Stent Insertion for Inoperable Hilar Cholangiocarcinoma: Comparison Between Unilateral Radioactive Stent and Bilateral Normal Stent.

OBJECTIVE: To comparatively analyze the clinical efficacy and safety of unilateral radioactive stent (RS) insertion versus bilateral normal stent (NS) insertion in patients with inoperable hilar cholangiocarcinoma (HC). PATIENTS AND METHODS: Patients with inoperable HC were treated in our hospital from January 2016 to December 2020. The treatment approach included the insertion of either unilateral RS or bilateral NS, evaluating the efficacy and safety of therapy in 2 distinct groups. RESULTS: A total of 58 individuals experienced the insertion of a unilateral RS, whereas 57 patients underwent the insertion of bilateral NS. No statistically significant difference between the unilateral RS and bilateral NS groups was seen in the technical success rates (98.3% vs 94.7%, P = 0.598) and clinical success rates (98.2% vs 100%, P = 0.514). While there is no statistically significant difference in the rates of stent restenosis (19.3% vs 9.3%, P = 0.132) between the two groups, the unilateral RS group demonstrated substantially longer stent patency (202 vs 119 d, P = 0.016) and overall survival (229 vs 122 d, P = 0.004) compared with the bilateral NS group. Moreover, 8 patients (14.0%) in the unilateral RS group and 14 patients (25.9%) in the bilateral NS group had postoperative complications with no significant difference ( P = 0.116). CONCLUSION: When inserting stents for inoperable HC, both unilateral RS and bilateral NS insertion procedures have demonstrated favorable therapeutic efficacy. Nevertheless, inserting a unilateral RS provided a longer duration of stent patency and overall survival than implantation of bilateral NS.

Phenotypic Switching of Atherosclerotic Smooth Muscle Cells is Regulated by Activated PARP1-Dependent TET1 Expression.

AIM: During the development of atherosclerosis, the vascular smooth muscle cells (SMCs) undergo phenotypic switching from contractile phenotype to synthetic phenotype. This study aimed at examining the role of DNA modification mediated by the oxidative stress dependent ten eleven translocation enzymes (TETs) expression at early stage of phenotypic switching. METHODS: Based on the in vitro SMCs calcification model, DNA damage, phenotypic switching and 5-hydroxymethylcytosine (5hmC) were examined by comet assay, alkaline DNA unwinding assay, immunofluorescence staining, Dot blotting and Western blotting. Then Western blotting and qRT-PCR were performed to analyze the TETs expression and the relationship between the activity of poly(ADP-ribose) polymerase 1 (PARP1) and TETs expression. We further alter 5hmC modification by inhibition of TET1 or PARP1 to rescue the phenotypic switching of SMCs using immunofluorescence staining, Dot blotting and qRT-PCR. We performed immunochemistry staining to examine the activated PARP1-TET1 pathway in vivo. RESULTS: The phenotypic switching was observed in the SMCs cultured with calcification medium as the expression of the cell markers of contractile SMCs decreased and cell proliferation increased. In contrast, PAR and 5hmC were markedly increased in SMCs with calcification due to DNA damage. Our study further demonstrated that oxidative stress-activated PARP1, promotes TET1 expression and 5hmC increase during the phenotypic switching. Inhibition of TET1 or PARP1 can rescue the phenotypic switching of SMCs with calcification. CONCLUSION: Our study demonstrated the important role of PARylation dependent 5hmC, in SMCs phenotypic switching. It raises the possibility to target TET1 and PARP1 for atherosclerosis treatment.

Aspiration therapy for acute embolic occlusion of the superior mesenteric artery.

