Diabetes mellitus and adverse outcomes after carotid endarterectomy: A systematic review and meta-analysis / 中华医学杂志(英文版)

BACKGROUND@#There is still uncertainty regarding whether diabetes mellitus (DM) can adversely affect patients undergoing carotid endarterectomy (CEA) for carotid stenosis. The aim of the study was to assess the adverse impact of DM on patients with carotid stenosis treated by CEA.@*METHODS@#Eligible studies published between 1 January 2000 and 30 March 2023 were selected from the PubMed, EMBASE, Web of Science, CENTRAL, and ClinicalTrials databases. The short-term and long-term outcomes of major adverse events (MAEs), death, stroke, the composite outcomes of death/stroke, and myocardial infarction (MI) were collected to calculate the pooled effect sizes (ESs), 95% confidence intervals (CIs), and prevalence of adverse outcomes. Subgroup analysis by asymptomatic/symptomatic carotid stenosis and insulin/noninsulin-dependent DM was performed.@*RESULTS@#A total of 19 studies (n = 122,003) were included. Regarding the short-term outcomes, DM was associated with increased risks of MAEs (ES = 1.52, 95% CI: [1.15-2.01], prevalence = 5.1%), death/stroke (ES = 1.61, 95% CI: [1.13-2.28], prevalence = 2.3%), stroke (ES = 1.55, 95% CI: [1.16-1.55], prevalence = 3.5%), death (ES = 1.70, 95% CI: [1.25-2.31], prevalence =1.2%), and MI (ES = 1.52, 95% CI: [1.15-2.01], prevalence = 1.4%). DM was associated with increased risks of long-term MAEs (ES = 1.24, 95% CI: [1.04-1.49], prevalence = 12.2%). In the subgroup analysis, DM was associated with an increased risk of short-term MAEs, death/stroke, stroke, and MI in asymptomatic patients undergoing CEA and with only short-term MAEs in the symptomatic patients. Both insulin- and noninsulin-dependent DM patients had an increased risk of short-term and long-term MAEs, and insulin-dependent DM was also associated with the short-term risk of death/stroke, death, and MI.@*CONCLUSIONS@#In patients with carotid stenosis treated by CEA, DM is associated with short-term and long-term MAEs. DM may have a greater impact on adverse outcomes in asymptomatic patients after CEA. Insulin-dependent DM may have a more significant impact on post-CEA adverse outcomes than noninsulin-dependent DM. Whether DM management could reduce the risk of adverse outcomes after CEA requires further investigation.

Surgical treatment of malignant carotid body tumor / 中华普通外科杂志

Objective:To summarize the surgical treatment of malignant carotid body tumor (MCBT).Methods:A retrospective analysis of 14 MCBT patients admitted at our hospital from Mar 2005 to Nov 2019 was made, and the imaging data, surgical records, perioperative complications and follow-up data were collected.Results:There were 8 males and 6 females, with an average age of (40.8±11.3) years. 10 patients underwent surgical resection of CBT, with one case undergoing tumor enucleation only, nine cases underwent internal carotid artery reconstruction, and all patients underwent intraoperative lymph node biopsy.Tumors were completely removed in all 10 patients. No perioperative death or cerebral infarction occurred. The intraoperative blood loss was (955±658.5) ml. Four patients had permanent nerve injury after surgery. The follow-up time ranged 1-132 months. There were no cases of cerebral infarction or death, and the reconstructed graft remained patent. Apart from the 2 patients who developed tumor metastasis after surgery, other patients recovered uneventfully with no disease progression.Conclusions:Surgery is still the main treatment for MCBT, but MCBT is large and Shamblin class is more advanced. Therefore, complete tumor removal and reconstruction of the carotid arteries are difficult. Surgery should seek to completely remove the tumor and neck lymph node biopsy should be performed to determine the lymph node metastasis.

