Advancement in endovascular therapy of aortoiliac occlusive disease / 中华外科杂志

Aortoiliac occlusive disease (AIOD) refers to the stenosis and occlusion of the distal abdominal aorta and(or) bifurcation of the aortoiliac artery,which is mainly caused by atherosclerosis,leading to pelvic and lower limb ischemia.Open surgery has always been the main treatment for complex AIOD.However,in recent years,with the development of endovascular surgery technologies and medical instruments,its treatment concept has been greatly changed.More and more clinical evidence has proved that the long-term efficacy of endovascular therapy is not inferior to that of traditional open surgery,so minimally invasive endovascular therapy has become the preferred treatment for AIOD.

Open and Endovascular Treatment of Trans-Atlantic Inter-Society Consensus II D Aortoiliac Occlusive Lesions: What Determines the Rate of Restenosis? / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Open surgery is the preferred approach for the treatment of type D lesions according to the Trans-Atlantic Inter-Society Consensus (TASC) II guideline, but endovascular solutions also appear to be a valid option in selected patients. The study aimed to identify the risk factors of restenosis after open and endovascular reconstruction of symptomatic TASC II D aortoiliac occlusive lesions (AIOLs).</p><p><b>METHODS</b>Fifty-six patients (82 limbs) who underwent open repair and endovascular treatment (ET) for symptomatic TASC ΙΙ D AIOLs between March 2005 and December 2012 were retrospectively reviewed. Baseline characteristics, preoperative and postoperative imaging, and operation procedure reports were reviewed and analyzed. Restenosis after revascularization was assessed by duplex ultrasound or computed tomography angiogram. Kaplan-Meier survival analysis, Log-rank test, and multivariate Cox regression were used to evaluate the relevance between risk factors and patency.</p><p><b>RESULTS</b>The mean duration of follow-up was 42.8 ± 23.5 months (ranging from 3 to 90 months). Primary patency rates at 1-, 3-, 5-, and 7-year were 93.6%, 89.3%, 87.0%, and 70.3%, respectively. Restenosis after revascularization occurred in 11 limbs. Kaplan-Meier survival analysis and the Log-rank test revealed that diabetes, Rutherford classification ≥5 th and concurrent femoropopliteal TASC II type C/D lesions were significantly related to the duration of primary patency. According to the result of Cox regression, diabetes and femoropopliteal TASC ΙΙ type C/D lesions were identified as the risk factors for restenosis after revascularization.</p><p><b>CONCLUSION</b>This study demonstrated that diabetes and femoropopliteal TASC ΙΙ type C/D lesions are risk factors associated with restenosis after open and ET of TASC II D AIOLs.</p>

Diagnosis and surgical treatment results of angio-Behçet syndrome: an analysis of 26 patients / 中华外科杂志

<p><b>OBJECTIVE</b>To analyze the diagnosis and surgical treatment results of angio-Behçet syndrome.</p><p><b>METHODS</b>The clinical data of pre-operation diagnosis, surgical treatment methods and prospective efficacy of 26 patients who were diagnosed as Behçet syndrome between January 2003 and April 2011 was analyzed retrospectively. There were 23 male and 3 female patients, aging from 20 to 76 years with a mean of (37 ± 6) years. Among them, 3 patients showed the clinical symptoms as arterial stenosis or occlusion, 9 patients had aneurysm, 13 patients had phlebitis or phlebothrombosis. One patient had both aneurysm and venous thrombosis. Totally 11 patients had experienced 22 cases surgical treatment including interventional therapy for 8 cases, open operation for 13 cases and hybrid operation for 1 case.</p><p><b>RESULTS</b>Twenty-two patients (84.6%) were followed up from 3 months to 96 months after various surgical treatment methods. The average follow-up periond was 39.3 months. Totally, perioperative mortality was 1/11 after surgical treatment. Healing rates were 7/8 and 8/13, recurrence rates were 5/8 and 7/8 in patients with interventional therapy compared with that of experiencing open surgery respectively.</p><p><b>CONCLUSIONS</b>Behçet syndrome patients combined with various vascular lesions should be thought of angio-Behçet syndrome. Choosing correct surgical treatment according to patient's condition and timing of pathological changes are the keys of gaining satisfactory results.</p>