BACKGROUND: Embolic superior mesenteric artery (SMA) occlusion is associated with high mortality rates. Delayed treatment often leads to serious consequences, including intestinal necrosis, resection, and even patient death. Endovascular repair is being introduced, which can improve clinical symptoms and prognosis and decrease the incidence of exploratory laparotomy. Many reports have described successful endovascular revascularization of embolic SMA occlusion. However, most of those reports are case reports, and there are few reports on Chinese patients. In this paper, we describe the technical and clinical outcomes of aspiration therapy using a guiding catheter and long sheath technique which facilitates the endovascular repair procedure. AIM: To evaluate the complications, feasibility, effectiveness, and safety of endovascular treatment for the acute embolic occlusion of the SMA. METHODS: This retrospective study reviewed eight patients (six males and two females) from August 2013 to October 2018 at Xuanwu Hospital, Capital Medical University. The patients presented with acute embolic occlusion of the SMA on admission and were initially diagnosed by computed tomography angiography (CTA). The patients who underwent endovascular treatment with a guiding catheter had no obvious evidence of bowel infarct. No intestinal necrosis was identified by gastrointestinal surgeons through peritoneal puncture or CTA. The complications, feasibility, effectiveness, safety, and mortality were assessed. RESULTS: Six (75%) patients were male, and the mean patient age was 70.00 ± 8.43 years (range, 60-84 years). The acute embolic occlusion of the SMA was initially diagnosed by CTA. All patients had undertaken anticoagulation primarily, and percutaneous aspiration using a guiding catheter was then undertaken because the emboli had large amounts of thrombus residue. No death occurred among the patients. Complete patency of the suffering artery trunk was achieved in six patients, and defect filling was accomplished in two patients. The in-hospital mortality was 0%. The overall 12-mo survival rate was 100%. All patients survived, and two of the eight patients had complications (the clot broke off during aspiration). CONCLUSION: Aspiration therapy is feasible, safe, and beneficial for acute embolic SMA occlusion. Aspiration therapy has many benefits for reducing patients' death, resolving thrombi, and improving symptoms.

Design and preparation of polyurethane-collagen/heparin-conjugated polycaprolactone double-layer bionic small-diameter vascular graft and its preliminary animal tests.

BACKGROUND: People recently realized that it is important for artificial vascular biodegradable graft to bionically mimic the functions of the native vessel. In order to overcome the high risk of thrombosis and keep the patency in the clinical small-diameter vascular graft (SDVG) transplantation, a double-layer bionic scaffold, which can offer anticoagulation and mechanical strength simultaneously, was designed and fabricated via electrospinning technique. METHODS: Heparin-conjugated polycaprolactone (hPCL) and polyurethane (PU)-collagen type I composite was used as the inner and outer layers, respectively. The porosity and the burst pressure of SDVG were evaluated. Its biocompatibility was demonstrated by the 3-(4,5-dimethyl-2-thiazol)-2,5-diphenyl-2H tetrazolium bromide (MTT) test in vitro and subcutaneous implants in vivo respectively. The grafts of diameter 2.5 mm and length 4.0 cm were implanted to replace the femoral artery in Beagle dog model. Then, angiography was performed in the Beagle dogs to investigate the patency and aneurysm of grafts at 2, 4, and 8 weeks post-transplantation. After angiography, the patent grafts were explanted for histological analysis. RESULTS: The double-layer bionic SDVG meet the clinical mechanical demand. Its good biocompatibility was proven by cytotoxicity experiment (the cell's relative growth rates (RGR) of PU-collagen outer layer were 102.8%, 109.2% and 103.5%, while the RGR of hPCL inner layer were 99.0%, 100.0% and 98.0%, on days 1, 3, and 5, respectively) and the subdermal implants experiment in the Beagle dog. Arteriography showed that all the implanted SDVGs were patent without any aneurismal dilatation or obvious anastomotic stenosis at the 2nd, 4th, and 8th week after the operation, except one SDVG that failed at the 2nd week. Histological analysis and SEM showed that the inner layer was covered by new endothelial-like cells. CONCLUSION: The double-layer bionic SDVG is a promising candidate as a replacement of native small-diameter vascular graft.

[Management strategies of arterial prosthetic graft infection in lower extremity:a report of 5 cases].

OBJECTIVE: To explore the management strategies of pyogenic vascular prosthetic graft infection. METHODS: The clinical data of 5 cases of prosthetic vascular graft infection in lower extremity between 2003 and 2010 were retrospectively analyzed. RESULTS: All of them were treated by antibiotics, debridement and drainage. One patient died from acute myocardial infarction and septic shock. Two patients were cured by extra-anatomic arterial bypass and removal of infected graft after a basic control of infections. And another two patients had the diseased limb amputated after the removal of infected vascular graft without blood reconstruction. CONCLUSION: Pyogenic infection of vascular graft is hard to treat with conservative measures. Revascularization prior to removal of infected graft is recommended for a better outcome.

Biological artificial vessel graft in distal arterial bypass for treating diabetic lower limb ischemia: a case report.

A 68-year-old female patient was treated for unhealed ulcer in the fourth toe of the left foot. Clinical examinations identified severe stenosis of the proximal segment and occlusion of the distal segment of the left anterior tibial artery, and occlusion of the left posterior tibial artery and the peroneal artery. The proximal stenotic segment of the left anterior tibial artery was dilated, but the distal occlusive part failed to be re-canalized. Left anterior tibial artery to dorsal pedal artery bypass was performed on the patient with an epoxide-crosslinked, special radicals antigen-sealed, porcine-derived biological graft; debridement of the left 4th digiti pedis was also performed. Postoperation course was uneventful. The pulse of the left dorsal pedal artery was strong. The ankle brachial index (ABI) increased from 0.60 to 1.09. Warfarin and two antiplatelet drugs were given after the operation. Six months after operation, computed tomographic angiogram (CTA) identified the patent graft.

