Zilun Li

Endovascular Stenting of Extracranial Carotid Artery Aneurysm: A Systematic Review

OBJECTIVE The objective of this study was to systematically review all available published data about endovascular stenting for patients with extracranial carotid artery aneurysm (ECAA). METHODS All clinical reports in the English language on endovascular stenting for ECAA from 1995 through 2010 were identified. General clinical information, aetiology and parameter of carotid artery aneurysm, information regarding devices, indications for endovascular stenting and in-hospital and follow-up data of each patient were extracted individually. RESULTS A total of 113 studies, involving a total of 224 patients, were included. Procedure success was reported in 92.8% of patients. Postoperative endoleak was reported in 8.1% of patients. The incidence of stroke was 1.8%. Cranial nerve injury occurred in 0.5%. Overall in-hospital mortality was 4.1%. The mean follow-up was 15.4 ± 15.3 months. Stent-graft patency rate was 93.2%. CONCLUSION Endovascular stenting is technically feasible with high procedure success and relatively low complication rate in patients with ECAA. Both short- and mid-term outcomes appear to be favourable.

Management of Acute Mesenteric Ischemia A Critical Review and Treatment Algorithm

Background: Acute mesenteric ischemia (AMI) due to a sudden loss or decrease in blood perfusion to the mesentery represents a highly lethal condition. However, the optimal surgical management remains debatable and merits a more clear recommendation based on a higher level of evidence. Methods: A systematic review of articles published between 2000 and 2013 was performed. Patients were divided into endovascular treatment (ET), open surgery (OS), and hybrid technique (HT) groups. Data of patients’ demographics, procedural information, clinical outcomes including mortality, morbidity, primary patency rate, technique success, primary intestinal resection rate, and second-look laparotomy rate, and follow-up were all retrieved. Comparison between the ET and the OS groups was made using 2-sided Student t test and 2-sided χ2 test or Fisher exact test where appropriate. Results: Twenty-eight articles with a total of 1110 patients were included for the review. The ET group had lower in-hospital mortality and morbidity but similar survival rate during follow-up compared to the OS group. The primary patency rate was higher in the ET group. The overall bowel resection rate was lower in the ET group, and nearly every patient in the cohort who required second-look laparotomy required bowel resection. The HT group seemed to have the lowest mortality and acceptable second-look laparotomy rate and morbidity. Comparison between the HT group and other groups was not possible due to the limited number of cases available for review. Conclusion: Endovascular treatment may serve as a first-line therapy for select patients when there is a low suspicion for intestinal necrosis. Open surgery should be reserved for emergency conditions requiring exploratory laparotomy. Hybrid technique may be an especially effective approach for treating AMI, with low morbidity and mortality, although further studies are required comparing it to OS and ET.

Initial and Middle-Term Outcome of Treatment for Spontaneous Isolated Dissection of Superior Mesenteric Artery.

AbstractSymptomatic isolated dissection of the superior mesenteric artery (SIDSMA) represents an extremely rare condition. Although various treatments including conservative treatment, endovascular stenting (ES), and surgical repair are currently available, consensus treatment guideline is absent due to scarce of SIDSMA cases. Thus, we present our experience in the treatment of SIDSMA at our single center.Fourteen cases of SIDSMA were treated with conservative treatment, catheter-directed thrombolysis (CDT), endovascular stenting (ES), or surgical repair at our center between January 2008 and January 2014. Demographics, clinical manifestations, coexisting medical conditions, imaging feature, treatments, and follow-up outcome of these patients were retrospectively collected and analyzed.For 13 patients without peritonitis, conservative treatment was given for 4 to 6 days initially. After the first observation cycle, symptoms and signs were alleviated in 8 patients, and conservative treatments were continued. The remaining 5 patients received technically and clinically successful ES (in 4) or CDT (in 1) due to worsening symptoms and signs during conservative treatment. One patient with peritonitis underwent emergency surgery, with the necrotic small intestine resected. However, the abdominal pain was not alleviated 17 days postoperatively, ES was thus performed and symptoms relieved immediately. Two weeks after ES, a new aneurysm and partial thrombosis in the distal part of the stent were found by computed tomography angiography in this patient. No intestinal infarction or mortality developed during hospitalization. Follow-up was accomplished in 11 cases, ranging from 4 to 74 months (23.5 ± 21.3). Except that one complained with mild abdominal pain, the other 10 achieved complete remission. All patients were free from new aneurysmal formation of SMA and all stents remained patent.For SIDSMA without peritonitis, conservative treatment can be provided with reasonable success rate, while ES may serve as an effective alternative once conservative treatment fails. For SIDSMA with peritonitis, open surgery remains the treatment of choice by resection of necrotic intestine and revasculization.

