Open and Endovascular Treatment of Trans-Atlantic Inter-Society Consensus II D Aortoiliac Occlusive Lesions: What Determines the Rate of Restenosis?

BACKGROUND: 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). METHODS: 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. RESULTS: 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. CONCLUSION: 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.

[Analysis of surgical treatment results in 120 cases of Budd-Chiari syndrome].

OBJECTIVE: To evaluate the results of the surgical treatment of patients with Budd-Chiari syndrome (BCS). METHODS: 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. RESULTS: 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%. CONCLUSIONS: 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.

[Surgical strategies on intravenous leiomyomatosis invading heart].

OBJECTIVE: To explore the diagnostic features and therapeutic methods of intravenous leiomyomatosis with a potential of heart invasion. METHODS: Eight cases of cardiac involvement with intravenous leiomyomatosis treated at our hospital from November 2002 to August 2011 were analyzed and compared. RESULTS: Either imaging or surgery confirmed that in all 8 patients the pelvic lesions originated from the inferior vena cava and heart involvement without pulmonary embolism. In 3 cases, palpitations and chest tightness were noticed. Four cases showed lower extremity edema and abdominal distension while no obvious clinical symptom was found for 1 case. All 8 cases had a history of uterine fibroids and 6 underwent previous hysterectomy. Among 8 patients, there were 5 cases of cardiopulmonary bypassing right heart, inferior vena cava tumor resection and pelvic involvement vein ligation and 2 cases of routine off-pumping of inferior vena cava with pelvic tumor resection. Palliative therapy was administered in 1 case. Two patients were resection the right heart and inferior vena cava tumor in the cardiopulmonary bypass, 3 months later were resection gynecologic uterine, double-accessories and broad ligament and were not treated with hormone. After operation, another 5 surgery patients received high-dose hormone treatments. 2 cases of recurrence in each group were found by ultrasound follow-ups from 15 - 90 months. CONCLUSION: Invasion of the heart intravenous leiomyomatosis is a rare case, which can be tackled with a good effect by completely surgical resection and a limited effect on hormone therapy to prevent recurrence.

[Surgical strategies for tumors with invasion of thoracic and abdominal great vessels].

OBJECTIVE: To summarize the vascular surgical strategies for chest and abdomen tumors with the invasion of great vessels. METHODS: The clinical data were collected for 67 patients undergoing surgical treatment for tumors with the invasion of thoracic and abdominal great vessels at our hospital from January 2001 to June 2009. Then a retrospective analysis was performed. Among this dataset, there were 31 cases with only vessel wall invasion and 20 cases with only intravascular tumor thrombus. In the meanwhile, both the invasion of vascular walls and the formation of tumor thrombus were located in 16 patients. RESULTS: Among 67 operated patients, various strategies were used, including surgical adhesion lysis (n = 15), vascular resection direct suture (n = 24), artificial blood vessel patch (n = 10), pericardial patch (n = 3), artificial vascular replacement or bypass (n = 15) and cavity thrombectomy (n = 36). Cavity thrombectomy was performed under cardiopulmonary bypass for 8 patents with tumor invasion of right atrium. Among them, 58 patients received radical tumor resection while palliative resection was performed for 9 patients with a rate of complete resection at 86.6%. There was no intraoperative mortality with the perioperative death of 8 cases. A follow-up study was successfully conducted for 52 patients. And 7 patients were lost to follow-up. The overall follow-up rate was 88.1%. By June 2009, the survival period of this group of patients was as follows: 18 cases (> 48 months), 29 cases (> 24 months), 38 cases (> 12 months), 50 cases (> 6 months) and 2 cases (≤ 6 months). Among these patients, the major cause of mortality was tumor metastasis. The patients with kidney cancer showed the most favorable surgical outcomes. CONCLUSION: Managed by a variety of vascular surgical techniques, the patients with tumors involving major blood vessels may achieve an excellent success rate of tumor resection and a better postoperative quality-of-life.

[Management of prosthetic graft occlusion after lower extremity bypasses].