Emergent headache after carotid endarterectomy / 中华普通外科杂志

Objective To determine the incidence and clinical features of headache after carotid endarterectomy (CEA).Methods A retrospective analysis was made on the data of patients undergoing CEA in the Department of Vascular Surgery,Peking Union Medical College Hospital from Jan 2014 to Jan 2015.There were 119 males and 24 females,including 97 cases of symptomatic carotid stenosis and 110 cases of severe carotid stenosis.Results The incidence of newly emergent headache after surgery was 44％ (63/143).The earliest time of headache was 30 minutes after surgery and the latest was 6 days after surgery.95％ of headache occurred within 48 hours after surgery (60/63).79.4％ (50/63) of the headache lay ipsilaterally with CEA,and bilateral headache accounted for 20.6％ (13/63).Severe headache accounted for 4.8％ (3/63),all were ipsilaterally frontal and temporal headache,complicating central nervous system symptoms.Conclusions After CEA headache is a common clinical symptom.Most were mild to moderate and unilateral,which can be relieved spontaneously.Cerebral hemodynamics need to be further examined to differentiate the different pathological states of severe headache on the operative side after CEA because of the high risk of developing hyperperfusion syndrome or cerebral infarction.History of TIA or stroke is the risk factor of post-CEA headache.

Impact of the Action Time of Inducers on Differentiation of 3T3-L1 Cells / 中国医学科学院学报

Objective To explore the effect of the action time of inducers on the differentiation of 3T3-L1 cells to adipocytes. Methods According to the "Cocktail" method,3T3-L1 cells were divided into three groups according to the action time of inducers,with the action time being 2,3 or 4 days,respectively. Cell morphology was observed using inverted microscope and adipose content were detected by Oil red "O" staining and detection of triglyceride. The cell viability was identified by trypan blue staining method. Results The proportion of samples (n=12) with differentiation rate above 80% in group A was 66% (12/18),while the differentiation rate of all the samples (n=18)in group B and group C were above 80%. For the Oil red "O",the OD value at 510 nm in group C was 2.59±0.17,which was significantly higher than that in group A (2.12±0.47;F=6.62,P=0.0001)and group B (2.20±0.17;F=5.15,P=0.0001),while no significant difference was found between group A and group B (F=1.14,P=0.74). As for the triglyceride,the value in group C was (1351.04±119.01)ng/ml,which was significantly higher than that in group A[ (1077.88±272.75)ng/ml;F=6.73,P=0.001] and group B [(1089.38±115.39)ng/ml;F=5.78,P=0.001],while no difference was found between group A and group B (F=0.27,P=0.64). The cell viability in group A,B,and C was (98.3±1.2)%,(98.5±1.8)%,and (98.9±2.1)%,respectively,showing no significant difference (F=0.18,P=0.83). Conclusions The modified procedure for the differentiation of 3T3-L1 cells to adipocytes can increase the differentiation rate and thus may be applied for establishing adipocyte models. The recommended action time is three days.

Prediction of Cerebral Hyperperfusion Syndrome with Velocity Blood Pressure Index / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Cerebral hyperperfusion syndrome is an important complication of carotid endarterectomy (CEA). An >100% increase in middle cerebral artery velocity (MCAV) after CEA is used to predict the cerebral hyperperfusion syndrome (CHS) development, but the accuracy is limited. The increase in blood pressure (BP) after surgery is a risk factor of CHS, but no study uses it to predict CHS. This study was to create a more precise parameter for prediction of CHS by combined the increase of MCAV and BP after CEA.</p><p><b>METHODS</b>Systolic MCAV measured by transcranial Doppler and systematic BP were recorded preoperatively; 30 min postoperatively. The new parameter velocity BP index (VBI) was calculated from the postoperative increase ratios of MCAV and BP. The prediction powers of VBI and the increase ratio of MCAV (velocity ratio [VR]) were compared for predicting CHS occurrence.</p><p><b>RESULTS</b>Totally, 6/185 cases suffered CHS. The best-fit cut-off point of 2.0 for VBI was identified, which had 83.3% sensitivity, 98.3% specificity, 62.5% positive predictive value and 99.4% negative predictive value for CHS development. This result is significantly better than VR (33.3%, 97.2%, 28.6% and 97.8%). The area under the curve (AUC) of receiver operating characteristic: AUC(VBI) = 0.981, 95% confidence interval [CI] 0.949-0.995; AUC(VR) = 0.935, 95% CI 0.890-0.966, P = 0.02.</p><p><b>CONCLUSIONS</b>The new parameter VBI can more accurately predict patients at risk of CHS after CEA. This observation needs to be validated by larger studies.</p>

