Atherosclerosis in intracranial or extracranial vessels in diabetic patients and the association with stroke subtype.

BACKGROUND: Diabetes mellitus (DM) is associated with increased prevalence and severity of atherosclerosis. This study aimed to assess the prevalence and location of atherosclerosis in intracranial and extracranial vessels in diabetic patients and to investigate their association with ischemic stroke subtype. METHODS: Diabetes patients (n=128) and nondiabetic patients (n=195) were enrolled. Brain MRI, MR angiography, and digital subtraction angiography (DSA) imaging findings in the two groups were retrospectively compared. The characteristics of atherosclerosis (prevalence, location, severity) and collateral flow in diabetic and nondiabetic patients and their association with stroke subtype were analyzed. RESULTS: Atherosclerosis in extracranial vessels was more common in diabetes patients than in nondiabetic patients (43.8% vs. 23.1%; P<0.001). Symptomatic stenoses were commonly in the proximal internal carotid artery (ICA) and proximal vertebral artery (pVA). Diabetes patients were more likely to have lacunar infarction (49.2% vs. 32.3%; P=0.002) and less likely to have large artery infarct (36.7% vs. 48.2%; P=0.042). DM (OR, 2.03; 95% CI, 1.96-4.30; P=0.006) and age >65 years (OR, 2.55; 95% CI, 1.24-5.22; P=0.011) were independent risk factors for lacunar infarct. Diabetes patients with symptomatic extracranial stenosis or occlusion, combined with good collateral circulation, had significantly higher risk of lacunar infarction than nondiabetic patients (47.8% vs. 30.5%; P=0.045). CONCLUSIONS: DM aggravates the severity of extracranial atherosclerosis. Lacunar stroke is relatively common in diabetic patients and could even be due to large artery disease (LAD).

Evaluation of Quiescent-Interval Single-Shot Magnetic Resonance Angiography in Diabetic Patients With Critical Limb Ischemia Undergoing Digital Subtraction Angiography: Comparison With Contrast-Enhanced Magnetic Resonance Angiography With Calf Compression at 3.0 Tesla.

PURPOSE: To assess the diagnostic performance of quiescent-interval single-shot magnetic resonance angiography (QISS-MRA) at 3 tesla in diabetic patients with critical limb ischemia (CLI) vs contrast-enhanced MR angiography (CE-MRA) using digital subtraction angiography (DSA) as the standard of reference. METHOD: Thirty-seven consecutive diabetic patients (mean age 71.8±7.2 years; 30 men) with CLI (Fontaine stage III-IV) underwent QISS-MRA and CE-MRA with calf compression; DSA was the standard. Image quality (5-point Likert-type scale) and stenosis severity (5-point grading) for QISS-MRA and CE-MRA were evaluated by 2 blinded readers in 1147 and 654 vessel segments, respectively. Per-segment and per-region (pelvis, thigh, calf) sensitivity, specificity, positive predictive value, and negative predictive value were calculated. RESULTS: Image quality of QISS-MRA was lower compared with CE-MRA in the pelvic region (p<0.001 in both readers) and thigh region (p=0.033 in reader 1 and p=0.018 in reader 2), whereas in the calf region, the image quality of QISS-MRA was better than CE-MRA (p=0.009 in reader 1 and p=0.001 in reader 2). In segment-based analyses, there was no difference between QISS-MRA and CE-MRA in sensitivity [89.5% vs 90.3% in reader 1 (p=0.774) and 87.6% vs 90.6% in reader 2 (p=0.266)] or specificity [94.2% vs 92.9% in reader 1 (p=0.513) and 92.9% vs 92.9% in reader 2 (p>0.999)]. In region-based analyses, QISS-MRA and CE-MRA yielded similar sensitivity and specificity in all areas but the pelvic region for reader 2 (specificity 95.5% vs 84.8%, p=0.041). CONCLUSION: QISS-MRA performed very well in diabetic patients with CLI and was a good alternative for patients with contraindications to CE-MRA.

Integrated application of antegrade and retrograde recanalization for femoral-popliteal artery chronic total occlusions: outcomes compared with antegrade recanalization.

