Research on the relationship between levels of soluble cluster of differentiation 40 ligand, matrix metalloproteinase 9 and pregnancy-associated plasma protein A in serum and stability of carotid plaques / 中华外科杂志

<p><b>OBJECTIVES</b>To study the relationship between serum levels of some inflammatory markers and stability of carotid plaques in the patients with carotid plaques and evaluate the ability of each serum marker in identifying vulnerable carotid plaques.</p><p><b>METHODS</b>The study included 65 consecutive patients with carotid plaques confirmed by imaging examinations from March 2008 to March 2010. All the patients were classified as stable plaques group (n = 21) and unstable plaques group (n = 44) according to the characteristic findings of the plaques in MRI such as the thickness of fibrous cap, the existence of large lipid core and the intra-plaque hemorrhage. The patients of unstable plaques group were further classified as unruptured plaques group (n = 29) and rupture plaques group (n = 15) according to the integrity of fibrous cap. Serum levels of soluble cluster of differentiation 40 ligand (sCD40L), matrix metalloproteinase 9 (MMP-9) and pregnancy-associated plasma protein A (PAPP-A) were determined by ELISA.</p><p><b>RESULTS</b>Serum levels of sCD40L and MMP-9 in patients of unstable plaques group, unruptured plaques group and rupture plaques group were all significantly enhanced compared to individuals of stable plaques group (SCD40L: χ(2) = 6.45, 12.04 and 16.23, P < 0.01; MMP-9; F = 2.55, 5.10 and 4.69, P < 0.05). Serum levels of PAPP-A in patients of unstable plaques group and rupture plaques group were all significantly enhanced compared to individuals of stable plaques group (χ(2) = 11.71 and 13.55, P < 0.05). Serum levels of PAPP-A in patients of rupture plaques group were significantly enhanced compared to individuals of unruptured plaques group (χ(2) = 13.19, P = 0.000). sCD40L ≥ 673.22 ng/L (OR = 22.47, 95%CI: 2.11 - 239.81, P = 0.010), MMP-9 ≥ 84.09 µg/L (OR = 10.01, 95%CI: 1.74 - 57.78, P = 0.010) and PAPP-A ≥ 0.101 µg/L (OR = 14.29, 95%CI: 2.69 - 75.90, P = 0.002) were all significantly correlated with the vulnerability of carotid plaques.</p><p><b>CONCLUSIONS</b>There appear to be a relationship between the serum levels of sCD40L, MMP-9 and PAPP-A and the stability of carotid plaques in patients with carotid plaques. High serum levels of the above-mentioned markers may indicate that the plaques were vulnerable or ruptured.</p>

Endovascular management of symptomatic carotid stenosis combined with kinking / 中华外科杂志

<p><b>OBJECTIVE</b>To study the necessity, feasibility, security of carotid angioplasty and stenting (CAS) for symptomatic carotid stenosis combined with kinking.</p><p><b>METHODS</b>Twelve patients with symptomatic carotid stenosis and kinking demonstrated by digital subtraction angiography (DSA) received CAS from December 2003 to December 2009. There were 9 male and 3 female patients, age ranged from 59 to 77 years (mean 69.3 years). All the patients' clinical, imaging, intervention and follow up data were collected and analyzed.</p><p><b>RESULTS</b>All CAS procedures were successfully performed with 14 self-expandable stents placed. The mean degree of stenosis was reduced from 85.6% before stenting to 11.2% after stenting, the angle of kinking, according to Metz' category, were improved from less than 90° to more than 120° in each case. No perioperative procedure related stroke and transient ischemic attack (TIA) occurred. The clinical symptoms and signs of cerebral ischemia were improved or disappeared for all patients. During follow-up of these 12 patients for 6 to 72 months, one patient experienced ipsilateral carotid territory TIA and another patient experienced contralateral carotid territory TIA. DSA follow up of 5 patients demonstrated 1 case with in-stent restenosis and arterial kinking remote to the stent of internal carotid artery. CAS were performed again and CT angiography follow up demonstrated no kinking and restenosis 2 years after the intervention. Duplex scan of the other 7 patients demonstrated neither kinking nor restenosis.</p><p><b>CONCLUSIONS</b>CAS seems to be feasible and safe for the patients with symptomatic kinking and stenosis, and maybe helpful to lower the risk of cerebral ischemia, but further study is needed.</p>