OBJECTIVE: Report the experience of management of graft occlusion in patients with lower extremity bypasses and discuss the appropriate treatment strategy. METHODS: From Oct. 2004 to Oct. 2009, 104 cases of graft occlusion were treated in 53 patients with lower extremity arterial bypasses, including medical therapy for 10 cases and redo operations for 94 cases: graft thrombectomy alone for 26 cases, redo bypass or extension bypass with prosthetic or autologous vein grafts for 23 cases, graft thrombectomy plus balloon angioplasty for 18 cases, major amputation for 14 cases, graft thrombectomy plus femoral or popliteal artery endarterectomy for 10 cases, removal of occluded graft with infection for 2 case, and autologous stem cell transplantation for 1 case. RESULTS: 77 reconstructive procedures were applied and graft failures recurred in 49 cases (63.6%). One patient died of acute renal failure during peri-operative period and 9 patients died during follow-up; 6 patients were lost to follow-up. The remaining 37 patients were followed: major amputation for 12 patients, patent grafts after reconstruction in 18 patients, and medical therapy after graft occlusion for 7 patients with limb salvage. Kaplan-Meier survival analysis revealed 3-year survival of 77.4%, limb salvage of 64.7%, and graft patency of 45.7%. Effect of different procedures on cumulative patency was of no statistical significance. CONCLUSIONS: Graft occlusions after lower extremity bypasses may result in high rate of reocclusion and amputation. Optimal management should be based on a thorough analysis of individual condition.

[Management of prosthetic graft infection after lower limb arterial bypasses].

OBJECTIVE: To summarize the experience in management of prosthetic graft infection (PGI) after lower limb arterial bypasses and investigate optimal measures for prevention and treatment. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

[Preliminary study on etiology of Budd-Chiari syndrome through clinic and experiment].

OBJECTIVE: To investigate the etiology of Budd-Chiari syndrome (BCS) preliminarily. METHODS: 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. RESULTS: 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). CONCLUSIONS: The membranous tissues and thrombus have the similar homogeneity and cytokines expression. The membrane and thrombus may be different pathological phases.

[Management of bypass graft occlusion of lower extremity].

OBJECTIVE: To explore the experience of management of graft occlusion in patients with lower extremity bypass grafting. METHODS: From July 2002 to September 2009, 115 cases of graft occlusion were treated in 64 patients with lower extremity arterial bypass, including medical therapy for 8 cases and redo operations for 107 cases: graft thrombectomy alone for 32 cases, redo bypass operation with prosthetic grafts for 27 cases, graft thrombectomy plus balloon angioplasty for 17 cases, major amputation for 13 cases, graft thrombectomy plus endarterectomy for 10 cases, removal of occluded graft with infection for 4 case, distally bypass grafting with autologous saphenous vein for 3 case, and autologous stem cell transplanting for 1 case. RESULTS: One patient died of acute renal failure during peri-operative period and 3 patients died during follow-up period, 5 patients were lost to follow-up including 2 with medical therapy. The remaining 55 patients were followed up for 4 to 70 months (average 39 months): medical therapy for 8 patients, major amputation for 12 patients (21.8%), and patent grafts after reconstruction in 35 patients (63.6%). CONCLUSION: For graft occlusions after lower extremity bypass grafting, redo bypass operation and graft thrombectomy plus endarterectomy or balloon angioplasty may produce better early results.

[Single-stage replacement of total aorta for type I dissection with renal failure].

OBJECTIVE: To investigate the feasibility of one-stage replacement of total aorta for patient with renal failure. METHODS: 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. RESULTS: 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. CONCLUSION: One-stage replacement of total aorta for patient with renal failure is feasible.

[Application of covered stent in the treatment of radiation-induced common carotid artery bleeding to a patient with nasoparyngeal carcinoma: a case report].

Bleeding is a rare but fatal complication after radiotherapy for nasoparyngeal carcinoma (NPC). In this article, we report an NPC case treated with radiotherapy complicated with bleeding of the common carotid artery(CCA). A 44-year-old man with NPC was treated with external radiotherapy 19 years ago, and a second course of treatment to the same field was administrated because of local nasoparyngeal recurrence 4 years ago. The patient was admitted to our hospital for massive bleeding. Conservative therapy including routine medication, blood transfusion and local compression showed almost no effect. Emergency carotid angiography revealed bleeding from the left CCA, and a self-expanding covered stent was deployed through percutaneous transluminal femoral approach. After the placement of the covered stent, angiography showed the bleeding was successfully controlled. So self-expanding covered stenting may be a safe, effective and minimal-invasive option for bleeding of the carotid artery. Long-term follow-up is required for further evaluation.