BACKGROUND: To investigate the efficacy of retrograde recanalization for chronic total occlusion (CTO) of femoral-popliteal artery in patients with peripheral arterial disease. METHODS: In this single-center retrospective study, all patients who had undergone endovascular recanalization for femoral-popliteal CTOs at our center from June 2011 to October 2014 were included. Patients' demographics, immediate and follow-up outcomes were analyzed. RESULTS: A total of 205 patients with 238 CTOs were enrolled. In total, successful recanalization was achieved in 228 CTOs (95.8%). The antegrade procedure was successful in 196 CTOs. The retrograde procedure was successfully performed in 32 CTOs after failed antegrade procedure. Ankle-brachial index increased from 0.48±0.18 to 0.79±0.16 in antegrade group vs. 0.41±0.13 to 0.76±0.13 in retrograde group (P=0.438). Pulse score increased from 0.48±0.50 to 2.30±0.76 in antegrade group vs. 0.48±0.51 to 2.30±0.79 in retrograde group (P=0.771). At 12 and 24 months, primary patency rate was 86.2% (169/196) and 51.5% (101/196) in the antegrade group, and 75.0% (24/32) and 43.8% (14/32) in the retrograde group, respectively (P=0.346). Kaplan-Meier analysis showed limb salvage rates of 85.7% in the antegrade group vs. 78.1% in the retrograde group (P=0.198). CONCLUSIONS: Retrograde recanalization is effective for CTO of femoral-popliteal artery after the failure of an antegrade procedure; immediate outcomes and mid-term patency and limb salvage rate are comparable with that of antegrade procedure.

Correction to: Morphological characteristics of chronic total occlusion: predictors of different strategies for long-segment femoral arterial occlusions.

The original version of this article unfortunately contained mistakes. The legends to Figs. 2-4 were incorrectly interchanged. The correct versions are given below. The original article has been corrected.

Morphological characteristics of chronic total occlusion: predictors of different strategies for long-segment femoral arterial occlusions.

OBJECTIVES: To investigate morphological characteristics used to predict recanalisation strategies in long-segment (>10 cm) femoral chronic total occlusion (LSF-CTO) angioplasty. METHODS: We retrospectively evaluated a range of morphological CTA and DSA features in patients who underwent recanalisation of LSF-CTO. The stage of CTO was classified into early (3-12 months) and late (>12 months) according to estimated duration. Characteristics including stump morphology, lesion length and calcification, proximal side branches, collaterals circulation, runoff vessels and concomitant arterial occlusion were used as predictors, and multivariate logistic regression analysis was performed to identify variables associated with late-stage CTO and retrograde technique. RESULTS: A total of 119 patients with 137 CTOs in 137 limbs were enrolled. Overall, successful recanalisation was achieved in 122 CTOs (89.1%). Flush occlusion [odds ratio (OR) 2.958; 95% confidence interval (CI) 1.172-7.465; p = 0.022], large collateral (OR 2.778; 95% CI 1.201-6.427; p = 0.017) and TransAtlantic Inter-Society Consensus II class D (TASC D) lesion (OR 1.743; 95% CI 1.019-2.981; p = 0.042) were predictors for late-stage CTO. Flush occlusion (OR 75.278; 95% CI 10.664-531.384; p < 0.001) and large collateral (OR 23.213; 95% CI 3.236-166.523; p = 0.002) were associated with high likelihood for retrograde approach. CONCLUSIONS: Flush occlusion and large collateral were associated with a CTO at late-stage which may require retrograde recanalisation. KEY POINTS: • CTO morphological characteristics help estimate lesion duration and optimise recanalisation strategies. • Flush occlusion and large collateral is associated with late-stage CTO and retrograde recanalisation. • Application of anterograde and retrograde recanalisation for long-segment femoral CTO is effective.

Percutaneous Aspiration Thrombectomy for Arterial Thromboembolism during Infrainguinal Endovascular Recanalization.