[Efficacies of carotid endarterectomy in the treatment of atherosclerotic carotid artery stenosis].

OBJECTIVE: To explore the feasibility and efficacy of carotid endarterectomy (CEA) in the treatment of atherosclerotic carotid artery stenosis (ACAS). METHODS: From January 2002 to December 2010, 126 ACAS patients undergoing carotid endarterectomy at our hospital were retrospectively analyzed. There were 92 males and 34 females with an average age of 65.5 years old (range: 48 - 75). Among them, 25 had sequelae of cerebral infarction, 69 symptomatic cerebral ischemia and 32 asymptomatic. Sixty-two patients were monitored intra-operatively with transcranial Doppler (TCD). Among them, 5 patients underwent arterial shunt due to a reduced of blood flow in middle cerebral artery for over 50%. The other 64 patients without TCD monitoring underwent intra-operative arterial shunt. And 22 patients underwent patch angioplasty with autologous or prosthetic vascular patch. Intracranial hyperperfusion was prevented by a compression of common carotid artery or control was successful without perioperative mortality. All patients with cerebral ischemic symptoms and some patients with cerebral infarction sequelae had much post-operative improvement. Deviated tongue protrusion occurred in 10 patients and 8 of them recovered at Week 2 post-operation. And 118 patients were followed up for a mean period of 46.5 months (range: 6 - 96). Two patients with deviated tongue protrusion had slight improvements; 2 patients with severe carotid artery stenosis underwent stent angioplasty; 4 patients with moderate carotid artery stenosis received conservative treatment; among 7 deceased patients, two died of cerebral infarction. CONCLUSION: CEA is effective in the treatment of carotid artery stenosis with a high success rate. TCD monitoring during CEA is valuable for preventing cerebral ischemia and intracranial hyperperfusion. Arterial shunt and arterial patch angioplasty should be considered according to certain conditions during CEA.

[Preliminary evaluation of clinical effects of below-knee arterial bypass on diabetic lower limb ischemia].

OBJECTIVE: To evaluate medium-long term patency of below-knee bypass on patients who suffered from diabetic lower limb ischemia. METHODS: Clinical and follow-up data of 51 patients was retrospectively analyzed who underwent 56 below-knee bypass because of diabetes from November 2001 to December 2006. There were 35 male and 16 female with an average age of 68 years. They endured 26 months ischemic time lag in average, and had suffered from diabetes for 11 years. All of the patients were performed bypass to below-knee (posterior tibial, anterior tibial or peroneal) arteries. Kaplan-meier method was applied. The subgroups of different operative methods and different out-flow vessels were compared by Log-rank tests. RESULTS: An average follow-up time of 23 months was achieved, and lost-follow-up rate was 15%. The total 1- and 5-year primary patent rates were 68% and 54% respectively, secondary patent rate were 70% and 60% respectively, limb salvage rates were 69% and 65%, survival rates were 82% and 60%. One year (3 years) of patent rate(s) of operative method subgroups of femoral-popliteal-infrageniculate bypass with composite grafts, femoral/popliteal-infrageniculate bypass with artificial grafts and femoral/popliteal-infrageniculate bypass with autologous veins were 70% (50%), 33% (33%) and 70% (70%) respectively. One year (4 years) of patent rate(s) of out-flow vessel subgroups of posterior tibial artery, anterior tibial artery and peroneal artery were 65% (60%), 80% (53%) and 77% (66%) respectively. However, both subgroups did not show any statistic differences by log-rank tests. CONCLUSIONS: Partial or whole autologous veins as bypass grafts should be chosen when infrageniculate bypass is considered in diabetic patients. Considerable patent rates are acceptable no matter what kinds of out-flow vessels are chosen.

[Treatment of severe cerebral ischemia in Takayasu's disease with arterial reconstruction].

