P4671A well-defined subgroup of chronic thromboembolic pulmonary hypertension patients are positive for antiphospholipid antibodies

Introduction

Recurrent thromboembolism is a major risk factor for chronic thromboembolic pulmonary hypertension (CTEPH). Antiphospholipid antibodies (aPL) are a recognized risk factor for recurrent thromboembolism, however, their contribution to the development of CTEPH is currently unknown.

Purpose

The aim of this study was to evaluate the prevalence of antiphospholipid autoantibodies in a large cohort of consecutive patients with CTEPH.

Methods

Starting May 2013 to December 2018, 297 CTEPHpatients were consecutively enrolled. Diagnosis was confirmed with standardized right heart catheterization, 2D or/and 3D pulmonary angiography in all patients.All patients were also screened for thrombophilia including lupus anticoagulant IgG/IgM anticardiolipin antibodies and IgG/IgM aβ2GPI antibodies. Clinical and demographic characteristics, laboratory profile and hemodynamic data were compared between patients with aPL positive and aPL negative laboratory profiles.

Results

Overall, 297 consecutive patients with CTEPH were assessed for aPLs. Of these, 23 patients (7.7%) resulted positive for laboratory tests exploring aPL. Among patients with positive aPL, profile 17 (74%) were positive for all three test exploring aPL (LA+, aCL+, aB2GPI+). When compared to CTEPH patients without aPL test positivity, those positive for aPL were significantly younger (30.0 vs 55.6 years, p<0.0001), had a positive history of pulmonary embolism (95.6% vs 65.7%, p=0.003), deep venous thrombosis (78.3% vs 41.9%, p=0.0008) and were more frequently affected by other autoimmune diseases (43.5% vs 2.9%, p<0.0001). Moreover, positive aPL patients showed better hemodynamics on right heart catheterization, had more proximal lesions, and had more frequently level I and II surgical classification (82.6% vs 40.5%, p=0.0002) on pulmonary angiography.

Conclusions

These findings suggest that young patients with pulmonary embolism should be assessed for aPLs to guide anticoagulation therapy and prevent recurrences. Additionally, younger age, more proximal lesions and less severe hemodynamic profiles make majority patients with APS good candidates for PEA surgery.

Endovascular Reconstruction from Aortic Valve to Aortic Arch Using One-Piece Valved-Fenestrated Stent Graft with a Branch: A Proof-of-Concept Study

Objective: To explore the feasibility of endovascular reconstruction of aortic root including aortic valve, sinus of valsalva and ascending aorta by a single stent-graft, a novel valved stent-graft with two fenestrae for preserving the coronary arteries was designed and performed in-vitro on a pig heart based circulation simulating system. Methods: Pig hearts were harvested from 30 healthy adult female pigs weighing between 60-65 kilograms. Before sacrifice, all the pigs received aortic computed tomography angiography (CTA) examinations and morphologic parameters of aortic root were measured. Then we customized the valved stent-grafts according to the CTA measurements. After the pig heart was fixed on the special platform according to the original orientation and connected to the circulation system, the stent graft was delivered through transapical access and covered the segment from aortic annulus to proximal part of aortic arch under DSA (digital subtraction angiography) guidance. Then changes of coronary flow before and after the procedure and fenestration alignment with coronary ostia were analyzed. Results: The overall technical success rate was 100%. The valve functions tested by ultrasound were in good condition under 120 mmHg circulation pressure. The flow of left coronary artery (LCA) did not decrease, but increased after the stent-graft implantation (340 ± 2.06 mL/min versus 288 ± 5.29 mL/min, P < .05). Similarly, the flow of right coronary artery (RCA) also increased (392 ± 9.17 mL/min versus 348 ± 8.01 mL/min; P < .05). The final angiography confirmed that both coronary arteries were patent. When generally observed from outer wall of valsalva sinus, both RCA and LCA orifices were aligned with the fenestrae. In 4 cases, the autologous valve leaflets blocked nearly 20% of the LCA fenestra’s area, but the flow did not significantly decrease in these cases. Conclusion: Stimulated on a pig heart-based circulation simulation system, the one-piece valved-fenestrated stent graft with a branch could be delivered via the transapical access and deployed accurately, which achieved endovascular reconstruction of aortic valve, sinus of valsalva and ascending aorta while preserving the coronary artery perfusion by fenestrations. More in-vivo experiments on animal models are mandatory to further verify its efficacy and safety.

A Retrospective Study Comparing the Effectiveness and Safety of EXOSEAL Vascular Closure Device to Manual Compression in Patients Undergoing Percutaneous Transbrachial Procedures

BACKGROUND

This study aimed to assess the safety and efficacy of EXOSEAL vascular closure device (EVCD) insertion by comparing its performance with manual compression (MC) in achieving hemostasis at the brachial artery puncture site.

METHODS

A retrospective study of brachial artery access by using either MC or EVCD for achieving hemostasis from March 2016 to October 2017 was conducted. Patients with Stanford type B aortic dissection (TBAD) undergoing percutaneous transbrachial procedures were included. Time to hemostasis (TTH) was the primary efficacy end point. Seven-day incidence of major access site-related complications was the primary safety end point. TTH and major and minor complications associated with treatment of these 2 groups were also evaluated.

RESULTS

A total of 157 patients with TBAD undergoing percutaneous transbrachial procedures entered the analysis. Of these, 107 patients underwent EVCD insertion and 50 patients underwent MC. The baseline characteristics of the 2 groups were similar. TTH was significantly shorter for EVCD over MC (P < 0.05). The TTH ≥10 min in the MC group was 100.0% (n = 50), but in the EVCD group, it was ≤2 min, 87.9% (n = 107); 2-5 min, 7.5% (n = 107); and ≥10 min, 4.7% (n = 107). The EVCD group had several major complications, while the MC group had none. Two patients (1.9%, n = 107) required vascular repair, one patient (0.6%, n = 107) required blood transfusion, and 1 patient (0.6%, n = 107) developed upper limb numbness and weakness after EVCD deployment. Minor complication such as the occurrence of hematoma (≤5 cm) in the MC group was 4 (8.0%) but was also 4 (3.7%) in the EVCD group, showing statistically significant difference (P = 0.030). The incidence of ecchymosis was 8 (7.5%) in the EVCD group when compared with 13 (26.0%) in the MC group, which showed statistically significant difference (P = 0.001). Other major and minor complications showed no significant differences between these 2 groups.

CONCLUSIONS

After invasive procedures by 6F percutaneous access via the brachial artery in preprocedurally fully anticoagulated patients, TTH was significantly reduced in patients who underwent EVCD when compared with patients who underwent MC. MC is a safer and more convenient way to achieve hemostasis but has higher incidence of minor complications.

