Jian-Bo Wang

Subintimal angioplasty for below-the-ankle arterial occlusions in diabetic patients with chronic critical limb ischemia.

Purpose: To assess the feasibility and efficacy of subintimal angioplasty (SA) in the treatment of below-the-ankle arterial occlusion in diabetic patients with chronic critical limb ischemia (CLI). Methods: SA was applied in 37 diabetic patients (24 men; mean age 70.9±8.5 years, range 52–88) with chronic CLI and occlusive disease of the dorsalis pedis artery (DPA) and/or plantar artery (PA) but were poor candidates for intraluminal angioplasty or bypass surgery. Tissue loss was present in 31 (54.4%) of 57 afflicted limbs, and rest pain was reported in 51 (89.5%) limbs. SA was performed to create continuous arterial flow to the foot for limb salvage. The clinical symptoms, DPA or PA pulse volume scores, and ankle-brachial index (ABI) were compared before and after SA. Wound healing, amputation, and restenosis of target vessels were also evaluated at follow-up. Kaplan-Meier curves were constructed to evaluate limb salvage, survival, and freedom from amputation. Results: Below-the-ankle SA was performed successfully in 55 (83.3%) of 66 arteries in 57 limbs. Median pulse volume scores and ABIs were 0.33±0.55 and 0.31±0.19 before SA and 2.04±1.05 and 0.80±0.14 after SA, respectively (p<0.0001 for both). The 30-day mortality was 2.7%. Median follow-up was 9.1±6.1 months (range 1–18). Major complications occurred in 1 (2.7%) patient and minor complications in 3 (8.1%). Twelve months after SA, Kaplan-Meier analysis showed that the limb salvage rate was 94.6%, the freedom from amputation was 89.2%, and the survival rate was 97.3%. Conclusion: SA of the dorsalis pedis artery and/or plantar artery is a useful technique for lower limb salvage in diabetic patients with chronic CLI who are not candidates for bypass surgery.

Retrograde transdorsal-to-plantar or transplantar-to-dorsal intraluminal re-entry following unsuccessful subintimal angioplasty for below-the-ankle arterial occlusion.

Purpose: To assess the technical feasibility and efficacy of transdorsal-to-plantar (TDP) or transplantar-to-dorsal (TPD) intraluminal re-entry following unsuccessful subintimal angioplasty for arterial occlusion below the ankle. Methods: TDP or TPD retrograde intraluminal re-entry angioplasty was attempted in 8 limbs of 8 diabetic patients (5 men; mean age 74.5±7.76 years, range 62–81) with chronic below-the-ankle arterial occlusive disease when standard transtibial subintimal angioplasty failed. The clinical symptoms, dorsal or plantar arterial pulse volume scores, and ankle-brachial indexes (ABI) were compared before and after the procedures. At follow-up, pain relief, wound healing, limb salvage, and the presence of any restenosis of the target vessels were evaluated. Results: TDP or TPD retrograde intraluminal re-entry angioplasty was performed successfully in 5 (62.5%) patients; foot pain improved, with median pulse volume scores and ankle-brachial indexes increasing from 0.60±0.55 and 0.32±0.20 before to 2.40±0.55 and 0.75±0.12, respectively, after the procedure (p<0.01 for both). At the end of follow-up, the visual analogue scale improved from 7.40±1.14 to 2.20±1.48 (p=0.002). Ulcers in 2 of the successfully treated patients either healed (n = 1) or improved (n = 1). No amputation occurred. Restenosis of 1 target vessel was revealed by magnetic resonance angiography. Conclusion: TDP and TPD retrograde intraluminal re-entry techniques are feasible and effective in the treatment of foot ischemia in diabetic patients when standard below-the-ankle angioplasty has failed.