OBJECTIVES: To evaluate the efficacy of percutaneous aspiration thrombectomy (PAT) for infrainguinal arterial thromboembolism in patients undergoing endovascular recanalization (EVR) and to investigate the predictors for thromboembolic complications. MATERIALS AND METHODS: In total, 23 patients (23 limbs) who underwent PAT for thromboembolism (PAT group, PG) during EVR and 237 patients (302 limbs) who underwent successful EVR without thromboembolic complications (control group, CG) were enrolled. Immediate post-operation and follow-up outcomes were compared between the two groups. Multivariate analysis was performed to identify the predictors of thromboembolic complications. Technical success of PAT was defined as achievement of <30% residual stenosis and restoration of mTIMI grade 3. RESULTS: The technical success rate was 95.7% in PG. After intervention, the ankle-brachial index (ABI), restoration of blood flow and improvement in dorsal/plantar arterial pulse score showed no significant differences between PG and CG. During follow-up in PG, a sustained ABI improvement was observed in 63.6% (70.9% in CG), an improvement in walking distance in 68.8% (79.9% in CG,), ulcer healing in 75.0% (71.7% in CG) and restenosis/occlusion in 31.8% (25.2% in CG). The limb salvage rate was 100% in PG (96.0% in CG), and pain relief was observed in 66.7% patients with critical limb ischaemia (81.6% in CG). Superficial femoral artery involvement [0.233; 95% confidence interval (CI), 0.108-0.461; P < 0.001], de-novo lesion occlusion (683.8; 95% CI, 36.5-12804.6; P < 0.001) and intraluminal angioplasty (118.4; 95% CI, 8.0-1758.0; P = 0.001) was associated with high incidence of thromboembolism. CONCLUSION: PAT is a safe and effective treatment for thromboembolism during infrainguinal arterial EVR. SFA involvement, de-novo lesion occlusion and intraluminal angioplasty may be predictors of thromboembolic complications.

Runoff detected by magnetic resonance angiography as an indicator for better recanalization outcomes in below-the-knee chronic total occlusions in diabetic patients.

PURPOSE: To compare the feasibility and efficacy of recanalizing below-the-knee (BTK) chronic total occlusions (CTOs) between patients with good or poor distal runoff based on magnetic resonance angiography (MRA) scans. METHODS: Two hundred long-segment BTK CTOs in 171 limbs of 113 diabetic patients (58 men; mean age 69.8±1.9 years) were divided into good distal runoff (GDR: 119 lesions, 98 limbs) or poor distal runoff groups (PDR: 81 lesions, 73 limbs) based on baseline MRA findings. After angioplasty, modified thrombolysis in myocardial ischemia (mTIMI) grades and ankle-brachial index (ABI) were used to assess immediate outcomes. Regularly scheduled duplex or MRA imaging was performed in follow-up. The restenosis and limb salvage rates were compared. RESULTS: The success rates were 93.3% and 87.7% in the GDR and PDR groups, respectively (p=0.21); subintimal angioplasty was more common in the PDR group (93.0% vs. 63.1%, p<0.01). Completion angiography indicated an mTIMI grade 3 blood flow in 71.2% lesions in the GDR patients and in 52.1% in the PDR (p=0.01) group. Improvement in the ABI was greater in the GDR limbs (p<0.001 vs. PDR). Mean imaging follow-up was 10.8±6.9 months in the GDR group and 11.1±6.6 months in the PDR group. Kaplan-Meier analysis showed a better restenosis-free rate in the GDR group (80.6% vs. 61.7%; p=0.02) at 12 months and for lesions with mTIMI grade 3 flow (p<0.01). At 24 months, Kaplan-Meier analysis revealed a better limb salvage rate in the GDR group (84.2% vs. 54.6%; p=0.02). CONCLUSION: Distal runoff detected using MRA could be a predictor for successful intraluminal recanalization, better distal tissue perfusion, improved long-term patency, and better limb salvage for patients with BTK CTOs.

Patency of runoff detected by MR angiography at 3.0 T with cuff-compression: a predictor of successful endovascular recanalization below the knee.