Total Endovascular Repair With Parallel Stent-Grafts for Postdissection Thoracoabdominal Aneurysm After Prior Proximal Repair

Purpose: To evaluate the safety and efficacy of total endovascular repair with parallel stent-grafts for postoperative residual dissection thoracoabdominal aortic aneurysm (TAAA). Materials and Methods: A retrospective study was undertaken of 21 patients (mean age 64.0±12.5 years; 17 men) undergoing total endovascular therapy with parallel stent-grafts for postdissection TAAA after prior proximal repair between 2014 and 2016. The preoperative minimum true lumen diameter was 12.3±4.8 mm and the mean extent of dissection was 248.1±48.2 mm. Pre-, intra-, and postoperative medical records were reviewed to assess technical success, spinal cord ischemia, patency of target branch arteries, endoleak, and short-term outcomes of this approach. Results: Technical success was achieved in 17 of 21 patients owing to 4 type I endoleaks at the end of the procedures. A total of 70 branch arteries were revascularized and 14 celiac trunks were covered intentionally without reconstruction. Of 7 intraoperative endoleaks, 2 were managed intraoperatively and 5 (4 type I and 1 type II) disappeared spontaneously within 1 month. No spinal cord or abdominal organ or limb ischemia was observed. Mean follow-up was 16.2±6.1 months. No death or type I or III endoleak occurred during the follow-up; 2 type II endoleaks were observed. Nineteen of the 21 false lumens thrombosed, and the total aortic diameter decreased (57.3±8.4 to 55.3±7.4 mm, p<0.01). Three (4.3%) of 70 target branch arteries occluded during follow-up. The cumulative patency of retrogradely and antegradely revascularized branch arteries was 97.3% vs 100% at 12 months and 91.2% vs 100% at 18 months. Conclusion: Total endovascular therapy with parallel stent-grafts could be an effective alternative in treating postdissection TAAA. Further studies with long-term follow-up and larger sample size are recommended to evaluate the technique.

Upregulation of miR-330-5p is associated with carotid plaque's stability by targeting Talin-1 in symptomatic carotid stenosis patients

BACKGROUND

The aim of this study was to investigate the relationship between Talin-1 and stability of carotid atherosclerosis plaque and also find out the role of miRNA, as an upstream regulator, in regulating the expression level of Talin-1.

METHODS

Human carotid plaques were obtained from 20 symptomatic carotid stenosis patients who underwent carotid endarterectomy (CEA) in our hospital between October 2014 and August 2017. Western blot analysis and immunohistochemistry was carried out to detect the distribution and expression level of Talin-1 in each plaque sample. The content of miRNAs in carotid plaque was decected by quantitative reverse transcription polymerase chain reaction (RT-qPCR), and the relative expression levels were calculated by 2^-△△Ct method after the (cycle threshold) Ct value (power amplification knee point) was obtained. Dual-luciferase reporter assays were applied to verify the successful transfections. Finally, we compared all the groups with independent-samples t-test and one-way analysis of variance (ANOVA).

RESULTS

Talin-1 was significantly downregulated in human unstable carotid plaque samples compared with stable carotid plaques (P < 0.05), and the distribution of Talin-1 was mainly found in the fibrous cap of carotid plaque. The overexpression of miRNA-330-5p was found in unstable carotid plaque, which significantly induced the inhibition of expression level of Talin-1.

CONCLUSION

Upregulated miR-330-5p may lead to unstable carotid plaques by targeting Talin-1 in symptomatic carotid stenosis patients. This might be a new target for the treatment of atherosclerotic diseases through future studies.

Morphology of the ascending aorta: a study on 114 Chinese patients

Purpose: This study aimed to investigate the morphological characteristics of ascending aortic dissection in detail. Materials and Methods: The ascending aorta was morphologically assessed in a consecutive series of patients between January 2009 and October 2014. A new assessment and evaluation method was used to describe 114 patients with ascending aortic dissection. Results: A large difference was found in the degree of curvature between the ascending aorta with and without dissection. The shape of the former was straighter and steeper (control group R, 47.46 ± 6.40 mm; experimental group R, 59.70 ± 10.27 mm, P < 0.001). In the case of aortic dissection involving the valves, the proximal edge of the first entry was obviously close to the aortic sinus. The orientation of the entries was mainly around the 10 o'clock and 1-2 o'clock positions, and most of their shapes were fusiform (111; 70.02%). The distance of the distal extending dissection was associated with cases involving the branch arteries (involving three branches 441.40 ± 101.13 mm vs 159.85 ± 131.86 mm in others, P < 0.001). Conclusion: The morphological features of the ascending aorta after dissection and the correlations among dissections, entries, and related factors were found.

A Promising Treatment of Distal Entry Tears Located in Branched Area of Abdominal Aorta With Coil-Stent Tear Occlusion Device: an Animal Experiment

This study aims to evaluate the effect of coil-stent tear occlusion device in treating entry tears located in branched area of abdominal aorta. An abdominal aortic dissection animal model was constructed by mesh suturing method. The animal models were treated by the occlusion device and were evaluated by computed tomography angiography (CTA) 1 month later. Eighteen pigs were adopted in the abdominal aortic dissection modeling experiment, two of them died of cardiopulmonary arrest during the operation. Sixteen models survived, two of them were found complete false lumen thrombosis by CTA 3 days after the operation. The false lumen kept patency in the remaining 14 cases which were then implanted with the occlusion device. The procedure was successful in 13 cases except for one. The coil-stent tear occlusion device provides a novel method for tears located in the branched area of abdominal aorta, and is worth of further study.

Indoor particle dynamics in a school office: determination of particle concentrations, deposition rates and penetration factors under naturally ventilated conditions

Recently, the problem of indoor particulate matter pollution has received much attention. An increasing number of epidemiological studies show that the concentration of atmospheric particulate matter has a significant effect on human health, even at very low concentrations. Most of these investigations have relied upon outdoor particle concentrations as surrogates of human exposures. However, considering that the concentration distribution of the indoor particulate matter is largely dependent on the extent to which these particles penetrate the building and on the degree of suspension in the indoor air, human exposures to particles of outdoor origin may not be equal to outdoor particle concentration levels. Therefore, it is critical to understand the relationship between the particle concentrations found outdoors and those found in indoor micro-environments. In this study, experiments were conducted using a naturally ventilated office located in Qingdao, China. The indoor and outdoor particle concentrations were measured at the same time using an optical counter with four size ranges. The particle size distribution ranged from 0.3 to 2.5 μm, and the experimental period was from April to September, 2016. Based on the experimental data, the dynamic and mass balance model based on time was used to estimate the penetration rate and deposition rate at air exchange rates of 0.03-0.25 h^-1. The values of the penetration rate and deposition velocity of indoor particles were determined to range from 0.45 to 0.82 h^-1 and 1.71 to 2.82 m/h, respectively. In addition, the particulate pollution exposure in the indoor environment was analyzed to estimate the exposure hazard from indoor particulate matter pollution, which is important for human exposure to particles and associated health effects. The conclusions from this study can serve to provide a better understanding the dynamics and behaviors of airborne particle entering into buildings. And they will also highlight effective methods to reduce exposure to particles in office buildings.

