Liangxi Yuan

Endovascular Repair of Ascending Aortic Dissection : A Novel Treatment Option for Patients Judged Unfit for Direct Surgical Repair

OBJECTIVES This paper sought to report the outcomes of patients who are considered unfit for urgent surgical repair of ascending aortic dissections (AADs) who were treated using a novel endovascular repair strategy. BACKGROUND AAD is best treated by direct surgical repair. Patients who are unable to undergo this form of treatment have poor prognoses. Previously, clinical case reports related to endovascular repair of AAD have been controversial. METHODS Between May 2009 and January 2011, 41 consecutive patients with AAD were treated in our institution. Fifteen patients were considered poor candidates for direct surgical repair and subsequently underwent the endovascular repair. RESULTS The nature of the referral process to our tertiary care facility made the median time from aortic dissection onset to treatment 25.5 days (range: 6 to 353 days). Dissections in 5 patients (33.3%) were considered acute, and those in 10 patients (66.7%) were considered chronic. The rate of successful stent-graft deployment was 100%, and there were no major morbidities or deaths in the perioperative period. Median follow-up was 26 months (range: 16 to 35 months). One new dissection occurred in the aortic arch at 3 months and was treated with a branched endograft. Significant enlargements of true lumens and decreases of false lumens and overall thoracic aorta were noted after the procedures. CONCLUSIONS Endovascular repair of AAD was an appropriate treatment option in patients who were considered poor candidates for traditional direct surgical repair by the clinical criteria used in our institution. A larger series of cases with longer follow-up is needed to substantiate these results.

Endovascular Repair of a Thoracic Arch Aneurysm with a Fenestrated Stent-Graft

Purpose: To report a new endovascular technique for thoracic aortic arch aneurysm repair with a fenestrated stent-graft. Case Report: A 75-year-old man presented with a 5.5-cm thoracic aneurysm involving the inner curve and left anterior lateral aspect of the aortic arch. The innominate and left carotid arteries shared a common trunk, and the right vertebral artery was dominant. Endovascular repair was performed utilizing a fenestrated stent-graft that allowed perfusion of the innominate and left carotid arteries but occluded the left subclavian artery. At 8 months post procedure, the patient is well; imaging documented the continued exclusion of the aneurysm and perfusion of the common trunk branches. Conclusion: Fenestrated endovascular grafts for specific thoracic aortic arch aneurysm can be used safely in the high-risk patient.

Endovascular therapy for long-segment atherosclerotic aortoiliac occlusion.

OBJECTIVE This retrospective nonrandomized study investigated the outcomes of endovascular therapy for long-segment atherosclerotic aortoiliac occlusion. METHODS From May 2008 to January 2013, 20 patients (one woman and 19 men; mean age, 66.1 years; range, 43-89 years) underwent stent implantation, with or without catheter-directed thrombolysis (CDT), for long-segment aortoiliac occlusion (>10 mm). RESULTS The technical success rate was 95% (19 of 20). No in-hospital mortality was recorded. Aortic thrombus was successfully eliminated with CDT in four patients before percutaneous transluminal angioplasty (PTA) and stenting. Retroperitoneal hemorrhage occurred in one patient, who refused further endovascular surgery. Another 15 patients were treated with PTA and stenting. Postoperative ankle-brachial indexes increased significantly from preoperative values (P < .05). Seventeen patients showed clinical improvement from baseline by an average of 2.5 Rutherford categories. The mean follow-up interval was 17.6 months (range, 4-39 months). The primary patency rates were 93.3% ± 6.4% at 6 months, 83% ± 11.3% at 18 months, and 66.4% ± 17.4% at 24 months. CONCLUSIONS Through brachial and femoral artery puncture, PTA, stenting, and CDT, endovascular therapy is feasible for complete long-segment infrarenal aortic occlusion, with lower complication rates and favorable midterm patency.

Treatment of type I endoleak after endovascular repair of infrarenal abdominal aortic aneurysm: success of fibrin glue sac embolization.