OBJECTIVES: Our aim was to assess the reliability of detecting distal runoff vessels using contrast-enhanced MR angiography (CE-MRA) that were occult on digital subtraction angiography (DSA) for predicting the outcome of endovascular recanalization (ER). METHODS: This retrospective analysis comprised 63 patients with diabetes (98 limbs) who underwent ER for infrapopliteal lesions. Before ER, they underwent CE-MRA and DSA for peripheral arterial disease; runoff vessels were detected with CE-MRA, but not with DSA. Immediate and follow-up postoperative outcomes were assessed. Univariate analysis was performed to identify variables associated with successful ER. RESULTS: Successful ER was achieved in 85.7 % of limbs, and runoff score was significantly lower than in failure limbs (5.1 ± 1.1 vs. 6.2 ± 1.3; P < 0.05). During follow-up, sustained ankle-brachial index (ABI) improvement was found in 76.6 % claudication patients, and walking distance improvement in 86.5 %; pain was relieved in 70.6 % of critical limb ischemia (CLI) limbs, ulceration healed in 81.3 %, and limb-salvage rate was 100 %. Restenosis/occlusion rate was higher for patients with CLI at 12 months (48.8 % vs. 96.3 % in claudication; P < 0.01). Runoff score was associated with a significantly higher likelihood of ER success (odds ratio = 4.096, 95 % confidence interval: 2.056-8.158; P < 0.001). CONCLUSION: Runoff vessels detected using CE-MRA could indicate immediate success and better outcome of ER for infrapopliteal occlusions. KEY POINTS: • 3-T MRA with cuff compression displayed distal below-the-knee (BTK) runoffs better than DSA • Detected runoffs indicate high recanalization rate and good clinical outcome • Runoff display provides potential opportunity to perform other backup recanalization strategies.

Retrograde transplantar arch angioplasty of below-the-knee arterial occlusions: outcomes compared to anterograde recanalization.

RATIONALE AND OBJECTIVES: To compare the clinical outcomes of retrograde transplantar arch angioplasty and conventional below-the-knee (BTK) anterograde recanalization. MATERIALS AND METHODS: One hundred twelve limbs in 96 patients underwent attempt at antegrade tibial angioplasty. Among 27 technical failures, retrograde trans-dorsal or -planter percutaneous transluminal angioplasty was attempted in 22 limbs. Ankle-brachial index (ABI), thrombolysis in myocardial infarction (TIMI) flow grade, and dorsal/plantar arterial pulse score improvement were compared immediately after the procedures between patients received successful anterograde angioplasty (anterograde angioplasty group [AAG], 85 limbs in 71 patients) and retrograde angioplasty (retrograde angioplasty group [RAG], 22 limbs in 20 patients). Target vessel restenosis and limb salvage were observed during follow-up. RESULTS: Primary technical success rate was 75.9% in the RAG (vs. 74.0% AAG, P > .05). ABI improved from 0.55 ± 0.21 to 0.93 ± 0.19 in the RAG (vs. 0.56 ± 0.14 to 0.89 ± 0.18 AAG, P > .05). TIMI flow grade demonstrated greater reperfusion of distal foot tissue in the RAG (2.3 ± 0.8 vs. 1.0 ± 0.8, P < .05). Primary patency rates at 12 and 24 months were 63.6% (14 of 22) and 45.5% (10 of 22) in the RAG and 52.9% (45 of 85) and 37.6% (32 of 85) in the AAG, respectively (P > .05). Kaplan-Meier analysis after 24 months found limb salvage rates of 93.8% in the RAG and 96.5% in the AAG (P > .05). CONCLUSIONS: Retrograde transplantar arch angioplasty achieved better immediate blood flow and similar ABI improvement, primary patency rate, and limb salvage rate compared to conventional transtibial angioplasty for BTK occlusions. This could become a supplementary technique when anterograde angioplasty fails.

Frequency and predictors of endoleaks and long-term patency after covered stent placement for the treatment of intracranial aneurysms: a prospective, non-randomised multicentre experience.

OBJECTIVE: We investigated immediate/late endoleaks and long-term patency following stent-graft placement for treatment of intracranial aneurysms located within the distal internal carotid artery (ICA) or vertebral artery (VA). METHODS: Forty-five aneurysms in 41 patients receiving covered stents in three centres were followed. Outcome measures included aneurysm occlusion rate, endoleaks, late in-stent stenosis rate, clinical improvement, neurological deficiencies and death. RESULTS: Total aneurysm exclusion was achieved in 69.2% (n = 27), with 30.8% (n = 12) experiencing immediate residual endoleaks. Angiographic follow-up (mean 43.5 ± 14.3 months) revealed that 87.2% (n = 34) were completely occluded with only 12.8% (n = 5) showing residual endoleaks. Predictors of immediate endoleaks in our patient group were stent number (P = 0.023) and stent diameter (P = 0.022), while predictors of late endoleaks in our patient group were stent diameter (P = 0.035) and stent angulation (P = 0.021). Late in-stent stenosis rates were 18.0 ± 13.3 and 29.0 ± 18.5% compared with the period immediately following implantation at 2- and 6-year follow-ups respectively. Smoking (P = 0.017) and stent angulation (P = 0.020) were predictors of late in-stent stenosis. CONCLUSION: Treating intracranial aneurysms with Willis stent-grafts has an acceptable immediate and late occlusion rate and long-term stented artery patency rate.