Endovascular Reconstruction with the Willis Covered Stent for the Treatment of Large or Giant Intracranial Aneurysms

Background: The purpose of this study was to evaluate the feasibility, safety and efficacy of endovascular treatment of large or giant intracranial aneurysms with the Willis covered stent. Methods: Nineteen patients, each with a large or giant intracranial aneurysm, were treated with the Willis covered stent. Of these 19 aneurysms, 6 were giant and 13 were large; 18 were located in the cranial internal carotid artery and 1 in the vertebral artery. Results of the procedure, technical events and complications were recorded. Clinical and imaging follow-ups were performed at 3 and 6–12 months after the procedure. Results: Placement of Willis covered stent was successful in all patients. Complete aneurysm exclusion was achieved in 13 of the 19 aneurysms immediately after the procedure. No mortality or morbidity developed during the treatment or the follow-up period. During the follow-up period, complete aneurysm exclusion was achieved in 18 of the 19 patients; 11 aneurysms were totally involuted, 3 decreased to 25% of the original diameter, 4 decreased to 50% and 1 remained unchanged. Nine patients experienced full recovery, 9 improved and 1 was unchanged. No obvious in-stent stenosis was noted. Conclusions: Endovascular treatment of large or giant intracranial aneurysm with the Willis covered stent is feasible, safe and efficacious in selected cases. Endoleak is a frequent issue after initial covered stent placement, but can be eliminated or dramatically reduced to minimal endoleak by additional covered stent placement and/or balloon reinflation. Minor endoleak is likely to spontaneously resolve over time.

Application of the Willis covered stent in the treatment of aneurysm in the cisternal segment of the internal carotid artery: a pilot comparative study with midterm follow-up.

Purpose: To compare the use of the Willis stent-graft versus coil embolization for complicated aneurysms in the cisternal segment of the internal carotid artery (ICA). Methods: Thirty-four patients (19 women; mean age 46.7±16.8 years, range 3–79) with 36 complicated aneurysms were treated either by Willis covered stents (n=19) or by coil embolization (n=17). Follow-up angiography was performed to investigate aneurysm recurrence, endoleak, and parent artery stenosis. Kaplan-Meier curves were constructed to compare the freedom from recurrence and parent artery stenosis rates in both groups. Clinical follow-up data were retrospectively analyzed and categorized as fully recovered, improved, unchanged, or worsened. Results: In the covered stent group, total exclusion was immediately achieved in 13 aneurysms; there were 5 minor endoleaks and 1 delivery failure. In the patients treated with coil embolization, total/near-total occlusion was achieved in 7 aneurysms, subtotal in 8, and partial in 2. Acute thrombosis occurred in 1 patient in each group, while 1 patient experienced recurrent hemorrhage after embolotherapy. Follow-up angiography (mean 14.3±9.4, range 3–31) revealed that 16 aneurysms were completely isolated in the stent-graft group, with only 2 mild in-stent stenoses. Eighteen months after the procedure, Kaplan-Meier analysis showed recurrence-free rates of 93.3% and 50% for the stent-graft versus coil groups, respectively; freedom from parent artery stenosis was 87.5% and 100%. Symptoms were fully eliminated in 9 patients in each group; they were improved in 3 and 5, unchanged in 2 and 2, and worsened in 1 and 0, respectively, at the end of the follow-up period. Conclusion: Willis stent-graft application is an alternative to treat complicated aneurysms in the cisternal segment of the ICA. In the case of a tortuous parent artery or potential side branch coverage, however, it is still not a first choice therapy.

Infrapopliteal angioplasty with a long over-the-wire (OTW) balloon in the treatment of severe limb ischemia in diabetic patients: a retrospective study.

Background: The use of short balloons in the treatment of infrapopliteal arterial occlusive disease in diabetic patients often has a poor clinical outcome. Purpose: To retrospectively evaluate the safety and efficacy of a long over-the-wire (OTW) balloon as a primary percutaneous transluminal angioplasty (PTA) treatment for diabetic infrapopliteal severe limb ischemia. Material and Methods: Infrapopliteal PTA with a long OTW balloon was performed between April 2007 and March 2008 in 34 patients (53 limbs), including a total of 119 lesions. Patient age was 71.8±7.4 years. All patients had limb ischemic symptoms. Angiography was retrospectively analyzed, and every lesion categorized and classified according to its length and severity. The mean follow-up period was 7.4±2.6 months. Lower-limb magnetic resonance angiography (MRA) was performed every 3 months during follow-up, and clinical data were collected. Results: Altogether, 92% of patients were successfully treated. Ankle-brachial index (ABI) and transcutaneous oxygen tension (TcPO2) improved from 0.50±0.18 and 18.85±12.08 mmHg, respectively, before the procedure to 0.81±0.12 and 39.85±12.67 mmHg, respectively, after the procedure. At the end of follow-up, 29 patients had maintained a stable outcome. Five patients had symptom recurrence, and three of them underwent a second PTA. Two major amputations and four minor amputations were performed, with a 94% limb salvage rate and 59% patency rate. Conclusion: Infrapopliteal PTA with a long OTW balloon was feasible, with encouraging midterm outcome, in the treatment of severe limb ischemia in diabetic patients in this single-center case series. Further research is warranted to evaluate long-term outcome.