Analysis of surgical treatment results in 120 cases of Budd-Chiari syndrome / 中华外科杂志

<p><b>OBJECTIVE</b>To evaluate the results of the surgical treatment of patients with Budd-Chiari syndrome (BCS).</p><p><b>METHODS</b>The clinic data of 120 BCS patients who underwent various consecutive surgical treatments from July 2001 to October 2010 was analyzed. There were 82 male and 38 female patients, aging from 11 to 72 years with a mean age of (41 ± 13) years. All patients experienced various examinations to identify the pathological type of BCS. There were 5 cases of small hepatic veins type, 28 cases of large hepatic veins (LHV) type, 31 cases of inferior vena cava (IVC) type and 56 cases of combined obstruction of LHV and IVC. Totally, 25 patients experienced interventional treatment, include percutaneous transluminal angioplasty and/or stenting for stenosis of hepatic vein and/or IVC, 77 patients experienced open-thorax operation for BCS radical resection under protection of right atrium by-pass with extracorporeal circulation.</p><p><b>RESULTS</b>Totally 97 cases were followed up from 1 to 120 months after various surgical treatment methods. Perioperative mortality was 6.2% (6/97). Follow-up period mortality was 8.2% (8/97). The restenosis of IVC and/or hepatic vein happened in 3 cases out of 25 cases in intervention treatment group in contrast with 15 cases out of 77 cases in radical resection group. The 5-year patency and survival rate of IVC/hepatic vein were 64.5% and 83.3%.</p><p><b>CONCLUSIONS</b>The surgical treatment of BCS need to get accurate diagnosis and pathological classification firstly, then, to choose appropriate therapeutic strategies based on individual pathological classification. The BCS radical resection can be an alternative method in some particular pathological classifications and the cases who failed in interventional treatment.</p>

Single-stage replacement of total aorta for type I dissection with renal failure / 中华外科杂志

<p><b>OBJECTIVE</b>To investigate the feasibility of one-stage replacement of total aorta for patient with renal failure.</p><p><b>METHODS</b>The patient was male, 43 years old. The type I aortic dissection was secondary to type III aortic dissection 4 months after endovascular treatment of descending aorta using stented graft 1 year ago. All important branches from aorta were irrigated by false lumen of dissection except left renal artery. The patient has been dialyzed because of renal failure before 5 months with low platelets. Single-stage replacement of total aorta from ascending aorta to iliac artery was successful under deep hypothermia and cardiopulmonary bypass. The operation lasted 12 h. Blood loss during operation was 9000 ml and infusion of blood and blood plasma 7300 ml (including 1500 ml of blood retrieval) and blood platelet 800 ml.</p><p><b>RESULTS</b>Autonomic activity of four limbs was recovered 2 d after operation, and mind recovered 4 d after surgery. The intubation of trachea was extracted 1 week after operation. Re-check through CT showed all vascular prostheses and reconstructed visceral arteries and intercostal arteries were patent though no recovery of renal function.</p><p><b>CONCLUSION</b>One-stage replacement of total aorta for patient with renal failure is feasible.</p>

Preliminary study on etiology of Budd-Chiari syndrome through clinic and experiment / 中华外科杂志