Protective effect of dl-3n-butylphthalide preconditioning on focal cerebral ischaemia-reperfusion injury in rats.

OBJECTIVE: To investigate the effect of dl-3n-butylphthalide (NBP) on the protection of cerebral tissue and possible mechanism on ischaemia-reperfusion injury, and to find out whether NBP therapy can extend the reperfusion window in an experimental stroke model in rats. METHODS: Seventy-two Sprague-Dawley rats were randomly divided into sham operation, ischaemia-reperfusion and ischaemia-reperfusion with NBP groups. Focal cerebral ischaemia was induced using the modified intraluminal thread method and maintained for 2, 3 or 4 h. The ischaemia-reperfusion group received reperfusion immediately after ischaemia-reperfusion. The NBP group received intraperitoneal injection of NBP immediately after ischaemia, followed by reperfusion. The sham operation group received only injection of physiological saline. The cerebral infarction volume and neurological deficit were analysed, and vascular endothelial growth factor (VEGF) expression in brain tissues was visualised by immunohistochemistry. RESULTS: NBP treatment caused a significant decrease in both infarction volume and neurological deficit compared with the ischaemia-reperfusion group at corresponding time points in each (p < 0.05). In the NBP group, the infarction volume and neurological deficit did not change with different ischaemia times. The expression of VEGF was significantly decreased in the ischaemia-reperfusion group compared with the sham group (p < 0.01), while this change was partly prevented in the NBP group (p < 0.01). The expression of VEGF in brain tissue in both the NBP and ischaemia-reperfusion groups gradually decreased when the ischaemic period was prolonged. CONCLUSION: NBP treatment has a protective effect against cerebral ischaemia; this possible mechanism maybe related to the VEGF expression and may extend the reperfusion window for subsequent salvage of cerebral ischaemia by reperfusion.

Treatment of traumatic internal carotid artery pseudoaneurysms with the Willis covered stent: a prospective study.

PURPOSE: To evaluate the efficacy of the Willis covered stent in the treatment of traumatic pseudoaneurysms of the internal carotid artery (ICA). MATERIALS: Thirty-eight patients with traumatic head and neck injury underwent angiography. We evaluated 14 delayed pseudoaneurysms in 13 patients who underwent angiography after treatment with the Willis covered stent. Prospective data on the technical success, initial and final angiographic results, mortality, morbidity, and final clinical outcome were analyzed immediately after the procedure, at the time of discharge from the hospital, at 3 months, 6 months, and 12 months after the procedures, and yearly thereafter. RESULTS: The Willis covered stent placement was successful in all 14 pseudoaneurysms. The initial angiographic results showed complete exclusion in 9 patients with 10 aneurysms (71.4% [95% confidence interval {CI}: 44-98%]) and incomplete exclusion in 4 patients. The angiographic follow-up (mean, 15 months [95% CI: 9-20 months]; range, 3-36 months) findings exhibited a complete exclusion in 12 patients with 13 aneurysms (92.9% [95% CI: 77-108%]) and an incomplete exclusion in 1 patient and maintained patency of the ICA in all patients. The clinical follow-up (mean, 20 months [95% CI: 14-27 months]) findings demonstrated full recovery (11 patients), symptom improvement (1 patient), or no change in the symptoms (1 patient). No procedure-related complications or deaths occurred during follow-up. CONCLUSION: Treatment with the Willis covered stent provides a viable approach for patients with traumatic pseudoaneurysms of the ICA, maintaining patency of the ICA and thus leading to excellent clinical results. An expanded clinical experiences and a larger sample are needed.

Treatment of complex ruptured anterior communicating arterial aneurysms by endovascular coil embolisation of the anterior communicating artery.