Purpose: To analyze a single-center experience of fibrin glue sac embolization to eliminate type I endoleaks after endovascular aneurysm repair (EVAR), assessing the feasibility and effectiveness of the technique in long-term follow-up. Methods: A retrospective study was conducted involving 783 EVAR patients treated between August 2002 and February 2009. Under a standardized protocol, 42 (5.4%) patients (37 men; mean age 73±8 years) underwent intraoperative transcatheter fibrin glue sac embolization to resolve type I endoleak persisting after initial intraoperative maneuvers to close the leak or in necks too short or angulated for cuff placement. Intrasac pressure was measured before and after glue injection. Computed tomographic angiography was performed to assess the outcome after 3, 6, and 12 months and annually thereafter. Results: In this type I endoleak cohort, 16 (38.1%) patients had proximal necks <10 mm long, and 5 (11.9%) patients had proximal neck angulation >60°; 22 additional devices (8 stents, 14 cuffs) had been placed in the initial attempts to resolve the endoleaks. After fibrin glue injection, 41 (97.6%) of the 42 endoleaks were resolved using a mean 15±10 mL of glue. Intrasac pressure decreased significantly in successfully treated cases. The patient who failed embolotherapy was converted to open surgery (2.4%); he died 2 months later from multiorgan failure. Two (4.8%) patients died in the perioperative period from myocardial infarction. One (2.4%) patient developed right lower extremity ischemia unrelated to the fibrin glue treatment. There were no allergic reactions. Over a median follow-up of 39.9 months (range 10–88), 3 (7.1%) patients died (1 aneurysm-related). Cumulative survival was 90.5% at 1 year, 87.0% at 3 years, and 82.6% at 5years. The mean maximal aneurysm diameter fell from the baseline 59.5±14.7 mm to 49.0±11.6 mm (p<0.001). Of the 4 patients with increased aneurysm diameter during follow-up, 1 was converted, 2 are being observed due to advanced age, and 1 died of renal failure. No recurrent type I endoleak or glue-related complications were observed in follow-up. Conclusion: Fibrin glue sac embolization to eliminate type I endoleak after EVAR yielded excellent results in our experience, effectively and durably resolving the leaks. Balloon occlusion of the proximal aorta must be done during glue injection to block proximal flow and facilitate formation of a structured fibrin clot.

Clinical results of percutaneous transluminal angioplasty for thromboangiitis obliterans in arteries above the knee.

OBJECTIVE This study was designed to retrospectively investigate whether percutaneous transluminal angioplasty (PTA) is efficacious and safe for the treatment of atypical thromboangiitis obliterans (ATAO) in arteries with occlusion of long segments. METHODS From January 2011 to July 2013, 9 consecutive male patients with ATAO involving the external iliac and superficial femoral arteries were treated by PTA alone, without stent placement. Their mean age was 35 years (range, 24-47 years). Preoperative symptoms included severe claudication (n = 2), ischemic pain at rest (n = 4), and ischemic ulcers (n = 3). No any infrapopliteal interventions were performed besides the proximal intervention. RESULTS Technical success using PTA was achieved in 100% of cases with occluded arteries, and there were no periprocedural complications. Clinical improvement was observed postoperatively with a significant improvement in Rutherford categories (range, 2-3) and significantly increased ankle-brachial indexes, from 0.59 ± 0.14 to 0.91 ± 0.17 (p < 0.01). Ischemic ulcers in three patients healed 3-5 months postoperatively. No recurrent ischemic ulcer was observed, and no amputation was performed in these patients. At follow-up examination (average, 20.9 months), restenosis of the superficial femoral artery was diagnosed in only one patient who continued with a conservative medication regimen and refused additional interventional treatment because his physical symptoms were minor. CONCLUSION PTA might be feasible and safe for the treatment of ATAO patients, and appears to provide positive clinical results at an average follow-up of 20.9 months.