Treatment of a canine carotid artery aneurysm model with a biodegradable nanofiber-covered stent: A prospective pilot study

AIM To evaluate the use of a biodegradable nanofiber-covered stent (BDNCS) in the treatment of a canine carotid artery aneurysm. MATERIALS AND METHODS Seventeen beagle dogs, each with one lateral saccular aneurysm created using a venous pouch, were selected to test the BDNCS. The BDNCS consists of three parts: A bare stent, a biodegradable nanofiber membrane, and a balloon catheter. The bare stent was sculpted by a laser from a cobalt chromium superalloy, and the biodegradable nanofiber membrane was constructed from polylactic acid (PLA) and polycaprolactone [PCL, P (LLA-CL)] by the electro-spinning method. The biodegradable nanofiber stent was premounted on a balloon catheter to form a BDNCS. Angiographic assessments were categorized as complete or incomplete occlusion. Data regarding technical success, initial and final angiographic results, mortality and morbidity were collected, and follow-up was performed at 1 and 3 months after the procedure. RESULTS BDNCS placement was successful in 17 canines with 17 aneurysms. The initial angiographies showed that a complete occlusion was achieved in 13 canines (76.5%) and an incomplete occlusion in 4 (23.5%). One canine died 1 week later. The angiographies obtained at 3-month follow-up exhibited complete occlusion in 14 canines (87.5%) and an incomplete occlusion in 2 canines, with mild in-stent stenosis in 5 canines. CONCLUSIONS Our results suggest that BDNCS may be a feasible approach for aneurysm occlusion, although the occurrence of mild in-stent stenosis was relatively high. Longer-term follow-up investigations are needed to validate these findings.

Safety, feasibility, and mid-term follow-up of Willis stent graft placement in the treatment of symptomatic complicated intra- or extra-cranial aneurysms: a multicenter experience.

Abstract We report the technical success rate and mid-term follow-up results after deploying stent-grafts to treat a cohort of patients with symptomatic complicated intra- or extracranial aneurysms (SCIEAs). This study was a retrospective review of 58 patients (39 male; mean age 40.4 ± 12.3 years) with 60 SCIEAs treated by 67 Willis covered stents at three medical centers in China between April 2005 and January 2010. The locations of the SCIEAs were as follows: Intracranial internal carotid artery (ICA) in 54 patients, extracranial ICA in one, intracranial vertebral artery (VA) in three and extra-cranial VA in two. Surgery was successful in 59 (98.3%) SCIEAs. Total exclusion was immediately achieved in 48 SCIEAs, and minor endoleaks were present in 11. Acute thrombosis occurred in two patients and hemorrhage in one. Follow-up angiography (mean 13.8 ± 8.9 months) revealed that 49 of 52 (94.2%) aneurysms were completely isolated, with mild in-stent stenosis in only two patients and in-stent occlusion in one patient. Willis stent-graft application is an alternative therapy to treat SCIEAs in either intra- or extracranial ICAs or VAs. In the case of a tortuous intracranial ICA or potential side branch coverage, however, it is still not a first choice.

Batroxobin Plus Aspirin Reduces Restenosis After Angioplasty for Arterial Occlusive Disease in Diabetic Patients With Lower-Limb Ischemia