OBJECTIVE: To evaluate the effect of surgical bypass and to explore the role of transcranial doppler (TCD) during the bypass operation. METHODS: From March 2003 to February 2008, sixteen patients (4 male and 12 female) with mean age of 32 years old and mean disease course of 7.5 years were treated by surgical procedures. The main clinical presentations were dizziness, headache, vertigo, and visional dysfunction. Variated degree of artery stenoses in the 4 arteries (bilateral carotid and vertebral arteries) were revealed by color doppler ultrasonography and DSA. Eight patients underwent aorto-bi-subclavian arteries prosthetic graft bypass. Three patients underwent aorto-bi-subclavian artery prosthetic graft bypass and graft-unilateral carotid artery bypass with autologous great saphenous vein. Three patients underwent aorta-unilateral subclavian artery-unilateral carotid artery prosthetic graft bypass. Two patients underwent aorta carotid artery bypass with autologous great saphenous vein, of which one patient underwent aortocoronary artery bypass simultaneously. Cerebral blood supply was monitored in 14 patients with transcranial doppler. Unilateral subclavian carotid and femoral carotid artery shunt was used respectively to avoid cerebral ischemia during operation in 2 patients. RESULTS: Symptoms and signs of cerebral ischemia improved in all patients with effective rate of 100% apart from deflected tongue-protrusion in 3 patients which recovered in 2 weeks after operation. All patients survived and no symptoms recurred at the end of a 2.2 year's follow-up. Unfortunately, two patients developed aneurysm at the anastomosis within 4 years after operation. CONCLUSIONS: Arterial reconstruction is an effective method for Takayasu's disease with severe cerebral ischemia. TCD monitoring plays an important role during the bypass operation. It can help to determine the revision of blood pressure and prevent postoperative brain reperfusion injury.

[Treatment of severe acute deep venous thrombosis in lower extremity].

OBJECTIVE: To explore the method and effectiveness of treatment for severe acute deep venous thrombosis (DVT) in lower extremity. METHODS: Eighteen patients with severe acute DVT treated in our hospital from January 1, 2002 to December 31, 2008 were retrospectively analysed. All the patients had limb edema and pain, sixteen had limb cyanochroia(one had calf skin ulcer and foot gangrene), two had limb pallor, ten had weakened dorsalis pedis artery pulsation, eight had silent dorsalis pedis artery pulsation. Colour Doppler ultrasonography revealed DVT and superficial venous thrombosis in all diseased limbs. One patient underwent above knee amputation for limb gangrene. Seventeen underwent surgical thrombectomy, of which three were simple thrombectomy, five were supplemented with suprapubic saphenous vein bypass, six with suprapubic PTFE graft bypass, three with iliac vein lysis angioplasty. RESULTS: One patient died (5.6%) on the third day after surgery. Limb edema relieved in seven patients (41.2%), reduced in ten patients (58.8%). All diseased limbs regained normal artery pulsation and skin appearance except for one limb amputated. Sixteen patients (94.1%) were followed up by a mean of 34 months. Limb edema disappeared in five patients (31.3%), reduced in eight patients (50%), recurrent in three patients (18.7%). Among three recurrent patients, one died of malignant tumor 9 months after operation, two had their graft occluded resulting from intimal hyperplasia. CONCLUSIONS: Surgical thrombectomy is an effective method for treating severe acute DVT in lower extremity.

[Management of difficult, severe and recurrent Budd-Chiari syndrome].

OBJECTIVE: To investigate the management of complicated, severe or recurrent Budd-Chiari syndrome. METHODS: From February 2004 to August 2007, 28 patients with complicated, severe or recurrent Budd-Chiari syndrome were treated. In this series, 16 patients relapsed after treated with percutaneous transluminal angioplasty or stent deployment, 2 cases relapsed after surgery; and the other 10 were under severe conditions and hard to treat, including malignancy of the inferior vena cava and right atrium. Meso-cavo-atrial shunt was carried out in 10 cases, meso-cavo-jugular shunt in 6 (capitis medusa was used in one case), cavoatrial shunt in 2 and cavo-jugular shunt in 1, mesocaval shunt in 2, and radical or extended radical correction in 7. RESULTS: One patient (3.6%) died in 24 hours after operation. Graft infection occurred in 1 case. Excellent, good, fair, poor and death rate were 22.2%, 55.5%, 14.8%, 3.7% and 3.7%, respectively, the overall effective rate was 92.5%. CONCLUSION: To select personalized treatment according to the disease status brings hopes to difficult, severe, recurrent Budd-Chiari syndrome.

Transplantation of autologous bone marrow mononuclear cells for patients with lower limb ischemia.