Should the distal tears of aortic dissection be treated? The risk of distal tears after proximal repair of aortic dissection

BACKGROUND

Patients with distal residual after proximal repair of aortic dissection (AD) have shown unsatisfactory long-term prognosis. However, possible mechanisms and risk factors for distal aortic segmental enlargement (DSAE) have been poorly understood.

METHODS

We analyzed 962 AD patients repaired to the descending aorta between 1999 and 2014. Aortic morphological characteristics of 419 patients (including 75 DSAE and 344 non-DSAE patients) were investigated and compared. Potential risk factors associated with DSAE were explored using logistic regression analysis or natural logarithmic transformation. Logistic multi regress equations were performed to identify independent risk factors.

RESULTS

Independent risk factors of DSAE are listed as follow: more tears in the thoracic descending aorta (odds ratio [OR], 1.65; 95% confidence interval [CI],1.24 to 2.19; P = .0005); fewer tears in the infra-renal abdominal aorta (OR, 3.00; 95% CI,2.04 to 4.55; P < .0001); closer distance of the first intimal tear to the left subclavian artery (OR, 1.51; 95% CI,1.28 to 1.69; P < .0001); larger average distance between tears (OR, 11.81; 95% CI,3.39 to 41.08; P = .0001); larger maximum distance between two tears (OR, 1.79; 95% CI,1.48 to 2.16; P < .0001), and larger area of remained tears (OR, 1.56; 95% CI, 1.38 to 1.76; P < .0001).

CONCLUSIONS

The location and size of remained tears are the key risk factors of DSAE patients. Long-segment aortic repair and aggressive exclusion of all distal tears located on the thoracic descending aorta in their initial therapy will be an optimal strategy.

The effects of a sodium-glucose cotransporter 2 inhibitor on diabetic nephropathy and serum oxidized low-density lipoprotein levels

OBJECTIVE

To investigate the effect of an SGLT-2 inhibitor on diabetic nephropathy and serum oxidized low-density lipoprotein (ox-LDL) levels.

PATIENTS AND METHODS

We randomly divided 126 patients with diabetic nephropathy into the treatment group and control group. The 63 patients in the treatment group received an SGLT-2 inhibitor in addition to routine insulin therapy, while the control group received only insulin to control blood glucose. All laboratory indexes were recorded before and after treatment with the SGLT-2 inhibitor. The prognosis of patients was followed-up. Simultaneously, 63 healthy and BMI-matched in-patients were selected as the healthy control group. Peripheral blood samples were collected from all groups, and the levels of ROS were measured by ELISA.

RESULTS

Renal function indexes such as urinary protein, creatinine, blood urea nitrogen, and glomerular filtration rate (GFR) were significantly higher with SGLT-2 inhibitor treatment compared with the control group (p<0.05). The fasting blood glucose level was not significantly increased before or after treatment (p>0.05). The levels of ROS in peripheral blood were significantly lower in the treatment group than in the control group (p<0.05). Observation at the 1-year follow-up showed that the average GFR was significantly higher in the treatment group than in the control group. Furthermore, the proportion of patients with stage 1-3 chronic kidney disease was significantly higher in the treatment group than in the control group (p<0.05).

CONCLUSIONS

The SGLT-2 inhibitor had a good therapeutic effect on renal function in patients with diabetic nephropathy, without having effects on fasting blood glucose. Additionally, it significantly delayed the progression of nephropathy. It is therefore worth clinical promotion.

Endovascular Treatment for a True Aneurysm of the Transplant Renal Artery using Noncovered Stent-Assisted Coil Embolization

True degenerative aneurysms involving the donor renal artery after kidney transplantation are rather rare. The indications for operation and optimal therapy to combat this vascular complication are still not clear. Surgical revision has been used as a potential treatment: nonetheless, it has been associated with high risk of complications. In the present study, we report on a 31-year-old woman with a true aneurysm located at a transplant renal artery after transplantation which was successfully managed with stent-assisted coil embolization, resulting in occluded aneurysm sac and well-preserved renal function without any complication. We present technical details of this endovascular procedure, which may be useful for transplant renal artery aneurysm repair in high-risk surgical patients.

Endovascular Treatment for Iliofemoral Vein Thrombosis with Composite Stents

BACKGROUND

To evaluate the applicability of endovascular treatment for iliofemoral vein thrombosis with composite stents.

METHODS

Between September 2013 and August 2016, 29 consecutive patients underwent endovascular therapy with composite stents for iliofemoral vein thrombosis and were followed up at our institution. All the patients with acute or chronic iliofemoral vein thrombosis enrolled in this study were evaluated by color Doppler ultrasonography and diagnosed by venography. Treatment measures and related complications were recorded, and cumulative stent patency was assessed with Kaplan-Meier curves.

RESULTS

Patients with acute iliofemoral vein thrombosis (n = 7) were successfully treated with catheter-directed thrombolysis treatment, balloon angioplasty, and stents, whereas patients (n =  = 22) with chronic deep vein thrombosis were treated successfully by balloon angioplasty and stent only. Among all patients, 2 stents were inserted in 25 patients, whereas 3 stents were deployed in 4 patients. Endovascular treatment for iliofemoral vein thrombosis with laser-cut stents combined with Wallstents showed primary patency of treated limbs at 6, 12, and 24 months was 96.6%, 93.1% and 93.1%, respectively. Mean duration of follow-up was 23 months, and there was no occurrence of contralateral vein thrombosis during follow-up by ultrasound.

CONCLUSIONS

Iliofemoral vein thrombosis was successfully recanalized by endovascular therapy with composite stents, and there was no occurrence of contralateral vein thrombosis by ultrasound during follow-up.

Antiplatelet and anticoagulant for prevention of reocclusion in patients with atrial fibrillation undergoing endovascular treatment for low extremity ischemia

Background

The purpose of this study is to report the efficacy of the mono antiplatelet plus anticoagulation therapy for prevention of reocclusion in patients with atrial fibrillation (AF) undergoing endovascular treatment for lower extremity ischemia.

Methods

From March 2014 to July 2016, 32 (21 males; range, 68-84 years) patients were submitted to endovascular therapy for low extremity ischemia with AF and all were treated with endovascular treatments to correct underlying lesions. Then 20 patients receive aspirin plus rivaroxaban post-operation and 12 patients receive aspirin plus warfarin to prevent reocclusion.

Results

Complete reconstruction of occluded femopopliteal arteries with unimpeded blood flow to legs were successfully obtained in all 32 patients; 12 (37.5%) patients had acute ischemia, 17 (53.1%) patients had chronic ischemia, 3 (9.4%) patients had acute on chronic ischemia. Endovascular treatments including percutaneous transluminal angioplasty (PTA) and stenting were performed to correct residual lesions after the thrombolytic/thrombectomy procedure or to correct native lesions for chronic patients. All 32 patients showed significant improvements in symptoms and 4 patients improved completely. The mean ankle-brachial index (ABI) had risen from 0.43±0.21 preoperatively to 0.81±0.16 postoperatively (P<0.01), and the primary patency rates were 88.9% at 12 months, and 81.5% at 24 months. No episodes of major bleeding and only one patient showed positive fecal occult blood tests during the follow-up.