Transbrachial and Femoral Artery Approach Endovascular Therapy for Flush Infrarenal Aortic Occlusion

OBJECTIVE The purpose of this study is to report the efficacy of transbrachial and femoral artery approach endovascular therapy with catheter-directed thrombolysis (CDT) and adjunctive therapy for flush infrarenal aortic occlusion (FIAO). MATERIALS AND METHODS From March 2012 to December 2013, 11 consecutive patients (9 males; mean age 68 years; range 54-80 years) were submitted to endovascular therapy for FIAO. All patients were treated with CDT initially and then adjunctive endovascular treatments were performed to correct the underlying lesions. RESULTS Complete reconstruction of occluded aortoiliac arteries was successfully achieved in 81.8% (9/11) of patients. Left brachial and bilateral femoral arterial accesses were obtained in nine patients, and brachial and unilateral femoral in two patients. The residual lesions after CDT were corrected in nine patients and concomitant endovascular recanalization of superficial femoral artery was performed in two patients. Self-expandable stents were implanted in the all aortoiliac lesions with pre- and post-dilation. No renal or distal runoff embolization was seen during intraoperative angiography. Seven (7/9) patients with rest pain or tissue loss showed significant improvements in symptoms and two (2/9) patients with intermittent claudication gained an improved walking distance. The ABI rose significantly between pre- and post-procedure (0.84 ± 0.18 vs. 0.44 ± 0.13 on the right leg, p < .01; 0.89 ± 0.23 vs. 0.48 ± 0.16 on the left, p < .01). CONCLUSIONS Transbrachial and femoral artery approach endovascular therapy for FIAO offers an alternative to surgical reconstruction with immediate outcomes.

Endovascular SilverHawk Directional Atherectomy for Thromboangiitis Obliterans With Occlusion of the Popliteal Artery

Thromboangiitis obliterans (TAO), also known as Buerger disease, is a nonatherosclerotic segmental inflammatory disease of small and medium-sized arteries of the distal extremities occurring predominantly in young men who are long-term tobacco smokers. We treated 2 patients who presented with TAO involving popliteal and tibial arteries. Directional atherectomy with a SilverHawk device was used to recanalize the arteries without major complications. During follow-up conducted using computed tomography or sonography, we observed that the treated vessels remained patent. These cases report illustrate the feasibility and immediate effectiveness of endovascular SilverHawk directional atherectomy in TAO patients with occlusion of the popliteal arteries.

Recanalization of native superficial femoral artery chronic total occlusion after failed femoropopliteal bypass in patients with critical limb ischemia

OBJECTIVES This study aimed to examine the outcomes of endovascular recanalization for native superficial femoral artery (SFA) chronic total occlusion (CTO) in patients with critical limb ischemia (CLI) after femoropopliteal bypass failure with limited surgical revascularization options. BACKGROUND Endovascular recanalization of native artery occlusions has been recently used as a new alternative for threatened limbs after bypass graft occlusion. The feasibility and efficacy has not been widely reported. METHODS We retrospectively analyzed 45 consecutive patients (45 limbs) undergoing endovascular recanalization of native SFA occlusion following failed femoropopliteal bypass between June 2010 and December 2016. RESULTS All limbs had Transatlantic Inter-Society Consensus class C (26.7%, 12/45) or D (73.3%, 33/45) lesions with a mean lesion length of 29.8 cm. The technical success rate was 95.6% (43/45 limbs). The ABI showed a significant increase from 0.3 ± 0.1 pre-procedure to 0.7 ± 0.1 post-procedure (P < 0.01). Two early (<30 days) below-knee amputations due to acute thrombotic ischemia occurred during perioperative period and resulted in one death due to myocardial infarction. The mean follow-up was 42.7 months (1-62 months). Two patients were lost to follow up. The primary patency rates at 12 and 36 months were 54% and 51%, respectively. Secondary patency rates at 12 and 36 months were 78% and 61%, respectively. Limb salvage rate was 95% and amputation-free survival rate was 88% at both 12 and 36 months. CONCLUSION Recanalization of native SFA CTO due to failed femoropopliteal bypass offers a feasible and safe alternative to surgical reconstruction with acceptable limb salvage.