PURPOSE: The current study evaluates the feasibility and safety of coil embolisation of the anterior communicating artery (ACoA) for the treatment of complicated anterior communicating arterial aneurysms (ACoAAs). METHODS AND MATERIALS: Five patients presented with a subarachnoid haemorrhage caused by a ruptured ACoAA. The ACoAA morphologies were well defined by three-dimensional digital subtraction angiography (3D-DSA) and magnetic resonance angiography (MRA). Two of the ACoAAs were tiny (<3 mm in diameter), and the remaining three ACoAAs were small (3-5 mm in diameter). All of the aneurysms were localised to the ACoA. The projection of the aneurysm dome was defined as being oriented superiorly or posteriorly in all five aneurysms. We performed a superselective catheterisation of each aneurysm, and we subsequently performed coil embolisation with balloon, stent or microcatheter assistance. Angiography and clinical follow-up occurred 3-6 months after the procedure. Clinical follow-up data were collected and retrospectively analysed, and patient responses were categorised as fully recovered, improved, unchanged or aggravated. RESULTS: All five patients with ACoAA were treated successfully using coil embolisation. In three patients, both the aneurysm sac and the ACoA were embolised using coils, and in two patients, only the ACoA was embolised. Acute angiography showed occlusion of the aneurysm and ACoA. Follow-up angiography confirmed complete occlusion of the aneurysm sac, and no ACoAA recurrence was detected in any of the patients. In clinical follow-up visits, none of the patients had haemorrhaged or had a stroke. CONCLUSION: Combined coil embolism of the aneurysm sac and the ACoA could be a feasible and safe method for the treatment of complicated ACoAAs without bilateral aplasia of the A1 segment.

Reconstructive endovascular treatment of intracranial aneurysms with the Willis covered stent: medium-term clinical and angiographic follow-up.

OBJECT: Placement of covered stents has emerged as a promising therapeutic option for cerebrovascular diseases. However, the medium- and long-term efficacy and safety of covered stents in the treatment of these diseases remain unclear. The purpose of this study was to evaluate the medium-term clinical and angiographic outcomes of covered stent placement for the treatment of intracranial aneurysms. METHODS: The authors' institutional review board approved the study. Thirty-four patients (13 females and 21 males; mean age 41.9 years) with 38 intracranial aneurysms were treated with the Willis covered stent. Clinical and angiographic follow-up were performed at 3 months, at 6-12 months, and annually thereafter. The initial procedural and follow-up outcomes were collected and analyzed retrospectively. RESULTS: Forty-two covered stents were successfully implanted into the target artery in 33 patients with 37 aneurysms, and 1 covered stent navigation failed in 1 patient. A complete aneurysm exclusion was initially achieved in 24 patients with 28 aneurysms, and a minor endoleak occurred in 9 patients with 9 aneurysms. Postoperatively, 2 patients died of complications related to the procedure. Angiographic and clinical follow-up data are available in 30 patients. The angiographic follow-up (17.5 ± 9.4 months [mean ± SD]) exhibited complete occlusion in 28 patients with 31 aneurysms, and incomplete occlusion in 2 aneurysms, with an asymptomatic in-stent stenosis in 3 patients (10%). The clinical follow-up (26.7 ± 13 months [mean ± SD]) demonstrated that 16 patients (53.3%) experienced a full recovery, and 14 patients (46.7%) improved. No aneurysm rupture, thromboembolic events, or neurological deficits resulting from closure of a perforating vessel by covered stent placement occurred. CONCLUSIONS: Endovascular reconstruction with the Willis covered stent represents a safe, durable, and curative treatment option for selected intracranial aneurysms, yielding an excellent medium-term patency of the parent artery and excellent clinical outcomes.

Endovascular reconstruction with the Willis covered stent for the treatment of large or giant intracranial aneurysms.

BACKGROUND: The purpose of this study was to evaluate the feasibility, safety and efficacy of endovascular treatment of large or giant intracranial aneurysms with the Willis covered stent. METHODS: Nineteen patients, each with a large or giant intracranial aneurysm, were treated with the Willis covered stent. Of these 19 aneurysms, 6 were giant and 13 were large; 18 were located in the cranial internal carotid artery and 1 in the vertebral artery. Results of the procedure, technical events and complications were recorded. Clinical and imaging follow-ups were performed at 3 and 6-12 months after the procedure. RESULTS: Placement of Willis covered stent was successful in all patients. Complete aneurysm exclusion was achieved in 13 of the 19 aneurysms immediately after the procedure. No mortality or morbidity developed during the treatment or the follow-up period. During the follow-up period, complete aneurysm exclusion was achieved in 18 of the 19 patients; 11 aneurysms were totally involuted, 3 decreased to 25% of the original diameter, 4 decreased to 50% and 1 remained unchanged. Nine patients experienced full recovery, 9 improved and 1 was unchanged. No obvious in-stent stenosis was noted. CONCLUSIONS: Endovascular treatment of large or giant intracranial aneurysm with the Willis covered stent is feasible, safe and efficacious in selected cases. Endoleak is a frequent issue after initial covered stent placement, but can be eliminated or dramatically reduced to minimal endoleak by additional covered stent placement and/or balloon reinflation. Minor endoleak is likely to spontaneously resolve over time.