Conclusions

The mono antiplatelet plus anticoagulation therapy offers a safe and effective alternative for prevention of reocclusion in patients with AF undergoing endovascular treatment for lower extremity ischemic.

Relationship between serum cortisol level and degree of false lumen thrombosis in patients with uncomplicated type B aortic dissection

Partial thrombosis of the false lumen in uncomplicated type B aortic dissection (uTBAD) is associated with an increased late mortality risk. Whether the serum cortisol level can affect false lumen thrombosis in patients with uTBAD has not been well characterized. This study was performed on 87 patients with uTBAD. A curve-fitting method was used to analyze the relationship between serum cortisol and partial thrombosis of false lumen. Univariate and multivariate logistic regression analyses were used to identify false lumen partial thrombosis–associated serum cortisol. Curve-fitting’s result revealed a characteristic U shape, and 14.0 µg/dL was considered as the cutoff point for serum cortisol. The results of univariate and multivariate logistic regression analyses suggested that when trisecting the serum cortisol level into three parts, the low and high levels of serum cortisol could significantly affect the occurrence of false lumen partial thrombosis compared with the middle level. The odds ratio value of the low and high levels of serum cortisol was 6.12 and 4.65, respectively, in the univariate analysis, and 24.32 and 3.93, respectively, in the multivariate analysis. Low or high levels of serum cortisol might influence the natural result of uTBAD through affecting the false lumen thrombosis.

Transcatheter aortic valve replacement with balloon-expandable valve : Analysis of initial experience in China

Background

Transcatheter aortic valve replacement (TAVR) is widely applied for the treatment of severe aortic stenosis (AS) in developed countries; however, in China, it is still in the early stage of utilization. On the basis of previous studies, this work explored the feasibility of TAVR in patients with severe AS in China and analyzed the cause of death in four cases.

Methods

This retrospective study included 20 patients who had severe AS and underwent TAVR with a balloon-expandable system (Edwards SAPIEN XT) in our hospital from January 2011 to June 2016. The valve and heart functions of 16 survivors before and after the TAVR procedure were compared. TAVR endpoints, device success, and adverse events were assessed according to the definitions of the Valve Academic Research Consortium-2 (VARC-2).

Results

There were 13 male and seven female patients aged 65–81 years (average, 73.15) who underwent TAVR. The TAVR approach was transfemoral in 19 patients and transapical in one patient. Four patients died (two of coronary artery occlusion and two of aortic annulus rupture) during the TAVR procedure or shortly after; six patients had mild paravalvular leakage, and the rest of the patients showed a significant improvement in cardiac function. During the follow-up period (2–62 months), one patient died of lung cancer 13 months after the TAVR procedure.

Conclusion

TAVR with a balloon-expandable system is safe and effective and can be used for patients with severe AS in China. It requires careful patient selection and preoperative assessment so as to reduce the 30-day postoperative mortality rate.

Comparison of open surgery and endovascular procedures as a therapeutic choice for visceral artery aneurysms

Objectives Visceral arterial aneurysms may be treated using open surgery or endovascular repair, but the best approach remains controversial. This was a retrospective study aiming to compare open surgery and endovascular treatment strategies for visceral arterial aneurysms. Methods The study included all 93 patients who were admitted with visceral artery aneurysms between January 2001 and January 2011 at the Department of Vascular Surgery, Changhai Hospital, Shanghai, China. All cases underwent either open or endovascular procedures. Overall survival and adverse events were compared between the groups. Success rate, blood loss, length of surgery, and length of hospital stay were also compared. The patients were followed up at three, six, and 12 months then every year until April 2014. Results Open surgery was performed on 34 patients and endovascular procedures on 59. There were no differences in characteristics of the patients between the open surgery and endovascular groups. The perioperative complication rate was 52.9 and 13.6% in the open surgery and endovascular groups, respectively. Mean follow-up was 36.8 months (range: 11 months to 10 years). The one- and five-year survival rates were 100 and 60.6%, respectively, in the open surgery group, compared to 100 and 84.5% in the endovascular group. Multivariate analysis for factors related to overall survival showed that there was a significant relationship with the treatment approach (HR = 0.479, 95%CI: 0.278-0.825; P = 0.008) and the presence of false aneurysm (HR = 2.929, 95%CI: 1.388-6.180, P = 0.005). Conclusions Endovascular repair could be considered as an effective method for visceral artery aneurysm. Endovascular repair showed lower perioperative complication rates and better long-term survival.

Unplanned stents in thoracic endovascular aortic repair for type B aortic dissection: A 16-year single-center report

Background

Unplanned stents in thoracic endovascular aortic repair mean additional stents implantation beyond the preoperative planning to achieve operation success. This study aimed to reveal the prevalence and consequences of unplanned stents in thoracic endovascular aortic repair for type B aortic dissection and explore the reasons, risk factors and solutions for unplanned stents.

Methods

Retrospectively analysis consecutive patients diagnosed as type B aortic dissection with initial tear originating distal from the left subclavian artery and underwent thoracic endovascular aortic repair from September 1998 to June 2014 in our center.

Results

Under the criteria, this study enrolled 322 patients, with 83 (25.8%) patients in unplanned group. The incidence rate of unplanned stents in thoracic endovascular aortic repair for type B aortic dissection in each year demonstrates as a bimodal curve. The curve showed that, 2003 and, 2004 was the first and highest peak and 2007 was the second peak. There was no difference in five-year survival rate between planned and unplanned patients (log-rank test, p = 0.994). The unplanned group had higher hospitalization expenses (142,699.08 ± 78,446.75 yuan vs. 175,238.58 ± 34,838.01 yuan; p = 0.019), longer operation time (104.50 ± 93.24 min vs. 179.08 ± 142.47 min; p < 0.001) and hospitalization time (17.07 ± 16.62 d vs. 24.00 ± 15.34 d; p = 0.001). The reasons for unplanned stents were type Ia endoleak (46 patients, 55.4%), bird beak (25 patients, 30.1%), and inappropriate shaping of stent (9 patients, 10.8%). Asymptomatic aortic dissection patients had higher incidence of unplanned stents. Short proximal neck length (2.66 ± 0.59 mm vs. 2.50 ± 0.51 mm; p = 0.016), short stent coverage length (154.62 ± 41.12 mm vs. 133.60 ± 44.33 mm; p = 0.002), and large distal stent oversize (75.44±10.77% vs. 82.68±15.80%; p <0.001) were risk factors for unplanned stents in thoracic endovascular aortic repair.

Conclusion

There are some special risk factors and reasons for unplanned stents in thoracic endovascular aortic repair for type B aortic dissection. Knowing these can we reduce the utilization of unplanned stents with appropriate methods.