<p><b>OBJECTIVE</b>To investigate the etiology of Budd-Chiari syndrome (BCS) preliminarily.</p><p><b>METHODS</b>The clinical findings of radical surgery of 109 cases with BCS from March 2001 to May 2009 were analyzed. The pathological components of membranous tissue (MT) from inferior vena cava (IVC) or hepatic vein (HV) of BCS patients were compared with that of thrombus from deep venous thrombosis (DVT), as well as the expression of transforming growth factor beta receptor (TGF-beta R), platelet derived growth factor receptor (PDGFR), endothelin (ET-1), factor VIII related antigen (FVIII-rAg), ferritin and alpha1-antitrypsin in MTs and thrombus through immunohistochemical method.</p><p><b>RESULTS</b>One hundred and four cases of BCS were due to IVC and/or HV membrane or thrombosis except that 4 cases due to IVC tumor or 1 case due to compression of fiber. The new-formed IVC membrane was found in 2 recurred cases whose IVC thrombus was excised before 1 year and 7 years. The development from organized thrombus to MT was found in 3 cases of segmental obstruction of IVC. The IVC membrane located below HV outlet was in 8 cases. Both MTs and thrombus had the pathological components such as fibroblast, neutrophil, granulation tissue, newly-formed blood vessels and so on under the light microscope. The expressions of TGF-beta R, PDGFR, ET-1, FVIII-rAg, and ferritin in MTs and thrombus were as follows: MT 72.3%, thrombus 50.0% (P > 0.05); MT 45.5%, thrombus 100% (P < 0.05); MT 100%, thrombus 0 (P < 0.05); MT 90.9%, thrombus 12.5% (P < 0.05); MT 72.3%, thrombus 100% (P > 0.05).</p><p><b>CONCLUSIONS</b>The membranous tissues and thrombus have the similar homogeneity and cytokines expression. The membrane and thrombus may be different pathological phases.</p>

Management of prosthetic graft infection after lower limb arterial bypasses / 中华外科杂志

<p><b>OBJECTIVE</b>To summarize the experience in management of prosthetic graft infection (PGI) after lower limb arterial bypasses and investigate optimal measures for prevention and treatment.</p><p><b>METHODS</b>Records of 15 cases of PGI between January 2004 and December 2009 were retrospectively analyzed, including 14 male and 1 female with the average age of 64.8 years (ranged from 40 to 84 years). PGI occurred from 5 d to 59 months (average 6.4 months) after the last reconstructive procedures with symptoms as follow: nonhealing wound with vascular graft exposure in 8 cases, persistent sinus related to vascular graft with purulent secretion in 5 cases and without secretion in 1 case, and ill-incorporated graft with peri-graft fluid in 1 case. Broad-spectrum antibiotics were administrated in all PGI cases. Surgical treatments included local debridement and drainage in 4 cases (one death from postoperative acute myocardial infarction), local debridement and skin flap rotation in one case, complete removal of the occluded infected grafts in 8 cases including major amputation in 3 cases, removal of patent infected graft and extra-anatomic bypass with silver-bonded Dacron vascular graft in 1 case, and partial removal of patent infected graft without reconstruction in 1 case with a re-canalized stent-graft.</p><p><b>RESULTS</b>Limb salvage was achieved in 9 cases, and 4 cases received major amputation. One case was failed to follow-up and one died of postoperative acute myocardial infarction. Initially 13 patients were followed and 2 died during follow-up (because of colon carcinoma and intracranial hemorrhage respectively). Eleven patients were followed for 1 to 70 months (average 22.3 months) including 8 cases with limb salvage and 3 with major amputation. Accumulative mortality rate, amputation rate, and graft occlusion rate were 20% (3/15), 26.7% (4/15), and 53.3% (8/15) respectively.</p><p><b>CONCLUSIONS</b>PGI after lower limb arterial bypasses is a devastating complication with high risk of graft occlusion and amputation. Removal of the infected grafts may be mandatory for most cases, but local management for patent infected grafts may be recommendable for selected cases.</p>

The expression of chemokine-like factor 1 in human atherosclerotic plaques / 中华外科杂志