Endovascular treatment of micro-intracranial aneurysms: adverse factors of micro-catheterization and its relevant managements / 中华外科杂志

<p><b>OBJECTIVES</b>To investigate adverse factors that may hinder successful placement and stabilization of the microcatheter during endovascular therapy of micro-intracranial aneurysms (≤ 3 mm in maximum diameter), and to explore the relevant managements.</p><p><b>METHODS</b>Forty-six patients with fifty-one micro-intracranial aneurysms treated by endovascular therapy from June 2001 to October 2009 were retrospectively analyzed for their intervention data.</p><p><b>RESULTS</b>Adverse factors of optimal micro-catheterization mainly included, tortuosity of the proximal vessels (PVs) and the parent artery (PA), relative large gap in diameter among the PVs, the PA and the microcatheter, relative large divergence in direction among the PVs, the PA and the aneurysm dome, and stent deployed in the PA.</p><p><b>CONCLUSIONS</b>Carefully considering the direction of the PVs and the PA, the aneurysm's location and dome orientation, choosing the microcatheter and microwire after balancing among their physical properties, as well as utilizing balloon and/or stent assistance, can facilitate micro-catheterization during endovascular treatment of micro-intracranial aneurysms.</p>

Effect of different duration of clopidogrel pretreatment on platelet activation in patients undergoing stenting / 中华外科杂志

<p><b>OBJECTIVE</b>To investigate the effect of two clopidogrel pretreatment duration on platelet activation in patients undergoing stenting.</p><p><b>METHODS</b>From July 2006 to December 2007 40 elective carotid or vertebral artery stenting patients were assigned into two groups: Group A (n = 24) initiated clopidogrel (75 mg/d) > or = 5 d before stenting; group B (n = 16) initiated 3 - 4 days. Platelet-monocyte aggregates and fibrinogen receptors analyzed by flow cytometric, and platelet aggregation tests using optical aggregometry, as well as serum soluble CD40 ligand quantified by enzyme-linked immunosorbent assay were assessed in peripheral blood samples obtained immediately before and at 0.5, 18 h and 6 d after stenting.</p><p><b>RESULTS</b>Platelet-monocyte aggregates, fibrinogen receptors and serum soluble CD40 ligand were higher in group B than in group A (14.59% vs 8.70%, P = 0.012; 4.87% vs 2.42%, P = 0.024; 5.79 microg/L vs 2.64 microg/L, P = 0.020) at 18 h after stenting. Serum soluble CD40 ligand was higher in group B than in group A (0.49 microg/L vs 0.31 microg/L, P = 0.033) at 0.5 h after stenting.</p><p><b>CONCLUSIONS</b>Premedication before stenting with clopidogrel 75 mg/d merely 3 - 4 d may be insufficient to achieve adequate platelet inhibition, whereas clopidogrel initiated at least 5 d could obtain preferable clinical antiplatelet efficacy.</p>

Evaluation of cerebral hemodynamics in geriatric carotid stenosis pre- and post-carotid artery stenting / 中华外科杂志