Glucocorticoids Regulate the Vascular Remodeling of Aortic Dissection Via the p38 MAPK-HSP27 Pathway Mediated by Soluble TNF-RII

Increasing researches suggest that inflammatory response is involved in vascular remodeling, which plays an important role in the development of aortic dissection. Glucocorticoids have been widely used in the clinical practice due to its powerful and effective anti-inflammatory property. However, the potential relationship between glucocorticoids and aortic dissection was still obscure. This study sought to elucidate the effect of glucocorticoids on the development and progression of aortic dissection, and the potential mechanism involved. Serum cortisol in aortic dissection patients was significantly higher than that in non-ruptured aortic aneurysm patients and healthy volunteers by radioimmunoassay. In modified C57BL/6 mouse model of aortic dissection, glucocorticoids reduced the incidence of aortic dissection and protected the collagen from degradation. Furthermore, glucocorticoids inhibited the TNF-α secretion of THP-1 monocytes, decreased the migration, phenotype switch from contractile type to synthetic type, and the apoptosis of human aortic smooth muscle cells induced by TNF-α. Finally, TNF-sRII was identified as an important cytokine in cellular interaction that participated in vascular remodeling by targeting the p38 MAPK-HSP27 pathway. These results indicate that glucocorticoids inhibit the incidence of aortic dissection by decreasing the TNF-α secretion and increasing the uncombined TNF-sRII, positively participating in vascular remodeling.

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Glucocorticoids participate in the vascular remodeling of aortic dissection mediated by soluble TNF-RII.

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Soluble TNF-RII may be used as a potential and attractive target for the intervention of aortic dissection in the future.

In clinical study, we found the serum cortisol in aortic dissection patients was significantly higher than that in non-ruptured aortic aneurysm patients and healthy volunteers. In modified C57BL/6 mouse model, we found glucocorticoids reduced the incidence of aortic dissection, and protected the collagen from degradation. Furthermore, glucocorticoids inhibited the TNF-α secretion of macrophages, decreased the migration, the phenotype switch from contractile type to synthetic type, and the apoptosis of human aortic smooth muscle cells induced by TNF-α. In general, glucocorticoids participate the vascular remodeling of aortic dissection via the p38 MAPK-HSP27 pathway mediated by TNF-sRII.

Recanalization of native superficial femoral artery chronic total occlusion after failed femoropopliteal bypass in patients with critical limb ischemia

OBJECTIVES

This study aimed to examine the outcomes of endovascular recanalization for native superficial femoral artery (SFA) chronic total occlusion (CTO) in patients with critical limb ischemia (CLI) after femoropopliteal bypass failure with limited surgical revascularization options.

BACKGROUND

Endovascular recanalization of native artery occlusions has been recently used as a new alternative for threatened limbs after bypass graft occlusion. The feasibility and efficacy has not been widely reported.

METHODS

We retrospectively analyzed 45 consecutive patients (45 limbs) undergoing endovascular recanalization of native SFA occlusion following failed femoropopliteal bypass between June 2010 and December 2016.

RESULTS

All limbs had Transatlantic Inter-Society Consensus class C (26.7%, 12/45) or D (73.3%, 33/45) lesions with a mean lesion length of 29.8 cm. The technical success rate was 95.6% (43/45 limbs). The ABI showed a significant increase from 0.3 ± 0.1 pre-procedure to 0.7 ± 0.1 post-procedure (P < 0.01). Two early (<30 days) below-knee amputations due to acute thrombotic ischemia occurred during perioperative period and resulted in one death due to myocardial infarction. The mean follow-up was 42.7 months (1-62 months). Two patients were lost to follow up. The primary patency rates at 12 and 36 months were 54% and 51%, respectively. Secondary patency rates at 12 and 36 months were 78% and 61%, respectively. Limb salvage rate was 95% and amputation-free survival rate was 88% at both 12 and 36 months.

CONCLUSION

Recanalization of native SFA CTO due to failed femoropopliteal bypass offers a feasible and safe alternative to surgical reconstruction with acceptable limb salvage.

Molecular epidemiological characterization of Brucella isolates from sheep and yaks in northwest China

Animal brucellosis is a re-emerging disease in China with high prevalence in the northwest region. A total of 66 isolates of Brucella were recovered from sheep and yaks in the Inner Mongolia, Xinjiang, Qinghai and Gansu provinces of northwest China in 2015 and 2016. Using classical biotyping and the Brucella AMOS PCR assay, all isolates were identified as Brucella melitensis biovar 3 (n = 58), B. melitensis biovar 1 (n = 1), Brucella abortus (n = 5), or Brucella suis biovar 3 (n = 2), and B. melitensis biovar 3 was found to be mainly responsible for sheep brucellosis in northwest China. Multilocus variable-number tandem-repeat analysis (MLVA) was used to identify the epidemiological relationships among the isolates and to assess their genetic diversity. Multilocus variable-number tandem-repeat analysis-16 identified 46 genotypes in these populations, including 37 unique and nine shared genotypes. Multilocus variable-number tandem-repeat analysis-11 showed that 71% of the isolates (47 of 66) were genotype 116 (1-5-3-13-2-2-3-2-4-41-8), a characteristic subgroup of the East Mediterranean group, showing that isolates from different geographical areas exhibit similar epidemiological characteristics in different regions and may be epidemiologically linked. Multilocus variable-number tandem-repeat analysis-11 also revealed that an isolate from Inner Mongolia had a novel genotype, 369 (1-5-3-13-2-2-3-2-7-41-8). Multilocus variable-number tandem-repeat analysis-16 genotyping of northwest China Brucella isolates allows a better understanding of the epidemiology of animal brucellosis in this region. This study is the first analysis of B. melitensis in Gansu province, and the results confirmed that in this province, isolates of this species are disorderly and unsystematic.

A G3P[13] porcine group A rotavirus emerging in China is a reassortant and a natural recombinant in the VP4 gene

Group A rotaviruses (RVAs) are a major cause of serious intestinal disease in piglets. In this study, a novel pig strain was identified in a stool sample from China. The strain was designated RVA/Pig/China/LNCY/2016/G3P[13] and had a G3-P[13]-I5-R1-C1-M1-A8-N1-T1-E1-H1 genome. The viral protein 7 (VP7) and non-structural protein 4 (NSP4) genes of RVA/Pig/China/LNCY/2016/G3P[13] were closely related to cogent genes of human RVAs, suggesting that a reassortment between pig and human strains had occurred. Recombination analysis showed that RVA/Pig/China/LNCY/2016/G3P[13] is a natural recombinant strain between the P[23] and P[7] RVA strains, and crossover points for recombination were found at nucleotides (nt) 456 and 804 of the VP4 gene. Elucidating the biological characteristics of porcine rotavirus (PoRV) will be helpful for further analyses of the epidemic characteristics of this virus. The results of this study provide valuable information for RVA recombination and evolution and will facilitate future investigations into the molecular pathogenesis of RVAs.