The Relationship Between Neutrophil–Lymphocyte Ratio and In-Stent Restenosis:

The neutrophil–lymphocyte ratio (NLR) has been proposed as a prognostic marker in patients with peripheral arterial disease, and a high NLR has predictive value for future vascular events. Chang et al in their paper entitled “The Relationship Between the Neutrophil-Lymphocyte Ratio and In-Stent Restenosis in Patients With Femoropopliteal Chronic Total Occlusions” reported that the NLR is independently associated with early in-stent restenosis (ISR) in patients with femoropopliteal chronic total occlusions (CTO). We would like to comment on confounding factors. First, inflammation is considered to play a key role in the pathophysiological process for many chronic diseases. So, the investigators should consider that many inflammation-related diseases, like chronic obstructive pulmonary disease, renal or hepatic dysfunction, and local or systemic infection, may influence the inflammatory state. Therefore, these inflammatory diseases should be identified by appropriate diagnostic methods. Second, many easily available inflammatory biomarkers including serum bilirubin, albumin, and resting heart rate may be independent risk factors for ISR and cardiovascular events. However, there were no data regarding those biological parameters in the study by Chang et al. Third, the authors demonstrated that the higher baseline NLR was independently and positively associated with a higher risk of early ISR. In addition, the percentage of patients with diabetes mellitus (DM) in the early ISR group was significantly higher than that both in the non-ISR and late ISR groups, and the difference between early ISR and non-ISR groups was significant. Should DM have been considered as an independent risk factor for the occurrence of ISR? Diabetes mellitus is a vital factor in poor prognosis in patients who received cardiovascular interventional therapy. Furthermore, DM was connected with restenosis in small femoropopliteal lesions. Thus, DM should be considered to have an independent relationship with ISR in patients with femoropopliteal CTO. In conclusion, NLR may have association with early ISR after stenting treatment in patients with femoropopliteal CTO. However, to identify factors associated with ISR after intervention, the comorbidities and health status of patients should be taken into consideration, particularly the effect of DM on ISR after stenting. Also, the combination of multiple inflammatory biomarkers may be helpful to assess the risk of ISR in patients who underwent stenting treatment for femoropopliteal CTO.

Antiplatelet and anticoagulant for prevention of reocclusion in patients with atrial fibrillation undergoing endovascular treatment for low extremity ischemia

Background The purpose of this study is to report the efficacy of the mono antiplatelet plus anticoagulation therapy for prevention of reocclusion in patients with atrial fibrillation (AF) undergoing endovascular treatment for lower extremity ischemia. Methods From March 2014 to July 2016, 32 (21 males; range, 68-84 years) patients were submitted to endovascular therapy for low extremity ischemia with AF and all were treated with endovascular treatments to correct underlying lesions. Then 20 patients receive aspirin plus rivaroxaban post-operation and 12 patients receive aspirin plus warfarin to prevent reocclusion. Results Complete reconstruction of occluded femopopliteal arteries with unimpeded blood flow to legs were successfully obtained in all 32 patients; 12 (37.5%) patients had acute ischemia, 17 (53.1%) patients had chronic ischemia, 3 (9.4%) patients had acute on chronic ischemia. Endovascular treatments including percutaneous transluminal angioplasty (PTA) and stenting were performed to correct residual lesions after the thrombolytic/thrombectomy procedure or to correct native lesions for chronic patients. All 32 patients showed significant improvements in symptoms and 4 patients improved completely. The mean ankle-brachial index (ABI) had risen from 0.43±0.21 preoperatively to 0.81±0.16 postoperatively (P<0.01), and the primary patency rates were 88.9% at 12 months, and 81.5% at 24 months. No episodes of major bleeding and only one patient showed positive fecal occult blood tests during the follow-up. Conclusions The mono antiplatelet plus anticoagulation therapy offers a safe and effective alternative for prevention of reocclusion in patients with AF undergoing endovascular treatment for lower extremity ischemic.