mortality. Immediate (24-hour) clinical improvement was achieved in 42 (91%) of 46 direct group patients vs 33 (73%) of 45 staged group patients (p<0.001). A significant reduction (p<0.001) in the length of hospital stay was noted in the direct group (4.59±0.91) compared with that in the staged group (5.8±1.6). The stents used in the direct group were longer but with similar diameter compared with the staged group. The thrombolysis rates were 81.50%±5.76% in the direct group and 85.67%±3.84% in the staged group (p<0.001). The VRIs declined (improved) significantly in both groups (11.68±1.92 to 3.21±1.44 in the direct group and 12.17±2.29 to 2.36±1.19 in the staged group, both p<0.001). The Villalta scores were significantly better in the staged group (p<0.001). Recurrent DVT occurred in 2 patients in the direct group. The primary patency rates at 1 year were 93.5% in the direct group and 97.8% in the staged group (p=0.323). Conclusion: Both direct and staged stenting are effective treatment modalities for patients with acute proximal DVT. Compared with staged stenting, direct stenting provides similar treatment success and a significant reduction in the length of hospital stay; however, it has lower thrombolysis efficacy, and the risk of PTS at 1 year is greater with direct stenting.