Circulating microRNAs: a novel potential biomarker for diagnosing acute aortic dissection

Acute aortic dissection (AAD) is a catastrophic emergency with high mortality and misdiagnosis rate. We aimed to determine whether circulating microRNAs allow to distinguish AAD from healthy controls and chest pain patients without AAD (CP). Plasma microRNAs expression were determined in 103 participants, including 37 AAD patients, 26 chronic aortic dissection patients, 17 healthy volunteers, 23 patients without AAD. We selected 16 microRNAs from microarray screening as candidates for further testing via qRT-PCR. The results showed that plasma miR-15a in patients with AAD (n = 37) had significantly higher expression levels than it from control group (n = 40; P = 0.008). By receiver operating characteristic curve analysis, the sensitivity was 75.7%; the specificity was 82.5%; and the AUC was 0.761 for detection of AAD. Furthermore, 37 patients with AAD had significantly higher plasma expression levels of let-7b, miR-15a, miR-23a and hcmv-miR-US33-5p compared with 14 CP patients of 40 controls (P = 0.000, 0.000, 0.026 and 0.011, respectively). The corresponding sensitivity were 79.4%, 75.7%, 91.9% and 73.5%, respectively; the specificity were 92.9%, 100%, 85.7% and 85.7%, respectively; and the AUCs of these microRNAs were 0.887, 0.855, 0.925 and 0.815, respectively. These data indicate that plasma miR-15a and miR-23a have promising clinical value in diagnosing AAD.

Retrograde Type A Aortic Dissection After Thoracic Endovascular Aortic Repair: A Systematic Review and Meta-Analysis

Background

Retrograde type A aortic dissection (RTAD) is a potentially lethal complication after thoracic endovascular aortic repair (TEVAR). However, data are limited regarding the development of RTAD post‐TEVAR. This systematic review aims to define the incidence, mortality, and potential risk factors of RTAD post‐TEVAR.

Methods and Results

Multiple electronic searches were performed. Fifty publications with a total of 8969 patients were analyzed. Pooled estimates for incidence and mortality of RTAD were 2.5% (95% confidence interval [CI], 2.0–3.1) and 37.1% (95% CI, 23.7–51.6), respectively. Metaregression analysis evidenced that RTAD rate was associated with hypertension (P=0.043), history of vascular surgery (P=0.042), and American Surgical Association (P=0.044). The relative risk of RTAD was 1.81 (95% CI, 1.04–3.14) for acute dissection (relative to chronic dissection) and 5.33 (95% CI, 2.70–10.51) for aortic dissection (relative to a degenerative aneurysm). Incidence of RTAD was significantly different in patients with proximal bare stent and nonbare stent endografts (relative risk [RR]=2.06; 95% CI, 1.22–3.50). RTAD occurrence rate in zone 0 was higher than other landing zones.

Conclusions

The pooled RTAD rate after TEVAR was calculated at 2.5% with a high mortality rate (37.1%). Incidence of RTAD is significantly more frequent in patients treated for dissection than those with an aneurysm (especially for acute dissection), and when the proximal bare stent was used. Rate of RTAD after TEVAR varied significantly according to the proximal Ishimaru landing zone. The more‐experienced centers tend to have lower RTAD incidences.

Endovascular Treatment of Distal Tears Located in the Reno-Visceral Segment with Bare-Metal Stents and Coils in a Complicated Type B Aortic Dissection

The purpose of the study was to provide an endovascular strategy of treating patent reentries adjacent to visceral branches in the management of aortic dissections. A 45-year-old male who had received endovascular treatment for a type B aortic dissection was again admitted for his intermittent abdominal pain. Distal tears located in the reno-visceral segment were left untreated in the initial procedure and were thought to be related to the expansion of the false lumen during follow-up. Another endovascular surgery aiming at sealing these reentries was then performed using the concept of low-porosity flow-diverting stents and coiling technique. Postoperative angiogram revealed a significant decrease in inflow rate through the distal tears, and further computed tomography scan showed a decrease in maximum aortic diameter during the follow-up. With the assistance of coils, the low-porosity bare stents showed the potential to significantly decrease the inflow rate and accelerate the thrombosis of the false lumen. Clinical success achieved in this case study proposes an endovascular strategy in treating the reentries without disturbing the adjacent branches, while its safety and efficacy are still waiting for the verification.

Endovascular treatment for chronic lower extremity ischaemia with sub-acute deterioration

OBJECTIVES

The purpose of this study is to report the efficacy of endovascular treatment for patients with sub-acute (14-day to 2-month) deterioration of chronic lower extremity ischaemia.

MATERIALS AND METHODS

Between June 2013 and May 2015, 26 consecutive patients (22 men, 4 women; mean age, 68.6 years; range, 50-86 years) were treated for sub-acute deterioration of chronic lower extremity ischaemia in our hospital. All patients were treated with catheter-directed thrombolysis initially and then adjunctive percutaneous transluminal angioplasty and/or stenting was performed to correct underlying lesions.

RESULTS

The 26 intra-arterial thrombolysis procedures were all performed in native lower arteries including 8 iliac, 13 femoropopliteal and 5 diffuse occlusions involving the iliac and femoropopliteal segments. Lesion length decreased from 194 mm (70-350 mm) to 92 mm (20-270 mm) after the thrombolytic procedures, and the residual lesions were corrected with percutaneous transluminal angioplasty alone in 4 (15.4%) limbs and stenting in 22 (84.6%) patients. No cross-joint stenting was seen in the 22 affected limbs that used stents. Throughout the treatment process, nine patients with intermittent claudication achieved an unrestricted walking distance, and 17 patients with rest pain or foot ulcers showed significant symptom improvement. The mean ankle-brachial index increased from 0.42 ± 0.16 preoperatively to 0.81 ± 0.25 postoperatively ( p < 0.01).

CONCLUSION

Endovascular therapy with catheter-directed thrombolysis and percutaneous transluminal angioplasty/stenting is feasible for sub-acute deterioration of chronic lower extremity ischaemia patients with favourable midterm results.

Downregulation of Talin-1 expression associates with increased proliferation and migration of vascular smooth muscle cells in aortic dissection

Background

This study aimed to assessed whether Talin-1 is involved in the pathogenesis of aortic dissection via regulating vascular smooth muscle cell (VSMC) biological function.

Methods

Human aortic samples were obtained from organ donors who died from nonvascular diseases as normal controls and from patients undergoing surgical repair of thoracic aortic dissection. The expression level and distribution of Talin-1 were detected using westernblot analysis and immunohistochemistry in each sample. We inhibited the expression of Talin-1 via RNA interference in VSMCs. VSMC proliferation was detected by Cell-counting Kit-8 analyses. Scratch test and flow cytometry were used to identify the migration and apoptosis ability. Antibody microarray analysis and qRT-PCR were used to detect some protein and mRNA changes which were induced by Talin-1 downregulation.