<p><b>OBJECTIVE</b>To evaluate the difference of the expression level of chemokine-like factor 1 (CKLF1) mRNA and protein between human atherosclerotic plaques and normal arteries.</p><p><b>METHODS</b>Real-time quantitative PCR was performed with experimental group (24 cases of atherosclerotic plaques) specimens and control group (25 cases of normal arteries) specimens. Serial microscopic sections were used for immunohistochemistry with CKLF1 antibody in 17 experimental group specimens and 10 control group specimens.</p><p><b>RESULTS</b>The endothelial cell, vascular smooth muscle cell (VSMC) and macrophage were CKLF1 positive expression cells in atherosclerotic plaques. There was a foundational expression of CKLF1 mRNA in control group (RQ(Median) = 2.4), and the expression of CKLF1 mRNA in experimental group is up-regulated significantly (RQ(Median) = 132.2, P < 0.05). The VSMC positive expression rate of CKLF1 protein was 100% in experimental group and 70% in control group, the former was up-regulated significantly.</p><p><b>CONCLUSIONS</b>The expression of CKLF1 is up-regulated in atherosclerotic plaques. It may play an important role in the process of immune and inflammatory responses of atherogenesis.</p>

Mid- to long-term outcome of artery bypass in chronic ischemia of lower extremities / 中华外科杂志

<p><b>OBJECTIVE</b>To report the mid- to long-term outcome of artery bypass in chronic ischemia of lower extremities.</p><p><b>METHODS</b>The clinical data of 212 patients treated with bypass operation from January 2002 to April 2007 were retrospectively reviewed. Femoropopliteal artery bypass to above-knee popliteal (FP-ak) was carried out in 111 cases, femoropopliteal artery bypass to below-knee popliteal (FP-bk) in 59 cases, aortoiliac bypass in 25 cases and femorofemoral bypass in 17 cases.</p><p><b>RESULTS</b>One hundred and eighty-six patients (87.7%) were followed up for 6 to 68 months (median, 18 months). One-year primary patency rate of FP-ak and FP-bk was 69.7% and 53.5%, respectively. After graft revision, 1-year secondary patency rate of FP-ak and FP-bk were 81.6% and 60.5%, respectively. The 3-year patency with FP-ak (56.3%) was significantly higher than that in FP-bk (23.8%) (P < 0.05). Fifty-two cases were reoperated on during the follow-up period. Crural or femoral amputation could not avoid in 23 cases (limb salvage rate 89.2%). Ten cases died in 1 to 30 days after the operation, 20 cases died later during followup, and most of them died of cardio-cerebrovascular diseases. Artificial vessel infection occurred in 6 cases.</p><p><b>CONCLUSIONS</b>The selection of surgical treatment for chronic ischemia of lower extremities should based on the ischemic state of the limb. The mid- to long-term patency rate of FP-ak is higher than that of FP-bk.</p>

Surgical treatment of tumor invading important vessel / 中华外科杂志

<p><b>OBJECTIVE</b>To sum up preliminary experience of successful resection of tumor involving important vessel in 77 cases.</p><p><b>METHODS</b>Seventy-seven cases were treated in this series including 47 cases in male and 30 cases in female. The ages ranged from 18 to 75 years with the average of 57. The tumor involving thoraco-abdominal cavity was in one case with malignant neuroblastoma. The tumor from retro-peritoneum invaded into the whole inferior vena cava (IVC), and into two-thirds of the right atrium. Tumor located in thoracic cavity were in 13 cases including IVC leiomyosarcoma in 2 cases, thymic carcinoma in 3 cases, malignant thymoma in 4 cases, malignant seminoma of superior mediastinum in 1 case, malignant lymphoma in 1 case, lung cancer in 2 cases. The tumor located in abdominal cavity were in 24 cases including renal carcinoma with tumor thrombi in 11 cases, inflammatory pseudotumor of retro-peritoneum in 4 cases, malignant fibrous histiocytoma of retro-peritoneum in 1 case, non-Hodgkin's disease of retro-peritoneum in 1 case, lymph metastasis of retro-peritoneum in 2 cases, paraganglion tumor of the right adrenal gland in 1 case, ampullary carcinoma in 1 case, leiomyosarcoma of abdominal IVC in 1 case, leiomyosarcoma of pelvic cavity and IVC in 1 cases, fibrosarcoma of pelvic cavity in 1 case. Tumor located in four extremities in 6 cases including osteogenic sarcoma in 3 cases, vascular endotheliosarcoma of the left iliac fossa in 1 case, neurofibroma of the left upper extremity in 1 case, lymphoma of double groin in 1 case. Tumor located in neck in 33 cases including carotid body tumor in 32 cases and neurofibroma of the left upper extremity in 1 case.</p><p><b>RESULTS</b>Complete resection of tumor was in 72 cases, with a rate of 93.5%, palliative resection of tumor was in 5 cases with a rate of 6.5%. No operative death occurred. Four cases died during peri-operative period. Reconstruction of involving vessel with vascular graft was in 13 cases, and shaping or patch closure of vessel was applied in 22 cases. Temporary shunt of carotid artery for neck tumor was used in 18 cases. No death occurred for benign tumor. The survival rate more than half year was 90.4%, and more than one year was 84.9%.</p><p><b>CONCLUSION</b>The radical resection rate for tumor involving important vessel may be improved with the help of vascular technique.</p>