Prevention and treatment for complications of endovascular therapy in aortoiliac artery occlusive disease / 中华普通外科杂志

Objective To discuss the strategies of prevention and treatment for complications of endovascular therapy in aortoiliac artery occlusive disease.Methods 220 cases who received endovascular interventions with aortoiliac artery occlusive disease were retrospectively reviewed from June 2012 to June 2014.Among these patients,189 cases were males.The age was between 46 to 85yrs and the average age was 64yrs.Results The overall technique success rate was 97.2％.Nine procedure-related major complications requiring additional endovascular or surgical treatment were encountered in 7 patients including 2 acute in-stent thrombosis,1 iliac artery rupture,1 distal embolism,and 5 puncture associated complications (2 acute artery thrombosis,1 arteriovenous fistula,1 hematoma,1 artery dissection).8 cases improved after second endovascular or remedial open surgery,among those 4 cases were managed by endovascular interventions including 2 catheter directed thrombolysis,1 cover-stent implantation and 1 balloon-based angioplasty,4 patients received open surgery including 3 thrombectomies,1 hematoma cleating.After 22 months follow-up,the primary patency,assistant-primary patency and secondary patency was respectively 90.8％,92.1％ and 99.2％.Conclusions More attentions should be paid to the complications of endovascular therapy in aortoiliac artery occlusive disease.Helpful to prevent these complications are a comprehensive evaluation of the lesions,and individualized surgical plan prior to the operations,and a careful intraoperative management.

Establishment and functional identification of a stable cell line overexpression heme oxygenase-1 / 中国医学科学院学报

<p><b>OBJECTIVE</b>To establish a stable cell line overexpression heme oxygenase-1 (HO-1) mediated by a modified lentivirus system and identify its function.</p><p><b>METHODS</b>The HO-1 gene was amplified by polymerase chain reaction and cloned into the modified pLentiLox3.7 expression vectors. The recombinant plasmids were transfected into HEK293T cells and the HO-1 was detected by Western blot. The recombinant plasmids were transfected into HEK293T cells to produce the viruses, with the helping plasmids including plp1, plp2, and VSVG. HEK293T cells were infected by the viruses and the cells that can express HO-1 were identified by Western blot. The reactive oxygen species were detected in the HO-1-overexpression HEK293T cells and the normal cells after the adding of hydrogen peroxide. The same experiment was performed with human umbilical vein endothelial cells.</p><p><b>RESULTS</b>The stable cell line that can overexpress HO-1 was established, which was verified by Western blot. The reactive oxygen species in the HO-1-overexpression HEK293T cells and human umbilical vein endothelial cells decreased obviously after exposure to hydrogen peroxide.</p><p><b>CONCLUSIONS</b>The lentivirus-carrying HO-1 was successfully packaged and the stable cell line overexpression HO-1 was established. HO-1 can play a protective role in the course of oxidative damage.</p>

Research advances in endotension after endovascular abdominal aneurysm repair / 中国医学科学院学报

When more abdominal aortic aneurysms are repaired by endovascular approaches, the post-operative endotension without endoleak increase along with the extended follow-up. An early detection of such endotension and a proper differentiation from endoleaks are particularly important for the treatment decision-making. This article reviews the mechanism, diagnosis, and management of endotension.