Results

Talin-1 was significantly downregulated in the media of aortic dissection samples compared with controls (P < 0.05). Talin-1 knockdown significantly induced VSMC proliferation and migration in vitro. Proteins which involved in cell cycle can be regulated by downregulating Talin-1. Down regulation of Talin-1 can significanly increased the expression of anaphase-promoting complex subunit 2 (APC2) and decreased p19 alternative reading frame (p19ARF), Cullin-3, and beta actin’s expression.

Conclusions

Talin-1 induces VSMCs proliferation and migration. It downregulated in aortic dissection, which might play a potential role in the development of aortic dissection.

Diagnostic implication of fibrin degradation products and D-dimer in aortic dissection

Fibrin degradation products (FDP) and D-dimer have been considered to be involved in many vascular diseases. In this study we aimed to explore the diagnostic implication of FDP and D-dimer in aortic dissection patients. 202 aortic dissection patients were collected as the case group, 150 patients with other cardiovascular diseases, including myocardial infarction (MI, n = 45), pulmonary infarction (n = 51) and abdominal aortic aneurysm (n = 54) were collected as non-dissection group, and 27 healthy people were in the blank control group. The FDP and D-dimer levels were detected with immune nephelometry. Logist regression analysis was performed to evaluate the influence of FDP and D-dimer for the aortic dissection patients. ROC curve was used to determine the diagnostic value of FDP and D-dimer. The FDP and D-dimer levels were significantly higher in aortic dissection patients than in non-dissection patients and the healthy controls. FDP and D-dimer were both the risk factors for patients with aortic dissection. From the ROC analysis, diagnostic value of FDP and D-dimer were not high to distinguish aortic dissection patients from the non-dissection patients. However FDP and D-dimer could be valuable diagnostic marker to differentiate aortic dissection patients and healthy controls with both AUC 0.863.

Identified key genes related to carotid atheroma plaque from gene expression chip

As one of the leading reason in morbidity and death in the world, atherosclerosis is usually associated with vessel stenosis, ulceration, and inflammatory cell infiltration. However, the formation mechanism of atheroma plaque is unknown. In this research, we have used bioinformatics tools to identify 118 differential expression genes from a GEO dataset. Besides, we also revealed KYNU as a crucial gene in atheroma plaque development.

Outcomes of different treatments on Takayasu's arteritis

BACKGROUND

Takayasu's arteritis (TA) is a nonspecific chronic inflammation of the aorta and its branches. This study compared the outcomes of surgical treatments including bypass surgery, cutting balloon angioplasty and conventional balloon angioplasty to TA patients exhibiting supra-aortic arterial (SAA).

METHODS

This retrospective study was conducted on 42 TA patients, obtained from hospital database, who underwent surgical therapy due to SAA lesions from January 2010 to March 2015. Ten patients were reconstructed using cutting balloon angioplasty, 16 patients received conventional balloon angioplasty and 16 patients from bypass surgery. The primary patency, recurrent symptoms, re-intervention, early (<30 days) and late complications associated with treatment were evaluated.

RESULTS

In the conventional balloon angioplasty group, two patients were converted to bypass surgery as the guidewire could not traverse the lesions. The follow-up at 30.07±17.96 months (range, 1-60 months) showed restenosis or occlusion development in 40.9% arteries in conventional balloon angioplasty, compared with 6.3% after bypass surgery (P=0.018). The restenosis or occlusion rate between cutting balloon angioplasty and conventional balloon angioplasty groups were insignificant (P=0.738). In the re-intervention, three out of four (75%) treated by cutting balloon angioplasty were patent as compared to the three out of nine arteries (33.3%) dealt with by conventional angioplasty that was patent (P=0.266). Intracerebral hemorrhage (n=1) was developed in the bypass surgery group. Mortality was not observed in any of the groups.

CONCLUSIONS

Cutting balloon angioplasty can be considered as a safe, effective, and less-invasive alternative for non-diffuse SAA lesions, especially in young TA patients. However, bypass surgery has better primary patency rate than endovascular treatment.

The relationship between preoperative serum cortisol level and the stability of plaque in carotid artery stenosis patients undergoing carotid endarterectomy

BACKGROUND

Stability of plaque has been implicated as risk factor for stroke. Serum cortisol regulates lipoprotein metabolism and immune response, contributing to plaque stability in atherosclerosis. However, the relationship between serum cortisol and stability of carotid plaque has not been well characterized. We conducted a serology analysis to identify the relationship between serum cortisol and carotid plaque stability.

METHODS

Between May 2013 to October 2015, 73 patients with carotid stenosis patients undergoing carotid endarterectomy (CEA) were enrolled in our study. Serum cortisol was analyzed at 8:00 AM in the morning before surgery via liquid chromatography tandem mass spectrometry. According to the classification made by the American Heart Association, hematoxylin-and-eosin staining was performed to divide these patients into either a stable or unstable group, according to the morphology of fibrous cap, lipid core and intima layer. A curve fitting method was used to identify the relationship between preoperative serum cortisol and stability of carotid plaque. Univariate and multivariate logistic regression analysis were used to identify carotid plaque stability-associated serum cortisol.

RESULTS

Curve fitting's result represents a U-shape characteristic. A total of 314.92 and 395.23 nmol/L were considered as the cut point for preoperative serum cortisol when trisected the patients. When adjusted for degree of stenosis, hyperlipemia, smoking and low-density lipoprotein (LDL), univariate and multivariate logistic regression analysis' results demonstrated that preoperative serum cortisol can significantly affect carotid plaque stability. The odds ratio values in multivariate logistic regression analysis for C reactive protein (CRP), white blood cell (WBC), interleukin-6 (IL-6) and preoperative serum cortisol level were 7.67 and 20.86 respectively.

CONCLUSIONS

Preoperative serum cortisol was associated with stability of carotid plaque in patients undergoing CEA. Low or high levels of preoperative serum cortisol might be an adverse factor for carotid plaque stability.

Impact of Oversizing on the Risk of Retrograde Dissection After TEVAR for Acute and Chronic Type B Dissection

Purpose: To find a suitable rate of thoracic stent-graft oversizing by exploring its association with the occurrence of retrograde type A dissection (RTAD) after thoracic endovascular aortic repair (TEVAR) for type B aortic dissection. Methods: From January 2013 to June 2014, 203 patients (mean age 55 years; 167 men) with type B aortic dissection underwent TEVAR. The mean rate of oversizing at the proximal landing zone was 10% (range 0%–32%). Patients were stratified into 2 groups based on the degree of oversizing: ≤5% (n=105, mean 1.2%±1.5%) and >5% (n=98, mean 18.5%±2.8%). TEVAR-related complications, including RTAD, stent migration, and type I endoleaks, were analyzed. Results: There were no significant differences in the preoperative proximal landing zone diameters between the groups (31.1 mm for the ≤5% group vs 31.8 mm for the >5% group, p=0.229). The incidence of type I endoleaks over a mean follow-up 15.1±6.4 months was 5.4% [6 (5.7%) in the ≤5% group vs 5 (5.1%) in the >5% group, p=0.847]. The stent migration rate was low in both groups (1% vs 2%, respectively; p=0.521). The occurrence of RTAD [0 in the ≤5% group vs 11 (11.2%) in the >5% group] was significantly associated with the rate of oversizing (p<0.001). Conclusion: The early and midterm outcomes of this study demonstrate that ≤5% oversizing may be a suitable option for thoracic endografts used to treat type B dissection. The smaller rate of oversizing can lower the incidence of RTAD without increasing stent migration or type I endoleak rates.

