Minyi Yin

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.

Role and mechanism of tissue plasminogen activator in venous wall fibrosis remodeling after deep venous thrombosis via the glycogen synthase kinase-3 beta signaling pathway

BACKGROUND Deep venous thrombosis (DVT) confers vein wall injury associated with fibrosis and extracellular matrix turnover. The activation of vascular smooth muscle cells (VSMCs) and phenotypic switching are postulated to be the significant contributing factors in the evolution of the pathogenic processes. This study investigated the effect of tissue plasminogen activator (tPA) on the phenotypic switching and collagen deposition of VSMCs, as well as related signaling pathway that leads to this activation. MATERIALS AND METHODS The model of stasis-induced DVT was established by ligation of the femoral vein. VSMCs transfected with the plasmid vector carrying a rat recombinant tPA gene with an enhanced green fluorescent protein (EGFP) tag (AdtPA-EGFP). Fibrotic change, expression of collagen type I, the cell number of media, and intimal thickness score were evaluated; the comparisons were made among the AdtPA-EGFP-transfected group, an empty vector (AdNull-EGFP) transfected group, and a phosphate-buffered saline perfused group in vivo. tPA induced VSMCs phenotypic switching and collagen deposition in vitro. The related signaling pathway molecules and the cell cycle progression were also investigated by western blot and flow cytometry. RESULTS In the AdtPA-EGFP stasis DVT model, early vein wall collagenolysis and deposition occurred more remarkable. Histological studies showed that the expression of vein wall collagen type I protein, cell number of media, and intimal thickness score was significantly increased (P < 0.05). In primary culture VSMCs, sustained stimulation with tPA induced collagen type I upregulation and triggered sequential signaling events involving Akt, extracellular signal-regulated kinases 1/2 (ERK1/2), glycogen synthase kinase-3 (GSK3)-β phosphorylation, and cyclin D1 induction. Blockade of phosphatidylinositol 3-kinase-Akt and ERK1/2 activation suppressed tPA-induced GSK3β phosphorylation, cyclin D1 expression, and the deposition of collagen type I. CONCLUSIONS tPA was a profibrotic factor that potentiated the phenotypic switching and the deposition of collagen in VSMC. The effect of tPA on VSMCs involved activation of Akt and ERK1/2 pathways and inhibition of GSK3β activity, which could promote a switch of the synthetic phenotype in VSMCs and lead to the remodeling of vascular injury.

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.

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 treatment of atherosclerotic popliteal artery disease based on dynamic angiography findings

Objective: To evaluate efficacy, safety, and midterm patency of endovascular treatment of obstructive popliteal artery (PA) disease. Methods: A retrospective evaluation of patients with atherosclerotic PA disease who underwent percutaneous transluminal balloon angioplasty and provisional stent, based on both conventional and dynamic angiographies, was conducted from June 2011 to June 2014. Forty‐three patients were included in the study, and most patients had limited surgical revascularization options. Demographic characteristics, angiographic findings, interventional data, complications, vessel patency, limb salvage rates, and survival rates were analyzed. Results: The median lesion length was 5 cm with 72.1% having total occlusions. The second popliteal segment (P2) was involved most frequently (60.5%, n = 26). Critical limb ischemia was present in 69.8%. The technical success rate was 92.9% (42/43 limbs), with 29 cases requiring adjunctive nitinol stents after balloon angioplasty (47.6% based on conventional angiography, 21.4% based on dynamic angiography, and 4.8% additional stents based on dynamic angiography). Complications included thromboembolism (2.3%), perforation (2.3%), pseudoaneurysm (2.3%), and myocardial infarction (2.3%). Stent fracture was present in three cases (7.1%) during the mean follow‐up period of 18.3 months. The baseline ankle‐brachial index significantly improved after the intervention, from 0.49 ± 0.11 to 0.92 ± 0.14 (P < .01). The Rutherford‐Becker class decreased from 3.95 ± 0.76 to 1.76 ± 0.95 (P < .01) at 12 months. The 1‐year primary, primary‐assisted, and secondary patency rates were 75.2% ± 6.8%, 82.4% ± 6.0%, and 89.9% ± 4.8%, respectively. The limb salvage and amputation‐free survival rates at 12 months were 91.6% and 87.0%, respectively. Conclusions: Balloon angioplasty with a provisional stent based on dynamic angiography is a feasible, safe, and effective therapy for patients with obstructive PA disease. Although the occurrence of stent fracture is still inevitable, patients with critical limb ischemia who have limited surgical options may get more benefits from the endovascular treatment of PA obstructive diseases.