Effect of structured home-based exercise on walking ability in patients with peripheral arterial disease: a meta-analysis.

BACKGROUND The present study is designed to investigate the effect of structured home-based exercise (SHE) programs on maximal walking time (MWT), pain-free walking time (PFWT), and self-reported walking ability in patients with peripheral arterial disease (PAD). METHODS We searched the databases including MEDLINE, EMBASE, ISI Web of Knowledge, and the Cochrane Library from inception to December 2013 for randomized controlled trials (RCTs) that assessed the effect of SHE programs on walking ability in patients with PAD. Meta-analysis was performed based on the searched results, moreover, we made a systemic review regarding the results along with our knowledge. RESULTS Of all the 348 publications we got from the databases, 5 RCTs covering 547 patients reached the inclusion criteria and were involved in the present study. Both inverse-variance fixed-effects and random-effects model were used to perform meta-analysis. SHE programs improved MWT by mean difference of 66.78 sec (95% confidence interval [CI], 5.15-128.41; P = 0.03), heterogeneity across studies was significant. When the trial accounting for significant heterogeneity was omitted, SHE programs improved MWT by mean difference of 91.21 sec (95% CI, 51.96-130.45; P < 0.0001). In contrast, there was no significant heterogeneity across the studies with regard to PFWT and Walking Impairment Questionnaire (WIQ) score. SHE programs improved both PFWT and WIQ scores (mean difference of PFWT, 57.76s; 95% CI, 20.42-95.10; P = 0.002; mean difference of WIQ distance score, 8.67; 95% CI, 3.86-13.49; P = 0.0004; mean difference of WIQ speed score, 8.05, 95% CI, 4.46-11.64; P < 0.0001; mean difference of WIQ stair-climbing score, 6.44; 95% CI, 2.55-10.34; P = 0.001). CONCLUSIONS SHE programs improve walking ability in patients with PAD.

Endovascular repair of a type B aortic dissection with a ventricular septal defect occluder

We report a successful endovascular repair of a type B aortic dissection (TB-AD) with a ventricular septal defect (VSD) occluder. In a 39-year-old male patient with TB-AD, the proximal entry tear was 5 mm distal to the orifice of the left subclavian artery (LSA). Ascending aorta-left common carotid artery (LCCA)-LSA bypass was performed, followed by obliterating the proximal entry tear with a VSD occluder endovascularly. One-month follow-up computed tomography angiography showed optimal position of the VSD occluder, absence of leak, complete false lumen thrombosis in the thoracic segment, expansion of the true lumen, and shrinkage of the false lumen.

MicroRNA-98 rescues proliferation and alleviates ox-LDL-induced apoptosis in HUVECs by targeting LOX-1

Oxidized low-density lipoprotein (ox-LDL) is a major and critical mediator of atherosclerosis, and the underlying mechanism is thought to involve the ox-LDL-induced dysfunction of endothelial cells (ECs). MicroRNAs (miRNAs), which are a group of small non-coding RNA molecules that post-transcriptionally regulate the expression of target genes, have been associated with diverse cellular functions and the pathogenesis of various diseases, including atherosclerosis. miRNA-98 (miR-98) has been demonstrated to be involved in the regulation of cellular apoptosis; however, the role of miR-98 in ox-LDL-induced dysfunction of ECs and atherosclerosis has yet to be elucidated. Therefore, the present study aimed to investigate the role of miR-98 in ox-LDL-induced dysfunction of ECs and the underlying mechanism. It was demonstrated that miR-98 expression was markedly downregulated in ox-LDL-treated human umbilical vein ECs (HUVECs) and that miR-98 promoted the proliferation and alleviated apoptosis of HUVECs exposed to ox-LDL. In addition, the results demonstrated that lectin-like oxidized low-density lipoprotein receptor 1 (LOX-1) was a direct target of miR-98 in HUVECs, as indicated by a luciferase assay. The results of the present study suggested that miR-98 may inhibit the uptake of toxic ox-LDL, maintain HUVEC proliferation and protect HUVECs against apoptosis via the suppression of LOX-1.

Endovascular versus Open Surgery Repair of Ruptured Abdominal Aortic Aneurysms in Hemodynamically Unstable Patients: Literature Review and Meta-Analysis

BACKGROUND The better outcome achieved by endovascular aortic repair (EVAR) in ruptured abdominal aortic aneurysm (rAAA) patients might derive from the fact that patients with hemodynamic instability preferentially underwent open repair. To further evaluate the effect of EVAR for rAAAs, a meta-analysis of studies in which hemodynamic instability was similar between the 2 treatment groups was conducted. METHODS MEDLINE, EMBASE, ISI Web of Knowledge, and the Cochrane Library were searched from January 2004 to May 2014 for randomized controlled trials (RCTs) and observational studies that compared EVAR with open surgery repair in rAAA patients. RESULTS Three RCTs and 10 observational studies covering 1,784 patients were included. Perioperative mortality occurred in 27.3% of the patients treated with EVAR and in 38.1% of the patients who underwent open repair. Subgroup analysis revealed consistent results in favor of EVAR in single-center, observational studies. Subgroup analysis and meta-regression analysis indicated that the superior effect of EVAR might be associated with more anatomically suitable patients in EVAR group. CONCLUSION The findings from our meta-analysis support EVAR in properly selective rAAA patients.