PURPOSE Aspirin is routinely given to reduce vascular events after angioplasty. Batroxobin has been shown to effectively prevent thrombosis after angioplasty via inhibition of the fibrinogen concentration. In this randomized clinical trial, the hypothesis that batroxobin plus aspirin is more effective than aspirin alone in reducing the incidence of restenosis/reocclusion in patients with diabetes undergoing angioplasty for lower-limb ischemia. MATERIALS AND METHODS Patients with diabetes and symptomatic arterial obstructions (N = 129) were randomized to receive aspirin 100 mg/d plus batroxobin 5 IU every other day for six doses (n = 58) or aspirin alone (n = 71). The primary outcome was restenosis documented by magnetic resonance (MR) angiography or duplex imaging at 12 months. Secondary outcomes included amputation above the ankle, death, and cumulative rate of amputation or death. Kaplan-Meier analysis was used to evaluate limb salvage and survival rates. RESULTS After 12 months, restenosis had occurred in 43.1% and 29.7% of patients in the control and batroxobin groups, respectively (P = .0018). MR angiography and duplex imaging revealed an improved restenosis rate for infrapopliteal lesions and for lesions longer than 10 cm (P = .0016). The primary and cumulative secondary outcomes indicated significant improvements in restenosis rate, symptom relief, and amputation rates in the batroxobin group compared with the aspirin-only group. Kaplan-Meier analysis showed limb salvage and survival rates of 78.3% in the aspirin-only group and 92.2% in the batroxobin group 12 months after angioplasty (log-rank test, P = .0414). CONCLUSIONS Batroxobin plus aspirin reduced the rate of restenosis after arterial angioplasty, particularly in lesions located below the knee and in those longer than 10 cm, with better clinical symptom relief and improved rate of limb salvage.

Batroxobin for Prevention of Restenosis in Diabetic Patients After Infrapopliteal Arterial Angioplasty: A Small Randomized Pilot Trial

BACKGROUND We designed a small randomized clinical trial to prospectively test the hypothesis that batroxobin is more effective than aspirin alone to prevent restenosis in patients with diabetes undergoing angioplasty of infrapopliteal arteries. METHODS After a successful angioplasty, a total of 52 diabetic patients with symptomatic infrapopliteal obstructions were randomized to either the treated group (n = 26) or the control group (n = 26). Patients in the treated group received 5 IU batroxobin through an intravenous drip once every alternate day, for a total of six doses. The primary end point was restenosis and reocclusion, which was documented by magnetic resonance angiography or duplex scanning at 12-month follow-up. The clinical symptoms relief and ankle-brachial index (ABI) were compared before and after the procedure, and during follow-up. Kaplan-Meier curves were constructed to evaluate restenosis or reocclusion-free, limb salvage, and amputation-free rates. RESULTS Restenosis and reocclusion occurred in 22.0% and 34.5% lesions in the treated and the control group, respectively (p = 0.0307). Statistical differences were observed between the ABI before the angioplasty procedure(p < 0.05) and the ABI at the 12-month follow-up (p = 0.0094) of the two groups. Clinical symptoms improvement and tissue healing occurred in 23 and 19 patients in the batroxobin group and the control group, respectively (p = 0.0544). Twelve months after angioplasty, Kaplan-Meier analysis showed that the restenosis and reocclusion-free rate was 74.0% and 54.8%, the limb salvage rate was 96.2% and 92.3%, and the amputation-free rate was 84.6% and 84.6%, in the treated and control group, respectively. CONCLUSION This pilot trial revealed that batroxobin usage was effective in preventing restenosis and reocclusion after infrapopliteal arterial angioplasty, and it might provide better clinical symptoms relief; however, it did not report preferable limb salvage or amputation-free rates.

Notoginsenoside Fc attenuates high glucose-induced vascular endothelial cell injury via upregulation of PPAR-γ in diabetic Sprague–Dawley rats

Endothelial injury from high glucose (HG) plays a dominant role in atherosclerosis, diabetes-induced vasculopathy, and vascular remodeling. Notoginsenoside Fc (Fc), a novel saponin isolated from P. notoginseng, has been shown to exhibit properties that counteract platelet aggregation. However, the potential roles and molecular mechanisms of Fc in preventing cardiovascular injury have yet to be explored. In this study, we present novel data that show the ability of Fc to prevent early atherosclerosis of diabetic Sprague-Dawley (SD) rats in vivo and to attenuate endothelial cell injury in vitro. Our results indicate that Fc protects rat aortic endothelial cells (RAOECs) from HG-induced injury by inhibiting apoptosis and promoting proliferation as well as by reducing endothelial cell production of pro-inflammatory cytokines: TNF-α, IL-1β, IL-6, ICAM-1. Furthermore, the downregulation of peroxisome proliferator-activated receptor-γ (PPAR-γ) in HG-challenged endothelial cells was prevented by Fc. Inhibition of PPAR-γ abrogated the effects of Fc on HG-induced pro-inflammatory cytokine production in RAOECs. These results indicate that Fc has a preventative effect on HG-induced endothelial cell injury partly through a PPARγ-mediated pathway, suggesting that Fc might provide a potential new therapeutic option for the treatment of diabetic vascular complications.