Midterm Outcomes of Stent Placement for Long- segment Iliac Artery Chronic Total Occlusions: A Retrospective Evaluation in a Single Institution

PURPOSE To assess the clinical and patency results of stent placement for long-segment iliac artery chronic total occlusions (CTOs). MATERIALS AND METHODS A retrospective analysis of 217 patients (141 men and 76 women; mean age, 76.6 y; 256 limbs) with long-segment (>5 cm) iliac artery CTOs treated with stent placement was conducted in a single institution from January 2005 to July 2011. Demographics, clinical presentation, classification, comorbidity, ankle-brachial index (ABI) before and after treatment, technical success, patency, and complications were recorded at follow-up. The approach was initial access from the left brachial artery or the contralateral femoral artery. RESULTS According to the TransAtlantic Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II) classification, 27 patients were type B, 143 were type C, and 47 were type D. Clinical presentation was recorded according to the Rutherford-Becker classification: 35 patients presented with stage 3; 108, with stage 4; 53, with stage 5; and 21, with stage 6. Technical success was 96.5% (247 of 256). Periprocedural in-stent thrombosis occurred in nine patients and was treated successfully with catheter-directed thrombolysis. ABI increased from 0.36±0.16 (range, 0-0.57) before the procedure to 0.79±0.24 (range, 0.56-1.12) after the procedure. The mean duration of follow-up was 25.4 months (range, 1-72 months). The primary, primary assisted, and secondary patency of the iliac artery was 95.1%, 98.4%, and 99.2% at 1 year and 91.9%, 95.6%, and 97.5% at 2 years, respectively. Major complications were encountered in 17 (6.6%) patients, and minor complications occurred in 12 (4.7%) patients. CONCLUSIONS These data suggest that stent placement is an effective, safe, and feasible method for treating long-segment iliac artery CTOs.

Catheter-Directed Thrombolysis of Acute Entire Limb Deep Vein Thrombosis From below the Knee Access

To evaluate the safety and efficacy of below the knee (BTK) approach in the treatment of entire limb deep vein thrombosis (DVT).

Endovascular management of extensive lower extremity acute deep vein thrombosis with AngioJet rheolytic thrombectomy plus catheter-directed thrombolysis from contralateral femoral access

Purpose The aim of the present study was to report the clinical outcomes of endovascular treatment for extensive lower limb deep vein thrombosis with AngioJet rheolytic thrombectomy (ART) plus catheter-directed thrombolysis (CDT) using a contralateral femoral approach. Methods A retrospective analysis of consecutive ART+CDT treatments in 38 deep vein thrombosis patients (LET I-III, from September 2014 to March 2016) was performed. Results The technical success rate was 100%. Complete lysis was achieved in 82% of LET III segments (calf veins), 87% of LET II segments (popliteal-femoral veins), and 90% of LET III segments (iliac veins). The best results were obtained in patients treated within seven days of symptom onset. During follow-up, well-preserved, competent femoral valves were observed in 86% of the patients, and recanalization of LET III, LET II, and LET I segments was achieved in 100%, 94%, and 91% of the patients, respectively. The post-thrombotic syndrome rate was 17% during a mean 20-month follow-up.

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.