<p><b>OBJECTIVES</b>To explore influencing factors of regional cerebral blood flow (rCBF) in geriatric carotid stenosis, and to analyze changes of rCBF and clinical symptoms after carotid stenting.</p><p><b>METHODS</b>During August 2005 and April 2008, 68 geriatric patients of carotid stenosis having SPECT examination in our hospital were retrospectively studied, whose diagnosis was approved by angiography. Correlated rCBF was compared separately in different stenotic degrees of carotid stenosis, in unilateral or bilateral stenosis, accompanied with vertebrobasilar stenosis (VBS) or not, with collateral circulation or not, before and after carotid stenting.</p><p><b>RESULTS</b>When patients of unilateral carotid stenosis were grouped by different clinical factors, cases of patients with reduced rCBF were compared using chi(2) test: the P value was 0.046 and 0.020 when comparing group of stenotic degree 90% - 99% with group 70% - 89% and group 50% - 69%; the P value was 0.927 between group accompanied with VBS and group without; the P value was 0.222 between group with collateral circulation and group without. When comparing reduced rCBF cases between unilateral and bilateral carotid stenosis, the P value was 0.046. After carotid stenting, 76% of patients had their rCBF improved, and also the scores of presenting symptoms evaluated by modified Rankin scale were elevated from 1.4 +/- 0.7 on admission to 0.4 +/- 0.3 postoperatively (P < 0.001).</p><p><b>CONCLUSIONS</b>The research indicates that higher stenotic degree and bilateral carotid stenosis may cause rCBF decrease in geriatric carotid stenosis. Carotid stenting may improve rCBF and change clinical symptoms significantly.</p>

Changes of nitric oxide and endothelin serum level after carotid balloon denudation or stent assisted angioplasty: an experimental and clinical observation / 中华外科杂志

<p><b>OBJECTIVE</b>To observe the changes of nitric oxide (NO) and endothelin (ET) serum level in the Guangxi BA-MA minipigs whose carotid arteries were injured by balloon denudation and in the patients with carotid stent assisted angioplasty.</p><p><b>METHODS</b>Twelve Guangxi BA-MA minipigs were chosen. High fat/cholesterol feeding and endovascular balloon denudation were used to create a carotid artery atherosclerotic stenosis animal model. Blood samples were collected from peripheral veins before starting the procedure, and again, at 2 and 3 weeks after the procedure, respectively. Serum NO and ET concentrations of blood samples were tested. Nineteen patients with carotid artery stenosis who underwent stent assisted angioplasty were randomly selected, and their serum NO and ET were tested using the same methods as above.</p><p><b>RESULTS</b>In the animal group, there was a significant decrease of mean NO concentration at 2 weeks after carotid injury (t-test, P < 0.05), however, no significant change of ET was observed. A very significant increase of ET was observed at 3 weeks after the procedure (t-test, P < 0.01). In the patient group, there were no significant differences among serum NO or ET concentration of peripheral vein blood before, immediately after, and 6 h after the endovascular treatment.</p><p><b>CONCLUSIONS</b>In this study, a decrease of NO concentration and an increase of ET concentration of peripheral vein blood are found in BA-MA minipigs after carotid arteries are injured by balloon denudation, which might be a cue for the formation of atherosclerosis. However, no significant changes are observed in this group of patients who underwent carotid angioplasty treatment. Therefore, further studies are needed.</p>

Treatment of patients older than 60 years with symptomatic vertebrobasilar artery stenosis / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Vertebrobasilar artery stenosis is an important cause of ischemic posterior circulation strokes. This study aimed at evaluating the safety and efficacy of treatment including conservative therapy alone and conservative plus endovascular therapy for elderly patients with symptomatic vertebrobasilar artery stenosis.</p><p><b>METHODS</b>Patients older than 60 years with symptomatic vertebrobasilar artery stenosis (> or = 50%) confirmed by cerebral angiography were enrolled. All of them were treated with medical therapy and some with additional stent-assisted angioplasty (the stenting subgroup). Their clinical, imaging, intervention and follow-up data were analyzed.</p><p><b>RESULTS</b>One hundred and seventeen consecutive elderly patients (100 men, mean age (68.1 +/- 5.1) years) were enrolled and followed up for a mean time of 28.4 months; 81.7% of them were symptomatically resolved or improved; a stroke rate of 5.1% and a stroke-related death rate of 1.7% were found among them during the hospitalization and follow-up. In the stenting subgroup, 78 balloon expandable stents were employed in the 70 patients with a technical success rate of 98.7% and the mean degree of stenosis was significantly reduced from (81.7 +/- 14.3)% before stenting to (8.3 +/- 4.2)% after stenting (P < 0.001). Four (5.7%) periprocedural strokes occurred, of whom two led to death within 30 days after the procedure. During the follow-up (mean 27.7 months), sixty of the surviving 68 patients in the stenting subgroup were symptomatically resolved or improved. Only one (1.5%) posterior circulation stroke occurred, while duplex ultrasound scan of 34 patients demonstrated 10 (29.4%) in-stent restenosis.</p><p><b>CONCLUSIONS</b>Appropriate utilization of conservative therapy alone and conservative plus endovascular therapy may improve short-term clinical outcomes for elderly patients with symptomatic vertebrobasilar artery stenosis. Furthermore, stent-assisted angioplasty is technically feasible and relatively safe in elderly patients.</p>