The regulatory role of smooth muscle 22 on the proliferation of aortic smooth muscle cells participates in the development of aortic dissection

OBJECTIVE

The aim of this study was to determine the role of smooth muscle 22 (SM22) in aortic dissection (AD) vascular remodeling and its regulatory mechanism on vascular smooth muscle cell function.

METHODS

Seven patients who underwent surgery for AD with no genetic predisposition and seven organ donors who died from nonvascular diseases were selected. In each aorta sample, the levels of SM22 were detected using immunohistochemistry and Western blot analysis. We inhibited the expression of SM22 with the application of RNA interference in human aortic smooth muscle cells (HASMCs). Cell-counting Kit-8 (Dojindo, Kumamoto, Japan) analyses were used to detect HASMC proliferation. Furthermore, the intracellular calcium concentration was detected using Rhod-2/AM (Dojindo) staining.

RESULTS

SM22 was significantly downregulated in the media of AD samples compared with controls (P < .05). In an in vitro study, downregulation of SM22 can significantly promote HASMC proliferation. Our research further revealed that cells treated with nifedipine can inhibit the promoter activity of SM22 downregulation on HASMC proliferation. Intracellular calcium concentration was a significantly varied during the process.

CONCLUSIONS

SM22 regulates HASMC function activity through intracellular calcium. It presents a downregulation in AD, which might play a potential role in vascular remodeling of AD.

The new indication of TEVAR for uncomplicated type B aortic dissection

The classical therapeutic indication for type B aortic dissection is based on either medication or open surgery; medication therapy is recommended for relatively stable uncomplicated type B aortic dissection. With improvements in endovascular repair and the potential risk of disease progression, it is now necessary to evaluate the requirement for revision of the therapeutic choice of uncomplicated type B aortic dissection based on morphological features and time window. Data from 252 patients diagnosed as uncomplicated type B aortic dissection from 1992 to 2015 were analyzed retrospectively. Among these cases, 117 patients received medication therapy and 135 patients underwent endovascular repair. The 60-month survival rate in the endovascular group was higher than that in the medication group (92.3% vs 67.6%). According to the morphological evaluation, visceral artery involvement and false/true lumen ratios over 0.7 were strong risk factors for medical treatment alone. Increased surgical time and blood loss were found in patients treated in the chronic phase, compared with those who underwent endovascular repair within 14 days of the onset of symptoms. With improvements in aortic remodeling techniques, endovascular repair has been shown to improve long-term survival rates of patients with uncomplicated aortic dissection. Considering the potential risk of death, we recommend that patients with visceral artery involvement and a false/true lumen ratio over 0.7 should receive endovascular repair aggressively. Furthermore, delayed endovascular repair in the chronic phase does not improve the long-term outcome of uncomplicated type B aortic dissection.

Nodular melanoma in trophic ulceration of a leprosy patient: a case study

Non-healing chronic trophic ulceration is very common in leprosy patients. Marjolin's ulcer consists of the malignant transformation of a chronic ulcerative lesion. Nodular melanoma developing from Marjolin's ulcer, caused by a trophic ulceration of a leprosy patient, is very rare with only a few cases reported in the literature. Due to the disguised presentation of these malignancies within trophic ulceration lesions in leprosy, neoplastic transformation is frequently overlooked, leading to misdiagnosed and delayed treatment. This paper reports a case of an 83-year-old man with lepromatous leprosy and chronic ulceration on the foot for 22 years. Over a period of 2 months, the ulcer enlarged, turned black, and became more painful. The patient underwent regional excision and immunotherapy after the diagnosis of malignant nodular melanoma. After 9 months follow-up, no metastasis was found.

DECLARATION OF INTEREST

There were no external sources of funding for this study. The authors have no conflicts of interest to declare.

Postoperative glucocorticoid enhances recovery after endovascular aortic repair for chronic type B aortic dissection: a single-center experience

Background

Thoracic endovascular aortic repair (TEVAR) has been chosen as a less invasive alternative for type B aortic dissections (TBADs). However, the therapeutic effect of TEVAR has been challenged by postoperative adverse events, which were induced by inflammatory response. Glucocorticoids have been widely used because of the powerful and effective anti-inflammatory properties. Nevertheless, the prognostic effect of glucocorticoids after TBAD patients underwent TEVAR remains unclear. The objective of this study was to assess the potential effect of postoperative glucocorticoids on the prognosis of TEVAR for TBADs.

Methods

A total of 92 chronic TBADs patients underwent TEVAR with epidural anesthesia between June 2012 and June 2014 was retrospectively reviewed. The patients were stratified into dexamethasone (DXM) and non-dexamethasone group (N-DXM). The indications for TEVAR were as following: malperfusion (n = 28); contained or impending rupture (n = 17); persistent intractable chest/back pain (n = 32); refractory hypertension (n = 15).

Results

No 30-day mortality and incision infection occurred in each group. The postoperative pain score on the second day was significantly higher in N-DXM group (3.60 ± 0.21 versus 4.83 ± 0.32, P = 0.001). The differences of white blood cell, body temperature and heart rate were pronounced in both groups judged by the peak values (13.01 ± 0.58 × 10⁹/L versus 10.04 ± 0.61 × 10⁹/L, 37.67 ± 0.08 °C versus 37.92 ± 0.09 °C and 89.06 ± 1.21 bpm versus 95.95 ± 1.70 bpm, P = 0.002, 0.04 and 0.001, respectively). The white blood cells in DXM group significantly increased on the second and third postoperative day (P = 0.009 and 0.023), while the body temperature and heart rate showed an apparent decline on the second (P = 0.001 and 0.028), third (P = 0.007 and 0.005) and fourth postoperative days (P = 0.024 and 0.018). However, the changes of false lumen volumes and the endoleak incidence at 3-month follow-up were comparable in the two groups. No significant difference of post-implantation syndrome was observed either.

Conclusions

Although postoperative prophylactic glucocorticoids administration was unable to influence mortality, incision infection or the change of false lumen volumes, it enabled to enhance the recovery of vital signs and alleviate the postoperative pain. A prospective, randomized controlled trial has been registered (NCT02523300), which will be warranted before prophylactic administration of glucocorticoids after TEVAR procedure could be recommended in the clinical work.

Electronic supplementary material

The online version of this article (doi:10.1186/s12872-016-0234-2) contains supplementary material, which is available to authorized users.