Balloon dilation alone in treatment of arteriosclerotic stenosis or occlusions of femoropopliteal arteries / 中华外科杂志

<p><b>OBJECTIVE</b>To evaluate the use and efficacy of balloon dilation in arteriosclerotic stenosis or occlusions of femoropopliteal arteries.</p><p><b>METHODS</b>Thirty patients (27 men, 3 women, age from 44 to 78 years, mean 70) with arteriosclerotic stenosis or occlusion of femoropopliteal arteries received balloon dilation. Thirty-one balloons, which included 3 common balloons, 16 cutting balloons, 10 "deep" balloons and 2 small balloons, were used. Follow-up surveillance featured periodic physical examination and duplex scanning.</p><p><b>RESULTS</b>In all 30 patients, the technique success was reached only with 6 minor dissections. Angiography after dilation showed that the treated vessels were all patent with a < 20% stenosis remaining in any given lesions. After treatment and over a follow-up of 1 to 17 months (mean 6 months), the symptoms were relieved and all treated vessels were patent except 1 patient (3.3%) who had a gangrene foot and received limb amputation.</p><p><b>CONCLUSION</b>Balloon dilation has a comparative ratio of one-stage success and short-term patency. Some special balloons seem to have a promising future in the management of femoropopliteal arterial arteriosclerotic lesions.</p>

Diagnosis and treatment of asymptomatic aortic dissection / 中华外科杂志

<p><b>OBJECTIVE</b>To summarize the diagnostic and therapeutic methods of asymptomatic aortic dissection (AD).</p><p><b>METHODS</b>Ten patients of asymptomatic AD were treated from January 2002 to June 2006. The patients were followed up and their data were reviewed retrospectively.</p><p><b>RESULTS</b>Two patients of type A AD treated by open surgery and the 6 patients of type B AD received endovascular stent-graft repair were successfully treated, and no in-hospital death and severe complication occurred. Furthermore, all of them survived during follow-up. One of the 2 patients of type B AD received medical treatment still survive, but the other suddenly died during follow-up. The most possible cause of his death was fatal aorta rupture.</p><p><b>CONCLUSIONS</b>The diagnosis of asymptomatic AD could be missed or mistaken easily because of its asymptomatic. Keeping a high clinical index of suspicion is crucial in establishing the diagnosis of asymptomatic AD. The asymptomatic AD also has high risk of fatal aorta rupture associated with re-dissection and aneurysmal dilatation. Therefore, type A and B asymptomatic AD should be treated by open surgery or endovascular repair respectively if possible. Endovascular stent-graft repair is a safe and effective method for the treatment of type B asymptomatic AD.</p>

Radical surgery for Budd-Chiari syndrome through exposure of the whole hepatic segment of inferior vena cava / 中国医学科学院学报