Clinical study and numerical simulation of hemodynamics in the tortuosity of internal carotid artery / 中华外科杂志

<p><b>OBJECTIVES</b>To establish a theoretical model for the tortuosity of internal carotid artery and summarize the hemodynamic rule of blood flow in a tortuous artery. To explore the relationship of cerebral ischemia and tortuous internal carotid artery.</p><p><b>METHODS</b>Taking the internal carotid artery as a prototype, a geometric model of a tortuous artery was constructed according to the normal physiological and anatomical parameters of internal carotid artery. The boundary conditions and calculation conditions of blood flow are proposed. The numerical simulation of the blood flow in the tortuous artery is carried out with finite element method. Hemodynamic parameters of internal carotid artery were measured in 15 cases with the tortuosity of internal carotid artery and in 15 cases of normal control group. Blood pressure was measured by microcatheter connecting a pressure transducer at internal carotid artery, pre-tortuous and post-tortuous artery. The diameter and length of the above artery were measured and calculated by DSA machine.</p><p><b>RESULTS</b>Numerical simulation results indicated pressure drop of blood flow and elongated length of artery is increased with diminution of the angle of tortuous artery. Clinical measurement data disclosed the same trend in the same curve as numerical simulation.</p><p><b>CONCLUSION</b>The elongation and tortuosity of internal carotid artery results in decrease of blood pressure in the distal segment of tortuous internal carotid artery, kinking of internal carotid artery may be one of factors related to attack of cerebral ischemia on certain conditions.</p>

Management of elderly patients with symptomatic vertebrobasilar insufficiency / 中华外科杂志

<p><b>OBJECTIVE</b>To evaluate the feasibility, safety and short-term efficacy of stent-assisted angioplasty and/or drug therapy for elderly patients with symptomatic vertebrobasilar insufficiency.</p><p><b>METHODS</b>Elderly patients (> or = 60 years old) with symptomatic vertebrobasilar stenosis (> or = 50%) demonstrated by cerebral angiography were treated with drug therapy and some with endovascular stenting further from April 2001 to June 2006. The clinical, imaging, intervention and follow-up data were collected and analyzed.</p><p><b>RESULTS</b>Eighty-one elderly patients were chosen for study, including 68 males and 13 females. The mean age is 70 years (60 - 87 years); stroke rate of 4.9% (4/81) and stroke-related mortality rate of 2.5% (2/81) were found in this group during hospitalization and follow-up (mean 28.1 months), and symptoms resolved or improved clinically in 66 (81.5%). Fifty-two balloon expandable stents were placed in 48 (59.3%) patients of this group with a technical success rate of 98.1% and the mean degree of stenosis was reduced from (82.4 +/- 13.1)% to (6.4 +/- 3.2)% (t = 22.4, P = 0.00).</p><p><b>CONCLUSIONS</b>Appropriate management including endovascular stenting and/or drug therapy may improve short-term outcomes of elderly patients with symptomatic vertebrobasilar insufficiency; meanwhile, stent-assisted angioplasty is technically feasible and relatively safe.</p>