Endovascular repair of an aortic arch pseudoaneurysm by an atrial septal defect occluder combined with a chimney stent

An aortic arch pseudoaneurysm distal to the left common carotid artery (LCCA) was repaired endovascularly with an atrial septal defect occluder. Aortography showed complete closure of the pseudoaneurysm but delayed blood flow in the LCCA. A chimney stent was then placed into the LCCA to salvage it. Completion angiography suggested free flow in the LCCA and a minor perioccluder leak, which disappeared at 1-month follow-up. The patient was free from any symptoms related to the pseudoaneurysm at 1-year follow-up, with the atrial septal defect occluder in a satisfactory position, absence of leaking, and complete thrombosis in the pseudoaneurysm cavity.

Restrictive bare stent prevents distal stent graft-induced new entry in endovascular repair of type B aortic dissection

Objective Distal stent graft‐induced new entry (SINE) can occur after thoracic endovascular aortic repair (TEVAR) of type B aortic dissection. This study investigated the mechanism of distal SINE and its prevention using a restrictive bare stent (RBS) technique. Methods From January 2013 to December 2014, 68 consecutive type B aortic dissection patients received endovascular repair at our center. The RBS technique was used with distal oversizing (between the diameter of the thoracic stent graft and the descending aorta true lumen diameter at the level of the intended distal edge of the thoracic stent graft) >20%. Results Twenty‐three patients received TEVAR with a single thoracic stent graft (TEVAR group, n = 23); the rest received TEVAR combined with the RBS technique (TEVAR + RBS group, n = 45). Four distal SINEs occurred in the TEVAR group. Distal oversizing (69.7% ± 35.5% vs 31.2% ± 24.5%; P = .005) and expansion mismatch ratio (132.2% ± 16.9% vs 106.5% ± 11.6%; P < .05) were significantly higher in the SINE patients. Compared with standard TEVAR, TEVAR + RBS was associated with significantly lower distal oversizing (TEVAR vs TEVAR + RBS group, 59.8% ± 24.7% vs 16.7% ± 7.6%; P < .05), lower expansion mismatch ratio (113.8% ± 14.6% vs 103.8% ± 11.7%; P = .012), and lower distal SINE rate (4/23 [17.4%] vs 0/45 [0%]; P = .011). Compared with the TEVAR group, the false lumen was reduced significantly at the level of the RBS distal edge (P = .029). Conclusions Excessive distal oversizing and distal expansion mismatch ratio may contribute to the occurrence of distal SINE. The RBS technique reduced the incidence of distal SINE. Based on our midterm and long‐term observations, implantation of an RBS may improve aortic remodeling.

Octopus Endograft Technique to Treat a Ruptured Thoracoabdominal Aortic Aneurysm

Purpose: To report the use of the octopus endograft technique to treat a patient with a ruptured thoracoabdominal aortic aneurysm (TAAA). Case Report: A 46-year-old man was diagnosed with a contained rupture of a 9-cm type V TAAA. The presence of an occluded superior mesenteric artery (SMA), a stenotic celiac trunk, an enlarged inferior mesenteric artery (IMA), and rich collaterals with the SMA and celiac trunk made endovascular repair with the octopus endograft technique appear feasible. Two stent-grafts were overlapped in the thoracic aorta with the short limb of the distal bifurcated stent-graft about 3 cm above the celiac trunk and the long limb at the level of the renal arteries. A limb graft was introduced into the long limb of the bifurcated stent-graft and deployed with the lower end just above the orifice of the IMA. The celiac trunk was embolized. Viabahn stent-grafts were deployed through the bifurcated stent-graft limbs to revascularize the renal arteries. Completion angiography suggested free flow in the renal arteries, though the gutters around the Viabahn stent-grafts generated a moderate endoleak that persisted at 4-month follow-up. The gutters were then sealed with coil embolization, which eliminated the endoleak and induced complete thrombosis in the aneurysm sac at the 6-month follow-up. One-year computed tomography revealed significant sac shrinkage. Conclusion: The octopus endograft technique may serve as a feasible, effective, and safe treatment alternative for highly selected patients with ruptured TAAA.