Comparison of endovascular aortic repair and open surgical repair for ruptured abdominal aortic aneurysm / 中国医学科学院学报

<p><b>OBJECTIVE</b>To compare the clinical efficacies of endovascular aortic repair(EVAR)and open surgical repair(OSR)for ruptured abdominal aortic aneurysm(rAAA).</p><p><b>METHODS</b>The clinical data of 28 rAAA patients undergoing emergent treatment between February 2002 and February 2013 in PUMC Hospital were retrospectively reviewed. Among them 13 cases were treated by EVAR and 15 cases by OSR.</p><p><b>RESULTS</b>Before the surgery,the general conditions,comorbidities,and hemodynamics were not significantly different between these two groups(all P>0.05),although the EVAR group had significantly higher mean age than OSR group(P=0.041). In the perioperative period,the EVAR group showed significantly lower 30-day mortality(P=0.044),less blood loss(P=0.005),less blood transfusion(P=0.003),less infusion quantity(P=0.000),shorter length of procedure(P=0.001),and shorter hospital stay(P=0.020). Also,the EVAR group had no severe perioperative complications and showed superior 1-year follow up survival(P<0.05).</p><p><b>CONCLUSIONS</b>EVAR is an effective treatment for rAAA and can improve the clinical outcomes. EVAR may be adopted as the first-line treatment for rAAA,especially for the aged.</p>

Expressions of p-c-jun and cyclinD1 between vascular smooth muscle cells and endothelial cells exposured to cigarette smoke extract / 中国医学科学院学报

<p><b>OBJECTIVE</b>To investigate the cell viabilities of vascular smooth muscle cells and vascular endothelial cells stimulated by cigarette smoke extract(CSE) .</p><p><b>METHODS</b>The CSE was prepared by smoke-bubbled phosphate buffered saline(PBS) generation.After culturing cells with different concentrations of CSE, we used the cell counting kit-8 to determine the cell viability.The expression levels of c-jun and cyclinD1 were analyzed through Western blot.The c-jun plasmid was transfected to detect the change of cyclinD1 expression.</p><p><b>RESULTS</b>The smooth muscle cell viability increased when the CSE concentration ranged 0.625%-10%, whereas the endothelial cells viability decreased when exposed to the CSE concentration. After exposure to CSE for 48 hours, there was no difference in c-jun expression between toxin group and PBS group;however, the expression of p-c-jun in the smooth muscle cells significantly increased in the toxin groups than in the PBS group(P<0.05) and the expression of p-c-jun in the vascular endothelial cells significantly decreased(P<0.05) . The level of cyclinD1 significantly increased after exposed to CSE, and its expression level also increased in respond to the c-jun overexpression.</p><p><b>CONCLUSION</b>CSE can enhance the proliferation of vascular smooth muscle cells and decrease in the activity of endothelial cells proliferation, which may be explained by the phosphorylation of c-jun and the expression of cyclinD1.</p>

New method to predict cerebral hyperperfusion syndrome after carotid endarterectomy by transcranial Doppler / 中华外科杂志

<p><b>OBJECTIVE</b>To determine the diagnostic value for predicting cerebral hyperperfusion syndrome (CHS) by adding a transcranial Doppler (TCD) measurement at the end of the carotid endarterectomy (CEA) at the operating room.</p><p><b>METHODS</b>Patients who underwent CEA between August 2009 and December 2011 of the prospective clinical trial in whom both intra- and post-operative TCD monitoring were performed were included. The middle cerebral artery velocities pre-clamping, post-declamping and post-operatively were measured by TCD. The intra-operative velocity increase ratio (VR1) was compared to the postoperative velocity increase ratio(VR2) in relation to CHS by calculating the sensitivity,specificity, positive predictive value, negative predictive value. The receiver operating characteristic curve (ROC) were also performed. The area under the curve (AUC) of ROC of VR1 and VR2 were compared.All the data were analyzed using SPSS 20.0 software.</p><p><b>RESULTS</b>VR1 > 100% was identified in 6 patients, while VR2 > 100% was identified in 18 patients, respectively. Ten patients were diagnosed with CHS. The AUC of VR2 (0.728) was higher than AUC of VR1 (0.636). The best fit cutoff point of VR2 was 100%. The sensitivity, specificity, positive predictive value, negative predictive value were 70%, 83%, 39%, 95%, respectively, which demonstrates a better predictive power than VR1.</p><p><b>CONCLUSION</b>Besides the commonly used intra-operative TCD monitoring, additional TCD measurement at the end of the carotid endarterectomy at the operating room is more useful to more accurately predict CHS.</p>

Risk analysis for cerebral hyperperfusion syndrome after carotid endarterectomy / 中华外科杂志