<p><b>OBJECTIVE</b>To summarize the preliminary experience of a new type of radical treatment of Budd-Chiari syndrome under genuine direct vision.</p><p><b>METHODS</b>We retrospectively analyzed the clinical data of 60 patients who were treated with radical exposing the whole inferior vena cava of hepatic segment in our hospital from September 2001 to October 2006.</p><p><b>RESULTS</b>All lesions were completely resected under direct vision. Among all the patients, 3 were performed under extracorporeal circulation, 52 under catheterization of right atrium, 4 under cell saver, 1 under auto-retrieving of blood. The retrieved blood was from 300 to 4 000 ml. The transfusion of banked blood was from 400 to 2 000 ml for 14 patients, and no transfusion of banked blood were required for other patients. One patient died of renal failure patient died of renal failure during peri-operative period. The new-formed inferior vena cava (IVC) membrane was found in one relapsed patient whose IVC thrombosis removed one year ago. Asymptomatic restenosis of IVC was found in one patient after operation. Symptoms and signs disappeared in other patients after operations.</p><p><b>CONCLUSION</b>The new radical resection provides clearer visual field during operation and thus facilitates the resection of injuries.</p>

Treatment of descending and abdominal aortic pseudoaneurysm with stent-graft: a report of 13 cases / 中华外科杂志

<p><b>OBJECTIVE</b>To explore the effects of stent-graft on treating descending and abdominal aortic pseudoaneurysms.</p><p><b>METHODS</b>Seven cases of descending and 6 cases of abdominal aortic pseudoaneurysms were treated with stent-graft, aging from 28 to 72 years, average 59 years.</p><p><b>RESULTS</b>Eight cases of aortic pseudoaneurysms were completely excluded after the procedure. Slight leakages were found in 5 cases. Leakages disappeared through balloon dilatation in 2 cases, and one more stent-graft cuff implanted in 1 case. Slight leakages were still presented after dilatation in the other 2 cases, however, the leakages disappeared 3 months later. Eleven cases were followed up from 4 to 30 months with a mean of 18.6 months. One case died of massive hemorrhage from upper digestive tract 5 months after operation. The stent-grafts of other cases maintained patent, and no migration occurred. The diameter of the pseudoaneurysm of all cases did not increased.</p><p><b>CONCLUSIONS</b>It is safe, effective and mini-invasive to use stent-graft in the treatment of descending and abdominal aortic pseudoaneurysm, however, the long-term investigation is needed.</p>

Lung squamous cell carcinoma-related genes cloned by using suppression subtractive hybridization / 中华外科杂志

<p><b>OBJECTIVE</b>To identify genes differentially expressed in human lung squamous cell carcinoma (LSCC).</p><p><b>METHODS</b>A subtracted cDNA library of human LSCC constructed by using suppression subtracted hybridization (SSH) method was screened. Clones representing mRNAs that were truly differentially expressed in LSCC but not in its adjacent non-cancerous tissues were identified by semi-quantitative RT-PCR in 12 patients with LSCC. Partial novel genes were detected by Northern blot.</p><p><b>RESULTS</b>Ten differentially expressed gene cDNA fragments of LSSC were obtained by SSH. Among them six were known genes; two sequences were identified but their functions were unknown (hypothetical protein); two were novel (GenBank accession numbers AF363068 and AY032661, respectively). The results from semiquantitative RT-PCR showed that the transcription expression level of PPP1CB, calumenin, S100A2, HSNOV1, OCIA and AY032661 was down-regulated in some LSCC cases, while the transcription of HSP90, ferritin, gp96 and AF363068 was up-regulated in others.</p><p><b>CONCLUSIONS</b>Six known genes identified by SSH technique have been implicated in the pathogenesis of lung carcinogenesis, or they are involved in immunological defense mechanism in human body. Two hypothetical proteins probably also play an important role in the pathogenesis of lung cancer. The function of the two novel genes in lung carcinogenesis are under investigation.</p>