Carotid endarterectomy in the real world: Controversies and thinkings / 第二军医大学学报

As the “gold standard” treatment for carotid artery stenosis to prevent ischemic stroke, carotid endarterectomy (CEA) has heen widely accepted in the western countries; hut was developing rapidly only within the past years in China. We noticed that many surgeons in China can master the surgical skills, hut there is still much room for improvement in their concept understanding, surgical procedure selections, technical concepts, complication management and other aspects. Many surgeons are still puzzled by the following questions during their clinical practices, such as “Is it the plaque or intima that should he resected in CEA?” “How to resect?” “How to select the resecting site?” “To what extent should it be resected?”. and “Whether to perform additional vascular culling and anastomotic plasty?”. Hereby, we summarize the above four controversies of CEA in the real world, including concept doubt, surgical tangle, conceptual differences and technical confusion. We also put forward our thinkings on the issues and shared the latest developments in this field.

Aortorenal bypass with autologous saphenous vein in Takayasu arteritis-induced renal artery stenosis: an analysis of 33 cases / 中华外科杂志

<p><b>OBJECTIVE</b>To clarify the outcome of surgical reconstruction for renal artery in Takayasu arteritis-induced renal artery stenosis (TARAS).</p><p><b>METHODS</b>A retrospective chart review was conducted on 33 consecutive patients with TARAS, who underwent aortorenal bypass (ARB) with autologous saphenous vein graft. There were 9 male and 24 female patients, with a mean age of (25 ± 11) years. The effects on blood pressure and renal function were analyzed. Primary, primary assisted, and secondary patency rates were determined. The effects of various factors on primary patency rate were analyzed. All patients showed hypertension. The mean blood pressure was (175 ± 26)/(100 ± 19) mmHg (1 mmHg = 0.133 kPa). The mean antihypertensive dosage was (2.1 ± 0.6) defined daily dose (DDD). Seventeen patients showed intractable hypertension. Mean estimated glomerular filtration rate was (78 ± 5) ml/min. One patient was dialysis-dependent, and 3 patients were combined with congestive heart failure.</p><p><b>RESULTS</b>ARB was performed for the 39 renal arteries, including 27 unilateral and 6 bilateral bypasses. Postoperative morbidity was 15.2%. All patients survived. During follow-up of mean (56 ± 18) months, two graft occlusions and four graft restenoses occurred. All graft restenoses were eliminated successfully with percutaneous angioplasty, but one patient experienced restenosis again six months later. At 1, 3, and 5 years of follow-up, primary patency was 92%, 89%, and 79%, respectively, primary assisted patency was 95%, 95%, and 91%, respectively, and secondary patency was 95%, 95%, and 91%, respectively. ARB resulted in a decrease in mean blood pressure to 139/85 mmHg (one month post-ARB, P = 0.000) and 136/80 mmHg (last follow-up, P = 0.000), and a reduction in mean antihypertensive dosage to 1.4 DDD (one month post-ARB, P = 0.084) and 0.6 DDD (last follow-up, P = 0.000). Mean estimated glomerular filtration rate increased to 82 ml/min (P = 0.458) one month post-ARB, and 91 ml/min (P = 0.044) at last follow-up, respectively. The dialysis-dependent patient no longer required hemodialysis, and left ventricular dysfunction resolved in all of the three patients.</p><p><b>CONCLUSION</b>ARB using the autologous saphenous vein graft is safe, effective and durable for treating TARAS.</p>

Effect of the size of abdominal aortic aneurysm on endovascular exclusion and its results / 中华外科杂志

<p><b>OBJECTIVE</b>To evaluate the effect of the diameter of abdominal aortic aneurysm (AAA) on endovascular exclusion (EVE) and its results.</p><p><b>METHODS</b>From March 1997 to June 2007, 429 AAA patients were treated with endovascular stent-graft exclusion. According to the maximal diameter of abdominal aortic aneurysm, the patients were divided into two groups: group A (diameter < 55 mm, n = 274) and group B (diameter > or = 55 mm, n = 155). The diameter of AAA, involvement of iliac artery, length, diameter and distortion of aneurismal neck in the two groups were recorded and compared retrospectively.</p><p><b>RESULTS</b>Patients in group B were significantly older than group A (73.7 vs 71.1 years, P < 0.05). More patients in group B was complicated with coronary artery disease than those in group A (P < 0.05). The mean diameter of AAA in group A was (46.6 +/- 6.8) mm, and (66.8 +/- 11.2) mm in group B (P < 0.05). Proximal aneurysmal necks were shorter, wider and more tortuous in group B than those in group A (P < 0.05). Extraperitoneal approach, embolism of inner iliac artery and reconstruction of another inner iliac artery and stretch technique were more applied in group B. There were more endoleak during operation in group B and more stent-grafts were used. There was significant difference in morbidity rate between the two groups, while no statistic difference in mortality. And in group B, there were a high rate of endoleak and secondary intervention post operation.</p><p><b>CONCLUSIONS</b>The diameter of AAA affects EVE and its results. In small aneurysms, EVE carries better outcome than in big aneurysms.</p>

Endovascular stent-graft exclusion for Stanford B type aortic dissections: a report of 146 patients / 中华外科杂志

<p><b>OBJECTIVE</b>To assess the operation indications, preoperative evaluation, technique essentials and clinical prospect of endovascular stent-graft exclusion for aortic dissection.</p><p><b>METHODS</b>From September 1998 to April 2003, endovascular stent-graft exclusion for aortic dissection (Stanford B) was preformed in 146 patients. CTA or MRA were used as preoperative evaluation methods. Graft was constructed from self-expanding Z-stents covered with a woven Dacron polyester fabric graft (Talent). The stent-grafts were inserted from the femoral or iliac artery to exclude the tear of dissection, and all operations were performed under DSA guidance.</p><p><b>RESULTS</b>The grafts were installed successfully in 145 patients. In 119 patients only proximal tears were excluded, and 26 patients who had both the proximal and distal tears were excluded. The mean follow-up period was 16 months (1 - 54 months). Six patients died within the perioperative period, 2 patients died during the follow-up, 2 patients had recurrence of aortic dissection (Stanford A) and cured by Bentall operation. The others were in good state. No accidents related to the dissection and operation occurred.</p><p><b>CONCLUSIONS</b>Endovascular graft exclusion may be a safe and effective treatment for selected patients with thoracic aortic dissection. Endoleak may lead to aneurysmal expansion and rupture. Further follow-up is necessary to evaluate its long-term effect.</p>