<p><b>OBJECTIVE</b>To analyze risk factors for cerebral hyperperfusion syndrome (CHS) after carotid endarterectomy (CEA).</p><p><b>METHODS</b>From September 2010 to September 2012, 183 consecutive patients with carotid artery stenosis who had indications for CEA entered the study. There were 149 male and 34 female patients, aged from 38 to 83 years with an average of (66 ± 9) years. Intracranial blood flow changes were monitored through transcranial Doppler routinely. Pre- and post-operative middle cerebral artery velocity (VMCA) were recorded. CHS was diagnosed by the combination of hyperperfusion syndrome and 100% increase of VMCA after operation compared with pre-operative baseline values. The patients who had CHS during hospitalization were recorded. Pre-operative and operative related factors were analyzed by univariate analysis, followed by Logistic regression model, to identify the risk factors of CHS.</p><p><b>RESULTS</b>Overall, CHS occurred in 15 patients (8.2%) after CEA. The average onset time was (2.6 ± 0.2) days after surgery. By decreasing blood pressure and using dehydration medicine, all the patients with CHS recovered before discharge. None of them developed to intracranial hemorrhage. On univariate analysis, significant risk factors for CHS were history of stoke, symptomatic carotid artery stenosis and shunting during operation. On Logistic regression model, independent risk factor was symptomatic carotid artery stenosis (OR = 6.733, 95%CI: 1.455-31.155, P = 0.015), while shunting during operation (OR = 0.252, 95%CI: 0.067-0.945, P = 0.041) was a protective factor.</p><p><b>CONCLUSIONS</b>Symptomatic carotid artery stenosis is an independent risk factor for CHS after CEA and shunting during operation is a protective factor. Using shunt may be an effective method of preventing CHS after CEA.</p>

Investigation of endovascular aneurysm repair of complex abdominal aortic aneurysm in high-risk patients / 中华外科杂志

<p><b>OBJECTIVE</b>To evaluate the results of a variety of alternative endovascular techniques applied to patients with complicated abdominal aortic aneurysm complex abdominal aortic aneurysm (cAAA) and unsuitable for open surgery.</p><p><b>METHODS</b>From January 2001 to December 2010, charts of all patients having an abdominal aortic aneurysm (AAA) were reviewed. Endovascular aneurysm repair (EVAR) was done in 138 patients, in which 9 patients were defined as cAAA such as juxta-renal AAA, short or angulated AAA neck, AAA with bilateral iliac artery aneurysms. There were 8 male and 1 female patients, aged from 26 to 87 years with a mean of 67 years. All these patients at high risk for open surgery were offered a modified EVAR technique including fenestrated technique, scallop technique, chimney technique, balloon assisted U-turn stenting and reverse-U stent-graft in 2, 5, 1 and 1 patients respectively.</p><p><b>RESULTS</b>All techniques were successful and without severe postoperative complications. An intraoperative endoleak was found in 4 patients and was corrected immediately. One patient with type I and III endoleaks underwent dilatation with a compliant balloon. Two patients with type I endoleak underwent coil embolization (1 patient) and bare stent (1 patient). During follow-up, one patient with a type II endoleak who demonstrated no increase in sac diameter during follow-up was observed. Mean follow-up was 25.9 months (ranging from 4 to 79 months). No rupture occurred and 8 aneurysms shrink significantly. In 7 patients, critical vessels (renal and mesenteric arteries) were protected during the initial procedure and remained patent except in one patient who was performed reverse "U" stent graft with thrombosis in hypogastric artery.</p><p><b>CONCLUSION</b>High-risk patients with cAAA inappropriate for traditional EVAR can be successfully treated by using simple ancillary endovascular techniques with acceptable short or mid-term results.</p>

Perioperative anticoagulation or antiplatelet therapy in cases of carotid endoarterectomy / 中华普通外科杂志