[Intravenous leiomyomatosis with intracardiac extension: a case report].

Intravenous leiomyomatosis is characterized by a proliferation of benign smooth muscular tissue growing into uterine with malignant appearance. On extremely rare occasions, the tumor may grow out of the pelvis and extend into the inferior vena cava and the right atrium. We report a case of intravenous leiomyomatosis extending into the right atrium. A 41-year-old woman complained of 20 days of intermittent abdominal pain and lower limbs swell. Medical history of the patient revealed a previous hysterectomy operation 3 years ago due to uterine leiomyoma. Echocardiography showed a homogenous mass extending from the inferior vena cava to the right atrium, without evidence of adherence to the right atrial wall, the left ventricular ejection fraction was only 60%. Computer tomography showed that a large mass arising from the left internal iliac vein and extending into the right chambers. Pelvic vascular ultrasound revealed the thrombotic material in the inferior vena cava and the left common iliac vein, and confirmed the presence of a complex mass in the left annex region. Based on the findings, the initial diagnosis was intracardiac and intravenous tumor. An operation was performed through a sternotomy and laparotomy to remove the whole tumor from the left common iliac vein to the right atrium, ligate left internal iliac vein mean-wile. No hormonal therapy was administrated after the operation. Immunohistochemical studies revealed that the tumor cells were fusiform shape, there was no karyokinesis and necrosis, and the tumor cells were positive for smooth muscle antigen and desmin, as well as estrogen receptor and progesterone receptor. Six months postoperation follow-up revealed no signs of recurrence. The differential diagnosis of the disease compared with primary cardiovascular sarcomas and thrombus was difficult. The final diagnosis relied on immunohistochemical analysis, however, the short-term result of operation was acceptable.

[Balloon dilation alone in treatment of arteriosclerotic stenosis or occlusions of femoropopliteal arteries].

OBJECTIVE: To evaluate the use and efficacy of balloon dilation in arteriosclerotic stenosis or occlusions of femoropopliteal arteries. METHODS: 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. RESULTS: 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. CONCLUSION: 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.

Aortic dissection originating from an aberrant right subclavian artery.

A 47-year-old male patient presented with aortic dissection originating from an aberrant right subclavian artery. Intraoperative arteriography showed an anomaly of the aortic arch including a common carotid trunk and an aberrant right subclavian artery. An intimal tear was located in the aberrant right subclavian artery. Dissection retrogradely involved the aortic arch and then anterogradely involved the distal aorta. We treated the patient endovascularly with a Wallgraft endoprosthesis deployed in the aberrant right subclavian artery to seal the entry site. Follow-up computed tomography showed a satisfactory healing process with complete thrombosis in the proximal part of the false lumen.

Radical surgery for Budd-Chiari syndrome through exposure of the entire inferior vena cava of the hepatic segment.

BACKGROUND: Several kinds of radical surgery for the treatment of Budd-Chiari syndrome (BCS) have been devised. We have described preliminary efforts to treat BCS using a novel radical resection technique to expose the entire inferior vena cava (IVC) of the hepatic segment. METHODS: Sixty patients with BCS were treated by radical resection, including 46 men and 14 women. BCS patients ranged in age from 11 to 62 years, with 3 months to 11 years since the BCS diagnosis. The lesions included membrane occlusion of the IVC in 16 patients, double membranes within the IVC in 2 patients, double membranes within the IVC and the hepatic vein (HV) in 3 patients, IVC membrane with distal thrombosis in 10 patients, long segment thrombosis of the IVC in 5 patients (organized thrombosis in 2 patients, fresh thrombosis in 3 patients), occlusion of the outlet of the HVs due to mural thrombosis in 2 patients, segmental occlusion of the IVC in 3 patients, membranes within the HV with IVC stenosis due to protrusion of HV stent in 1 patient, HV membranes in 11 patients, extensive occlusion of HVs in 1 patient, the whole IVC tumor thrombus with tumor thrombus of 2/3 right atrium resulting from a posterior peritoneum tumor in 1 patient, IVC leiomyosarcoma in 2 patients, IVC leiomyosarcoma with tumor thrombus into 1/2 right atrium in 1 patient, IVC thrombosis extending into right atrium in 1 patient, compression of supra-hepatic segment of IVC due to fiber trabs in 1 patient. RESULTS: All lesions were successfully resected under direct supervision. Three procedures were performed under extracorporeal circulation, 52 patients with catheterization of the right atrium, 4 patients with a cell saver, and one patient with auto-retrieval of blood. The retrieved blood was from 300 ml to 4000 ml. Transfusion of banked blood was from 400 ml to 2000 ml for 14 patients. For the other patients no transfusion of banked blood was required. One patient died of renal failure peri-operatively. Newly formed IVC membrane was found for one recurrent patient whose IVC thrombosis was removed one year prior. Restenosis of the IVC was observed post-operatively without symptoms in one patient. In the other patients, no recurrent symptom was found during the follow-up periods. CONCLUSION: This novel surgery provides a clear visual field during the procedure and yields satisfactory short and long-term results.