Safety, feasibility, and mid-term follow-up of Willis stent graft placement in the treatment of symptomatic complicated intra- or extra-cranial aneurysms: a multicenter experience.

We report the technical success rate and mid-term follow-up results after deploying stent-grafts to treat a cohort of patients with symptomatic complicated intra- or extracranial aneurysms (SCIEAs). This study was a retrospective review of 58 patients (39 male; mean age 40.4 ± 12.3 years) with 60 SCIEAs treated by 67 Willis covered stents at three medical centers in China between April 2005 and January 2010. The locations of the SCIEAs were as follows: Intracranial internal carotid artery (ICA) in 54 patients, extracranial ICA in one, intracranial vertebral artery (VA) in three and extra-cranial VA in two. Surgery was successful in 59 (98.3%) SCIEAs. Total exclusion was immediately achieved in 48 SCIEAs, and minor endoleaks were present in 11. Acute thrombosis occurred in two patients and hemorrhage in one. Follow-up angiography (mean 13.8 ± 8.9 months) revealed that 49 of 52 (94.2%) aneurysms were completely isolated, with mild in-stent stenosis in only two patients and in-stent occlusion in one patient. Willis stent-graft application is an alternative therapy to treat SCIEAs in either intra- or extracranial ICAs or VAs. In the case of a tortuous intracranial ICA or potential side branch coverage, however, it is still not a first choice.

Batroxobin for prevention of restenosis in diabetic patients after infrapopliteal arterial angioplasty: a small randomized pilot trial.

BACKGROUND: We designed a small randomized clinical trial to prospectively test the hypothesis that batroxobin is more effective than aspirin alone to prevent restenosis in patients with diabetes undergoing angioplasty of infrapopliteal arteries. METHODS: After a successful angioplasty, a total of 52 diabetic patients with symptomatic infrapopliteal obstructions were randomized to either the treated group (n = 26) or the control group (n = 26). Patients in the treated group received 5 IU batroxobin through an intravenous drip once every alternate day, for a total of six doses. The primary end point was restenosis and reocclusion, which was documented by magnetic resonance angiography or duplex scanning at 12-month follow-up. The clinical symptoms relief and ankle-brachial index (ABI) were compared before and after the procedure, and during follow-up. Kaplan-Meier curves were constructed to evaluate restenosis or reocclusion-free, limb salvage, and amputation-free rates. RESULTS: Restenosis and reocclusion occurred in 22.0% and 34.5% lesions in the treated and the control group, respectively (p = 0.0307). Statistical differences were observed between the ABI before the angioplasty procedure(p < 0.05) and the ABI at the 12-month follow-up (p = 0.0094) of the two groups. Clinical symptoms improvement and tissue healing occurred in 23 and 19 patients in the batroxobin group and the control group, respectively (p = 0.0544). Twelve months after angioplasty, Kaplan-Meier analysis showed that the restenosis and reocclusion-free rate was 74.0% and 54.8%, the limb salvage rate was 96.2% and 92.3%, and the amputation-free rate was 84.6% and 84.6%, in the treated and control group, respectively. CONCLUSION: This pilot trial revealed that batroxobin usage was effective in preventing restenosis and reocclusion after infrapopliteal arterial angioplasty, and it might provide better clinical symptoms relief; however, it did not report preferable limb salvage or amputation-free rates.

An effective guidewire looping technique for the recanalization of occlusive segments of infrapopliteal vessels.