Objective To evaluate the efficacy and safety of perioperative anticoagulation and antiplatelet therapy of carotid endoarterectomy (CEA). Methods A retrospective study on 110 cases (122 CEAs) of carotid stenosis between Jan 2004 and Dec 2008 was undertaken. 122 cases were divided into anticoagulation group and antiplatelet group according to the perioperative medical treatment. Postoperative results of stroke/death and wound hemotoma were compared between the two groups and statistically analyzed. Results 45 CEAs were given perioperative combination of anticoagulation and antiplatelet treatment. This comprised the anticoagulation group. The antiplatelet group consisted of the other 77 CEAs which were treated with antiplatelet solely. Perioperative stroke/death rates were equivalent (2.2% anticoagulation vs. 2.6% antiplatelet, P =0.897). Wound hemotoma rates were found with statistical significant difference between the two groups (13.3% anticoagulation group vs. 1.3% antiplatelet group, P = 0. 006 ). Conclusion Our results suggest that perioperative antiplatelet therapy in perioperative carotid endoarterectomy does not increase perioperative stroke/death risk, while perioperative anticoagulation increases the risk of wound hematoma.

Diagnosis and treatment of 193 cases under 45 years old with peripheral arterial disease / 中华外科杂志

<p><b>OBJECTIVE</b>To analyze the etiology, characteristics, and treatment outcomes of peripheral arterial disease (PAD) in patients under 45 years old.</p><p><b>METHODS</b>One hundred and ninety-three cases under 45 years old with PAD were included from January 1999 to January 2009. The demography, etiology, surgical data, treatment outcomes of these patients were evaluated and analyzed. Among these patients, males are 171 cases. The age was 13 to 44 years old (average age 35 years old) and the average time between onsets of PAD to admission was 3.6 months. In the 138 patients who underwent surgical interventions, 30 patients had serologically proven thrombophilia, 50 patients without thrombophilia had other definite reasons but not Burger's disease. A total of 116 cases underwent open operations, 17 cases were received endovascular interventions and 5 cases underwent combinative treatments.</p><p><b>RESULTS</b>Among the 193 patients, 140 cases (72.5%) had definite reasons. Forty patients (28.6%) were diagnosed with congenital or acquired hypercoagulability in the 140 cases. The thrombophilia group had poorer primary patency (70.0% vs. 92.0%, P = 0.010) and secondary patency (83.3% vs. 98.0%, P = 0.016) than non-thrombophilia group and more likely to underwent second revascularization because of recurrent thrombosis within 30 days after operations. After 16 months follow-up, the patients with thrombophilia had lower primary patency (65.0% vs. 75.7%, P = 0.392) and secondary patency (80.0% vs. 91.9%, P = 0.192) than the ones without thrombophilia and the rate of amputation was higher in thrombophilia group (15.0% vs. 5.4%, P = 0.222) but, these didn't achieve statistical significance.</p><p><b>CONCLUSIONS</b>A high prevalence rate of thrombophilia is found in patients less than 45 years old with PAD requiring revascularization. Thrombophilia may have contributed to early postoperative thrombosis of the vascular procedure. So the screening and medical therapy to thrombophilia in young adults with PAD should be reinforced before surgical treatment.</p>

Endovascular treatment of critical leg ischemia of arteriosclerosis obliterans / 中国医学科学院学报

<p><b>OBJECTIVE</b>To evaluate the outcomes of percutaneous transluminal angioplasty (PTA) and stenting in the treatment of critical lower extremity ischemia of arteriosclerosis obliterans.</p><p><b>METHODS</b>From April 2005 to May 2006, PTA and stenting was performed on 29 limbs of 24 patients with critical lower limb ischemia. Among all these patients, their main clinical symptom was rest pain, while ulceration and gangrene were also found in 12 patients. Four limbs underwent PTA, 4 limbs underwent prosthetic femoral-popliteal bypass with infrapopliteal balloon dilatation simultaneously, and the remaining 21 limbs were performed by PTA and stent placement.</p><p><b>RESULTS</b>The success rate of endovascular procedure was 100% for femoral-popliteal artery, and 88% for infrapopliteal artery. Rest pain disappeared and the ulcers were healed after the operations. Only 1 patient received amputation during the operation.</p><p><b>CONCLUSION</b>Endovascular therapy is an effective and safe procedure for the treatment of critical lower limb ischemia.</p>