BACKGROUND: Many treatment options for lower limb ischemia are difficult to apply for the patients with poor arterial outflow or with poor general conditions. The effect of medical treatment alone is far from ideal, especially in patients with diabetic foot. A high level amputation is inevitable in these patients. This study aimed to explore the effect of transplantation of autologous bone marrow mononuclear cells on the treatment of lower limb ischemia and to compare the effect of intra-arterial transplantation with that of intra-muscular transplantation. METHODS: In this clinical trial, 32 patients with lower limb ischemia were divided into two groups. Group 1 (16 patients with 18 affected limbs) received transplantation of autologous bone marrow mononuclear cells by intra-muscular injection into the affected limbs; and group 2 (16 patients with 17 affected limbs) received transplantation of autologous bone marrow mononuclear cells by intra-arterial injection into the affected limbs. Rest pain, coldness, ankle/brachial index (ABI), claudication, transcutaneous oxygen pressure (tcPO(2)) and angiography (15 limbs of 14 patients) were evaluated before and after the mononuclear cell transplantation to determine the effect of the treatment. RESULTS: Two patients died from heart failure. The improvement of rest pain was seen in 76.5% (13/17) of group 1 and 93.3% (14/15) of group 2. The improvement of coldness was 100% in both groups. The increase of ABI was 44.4% (8/18) in group 1 and 41.2% (7/17) in group 2. The value of tcPO(2) increased to 20 mmHg or more in 20 limbs. Nine of 15 limbs which underwent angiography showed rich collaterals. Limb salvage rate was 83.3% (15/18) in group 1 and 94.1% (16/17) in group 2. There was no statistically significant difference in the effectiveness of the treatment between the two groups. CONCLUSIONS: Transplantation of autologous bone marrow mononuclear cells is a simple, safe and effective method for the treatment of lower limb ischemia, and the two approaches for the implantation, intra-muscular injection and intra-arterial injection, show similar results.

[Clinical analysis of vascular reconstruction in 56 cases of lower extremity ischemia suffering from infrapopliteal arterial occlusion].

OBJECTIVE: To summarize therapeutic efficacy of vascular reconstruction in treating infrapopliteal arterial occlusion. METHODS: Retrospective analysis of vascular reconstruction of lower extremity was made in 56 cases suffering from popliteal arteries or 3 branches of popliteal arteries (anterior tibial, posterior tibial, peroneal artery) between July 2001 and August 2005 in our hospital. According to the level of lower extremity arterial occlusion, a composite grafts which consisting of a combined proximal PTFE prosthesis grafts with autogenous vein grafts were used to establish the sequential vascular reconstruction for multilevel and multistage arterial occlusive disease. RESULTS: The mean follow-up period after operation was 17 months. The primary graft patency rates in this series was 67.3%, the secondary graft patency rate was 78.8%. CONCLUSIONS: The treatment of composite sequential bypass is a practical means for multilevel arterial occlusive disease suffering from femoral-infrapopliteal arteries, which effectively resolves the insufficiency supply of autogenous vessel grafts and the problem of bad patency rate for vascular reconstruction with prosthetic grafts alone in arterial occlusion suffering from infrapopliteal arteries.

Surgical treatment of 82 patients with diabetic lower limb ischemia by distal arterial bypass.

BACKGROUND: Diabetic lower limb ischemia is a serious complication of diabetes mellitus. This study was conducted to investigate the effectiveness of distal arterial bypass treatment in diabetic patients with lower limb ischemia. METHODS: From July 2000 to July 2004, 96 lower limbs of 82 diabetic patients (type 2) with severe lower limb ischemia were treated in Xuan Wu Hospital. Arterial bypass with femoro-popliteal polytetrafluoroethylene (PTFE) and graft-tibial autologous grafts was performed on 31 limbs (32.3%). Popliteal-tibial artery bypass alone was performed on 22 limbs (22.9%). Combined iliac artery stenting, femoro-popliteal artery PTFE graft bypass, and graft-tibial artery autologous graft bypass was performed on 12 limbs (12.5%), and femoro-tibial artery graft bypass was performed on 10 limbs (10.4%). Popliteal-tibial-pedal artery graft bypass was performed on 7 limbs (7.3%). RESULTS: Arterial grafts in 92 limbs of 79 patients were patent on discharge. Three patients with 4 ischemic limbs (3.7%) died of respiratory failure 12 hours, 3 days and 7 days after operation respectively. Early operation success rate was 96.3% (79/82). Graft patency rate of patients on discharge was 95.8% (92/96). The short-term total effectiveness rate was 83.3% (80/96). Foot ulcer healing rate was 35.7% (10/28). 97.4% (75/77) patients were followed up for a mean of 13.5 months. The long-term total effective rate was 80.7% (71/88). The total amputation rate was 4.5% (4/88). Mortality was 4.5%. The total graft patency rate was 90.9% (80/88). CONCLUSION: In the treatment of diabetic foot, distal lower limb arterial bypass can help to avoid amputation or lower the amputation level, and may promote foot ulcer healing and improve patient's quality of life.