OBJECTIVE: To determine the efficacy, safety and primary follow-up results of a guidewire looping technique for the treatment of infrapopliteal arteries. MATERIALS AND METHODS: From October 2006 to May 2008, an intraluminal angioplasty of the infrapopliteal arteries was attempted in 200 consecutive patients. Altogether, 417 infrapopliteal lesions, with lengths varying from 2 cm to 32 cm, were treated as part of this study, including 305 lesions in the anterior tibial arteries, 89 in the posterior tibial arteries, and 23 in the peroneal arteries. The 'U'-shaped guidewire technique was attempted in 393 lesions from 361 limbs. The tip of a hydrophilic 0.035-inch guidewire was formed into a 'U' shape with the aid of a 4-Fr catheter and collateral branch vessel to recanalize the completely occluded long segment lesions. RESULTS: A successful angioplasty with at least one artery recanalized directly to the malleolar or dorsal foot was achieved in 322 limbs (89%). The looping technique had a success rate of 90% (352 of 393 lesions). After the procedure, the rest pain was relieved in 58 of 69 patients, while 207 of 245 limbs (85%) showed improvement for intermittent claudication. Complete wound healing was noted in 21 of 54 patients, while 20 of 54 patients showed an improvement in the wound size or depth. A total of 38 major immediate procedure-related complications were noted, including retroperitoneal hematoma, distal emboli, and vessel rupture. CONCLUSION: The results of this study suggests that the guidewire looping technique is a safe and effective method for the recanalization of the occluded lesions in infrapopliteal vessels.

Application of the Willis covered stent in the treatment of aneurysm in the cisternal segment of the internal carotid artery: a pilot comparative study with midterm follow-up.

PURPOSE: To compare the use of the Willis stent-graft versus coil embolization for complicated aneurysms in the cisternal segment of the internal carotid artery (ICA). METHODS: Thirty-four patients (19 women; mean age 46.7+/-16.8 years, range 3-79) with 36 complicated aneurysms were treated either by Willis covered stents (n = 19) or by coil embolization (n = 17). Follow-up angiography was performed to investigate aneurysm recurrence, endoleak, and parent artery stenosis. Kaplan-Meier curves were constructed to compare the freedom from recurrence and parent artery stenosis rates in both groups. Clinical follow-up data were retrospectively analyzed and categorized as fully recovered, improved, unchanged, or worsened. RESULTS: In the covered stent group, total exclusion was immediately achieved in 13 aneurysms; there were 5 minor endoleaks and 1 delivery failure. In the patients treated with coil embolization, total/near-total occlusion was achieved in 7 aneurysms, subtotal in 8, and partial in 2. Acute thrombosis occurred in 1 patient in each group, while 1 patient experienced recurrent hemorrhage after embolotherapy. Follow-up angiography (mean 14.3+/-9.4, range 3-31) revealed that 16 aneurysms were completely isolated in the stent-graft group, with only 2 mild in-stent stenoses. Eighteen months after the procedure, Kaplan-Meier analysis showed recurrence-free rates of 93.3% and 50% for the stent-graft versus coil groups, respectively; freedom from parent artery stenosis was 87.5% and 100%. Symptoms were fully eliminated in 9 patients in each group; they were improved in 3 and 5, unchanged in 2 and 2, and worsened in 1 and 0, respectively, at the end of the follow-up period. CONCLUSION: Willis stent-graft application is an alternative to treat complicated aneurysms in the cisternal segment of the ICA. In the case of a tortuous parent artery or potential side branch coverage, however, it is still not a first choice therapy.

Direct-soldering 6061 aluminum alloys with ultrasonic coating.

In this study, the authors applied furnace soldering with ultrasonic coating method to solder 6061 aluminum alloy and investigated the effects of both coating time and soldering temperature on its properties. The following results were obtained: firstly, the solder region mainly composed of four kinds of microstructure zones: rich Sn zone, rich-Pb zone, Sn-Pb eutectic phase and rich Al zone. Meanwhile, the microanalysis identified a continuous reaction product at the alumina-solder interface as a rich-Pb zone. Therefore, the joint strength changed with soldering time and soldering temperature. Secondly, the tensile data had significantly greater variability, with values ranging from 13.99MPa to 24.74MPa. The highest value was obtained for the samples coated with Sn-Pb-Zn alloy for 45s. Fractures occurred along the solder-alumina interface for the 6061 aluminum alloy with its surface including hybrid tough fracture of dimple and tear ridge. The interface could initially strip at the rich Bi zone with the effect of shear stress.