[Diagnosis and treatment of Budd-Chiari syndrome].

The etiology and pathology of Budd-Chiari syndrome (BCS) remain unclear. The membrane in some membranous BCS may be derived from the absorption and organization of the thrombus of inferior vena cava (IVC). The long-term efficacies of currently available graft shunt operations are unsatisfactory. Interventional therapy or radical resection of lesion should be recommended. The IVC stenosis actually results from the compression of hepatomegaly and should not be classified as BCS. The membranous BCS is an acquired disease.

[The pilot study of the effect of paclitaxel by local slow delivery on intimal hyperplasia of vascular anastomosis after vascular graft bypass].

OBJECTIVE: To develop a new way to prevent restenosis in the anastomotic site due to intimal hyperplasia after vascular graft bypass (VGB) in peripheral arteries. METHODS: Five mongrel dogs received bilateral iliac-femoral VGB and their arteries between the graft were ligated and cut off under general anaesthesia. The mixture of the paclitaxel and fibrin gel (FG) were randomly sprayed onto one side of grafts including distal and proximal anastomotic site, and the fibrin gel served as control were sprayed onto the other one. The bilateral grafts including distal and proximal anastomotic site were harvested four weeks postoperationally and the anastomotic sites were observed grossly, pathologically and by electron microscopy. The intimal thickness and area of each anastomotic site were measured, then the data were analysed statistically. RESULTS: The bilateral grafts of all dogs were patent and the neointima of all anastomotic sites have been seen grossly. The neointimal thickness and area of the experimental side were significantly reduced compared with the control side (P < 0.05). Scanning electron microscopy showed that the anastomotic intima of the experimental side was covered with one layer of intact and regular endothelium cells with deposition of little blood components, but the anastomotic intima of the control side was covered with irregular endothelium cells and deposited with a lot of blood cells and fibrins. Transmission electron microscopy showed the anastomotic intima of the control side that rich in vascular smooth muscle cells and the matrix of the intima was composed of regular collagenous fibers, and that of the experimental side consisted of several types of cells with a lot of foreign particles in the matrix. CONCLUSION: It is safe and effective to locally use low dose of paclitaxel carried by FG in the prevention of vascular anastomotic site intimal hyperplasia. Paclitaxel molecules can penetrate the graft wall and stay in the anastomotic intima more than four weeks postoperationally.

Radical surgery under genuine direct vision for the treatment of Budd-Chiari syndrome.

BACKGROUND: Budd-Chiari syndrome (BCS) develops with complete or incomplete obstruction of the hepatic veins (HV), the super hepatic inferior vena cava (IVC), or both. Various methods have been reported regarding the treatment of BCS. In this article, we present our preliminary experience with radical surgery in the treatment of Budd-Chiari syndrome under genuine direct vision. METHODS: In 13 patients aged from 17 to 48 years, the disease lasted from 3 months to 5 years. Membranous obstruction of the inferior vena cava (IVC) was observed in 3 patients, right hepatic venous (HV) membrane in 1, IVC membrane with distal thrombosis in 6, long-segment thrombosis of the IVC in 2, and IVC thrombosis caused by retroperitoneal tumor extending to the right atrium in 1. RESULTS: All lesions were successfully resected. Extracorporeal circulation was used in one patient, and the cell saver in 2 patients. No blood transfusion was given except for 3 patients receiving blood transfusion of 2000, 400, and 400 ml, respectively. One patient died of renal failure during the postoperative period. Signs and symptoms disappeared after the operation in the remaining patients. CONCLUSION: This new radical surgery gives access to the lesions under clear direct vision in further facilitating the correction needed.