Short-term curative effect of endovascular stent-graft treatment for aortic diseases in China: a systematic review

Comparison of the bifurcated graft reconstruction and aortic stump closure in open surgical conversion after endovascular aneurysm repair

OBJECTIVES

The optimal management of the aortic stump in open surgical conversion (OSC) after AAA endovascular aneurysm repair (EVAR) is debated. Therefore, we aimed to compare the efficacies and safety between the bifurcated prosthetic vascular graft in situ stump reconstruction (p-graft ISSR) and aortic stump closure (ASC) in OSC.

METHODS

We analyzed 973 elective AAA patients admitted from 1/1/2001 to 12/31/2020, at the First Affiliated Hospital of Sun Yat-sen University. We conducted a statistical analysis of the clinical characteristics, procedural data, as well as outcomes and technique considerations of aortic stump management in OSC patients.

RESULTS

A total of 24 male patients had OSC after EVAR. The rate of stent graft infection was 54.17% before OSC. Eleven patients underwent ASC, and 13 patients were treated with p-graft ISSR. The major complication after OSC was aortic stump bleeding (total incidence was 37.50%) (1 patient with a periaortic hematoma and 8 patients with a stump blowout). The total incidences of stump blowout between the patients with ASC and those with p-graft ISSR were significantly different (45.45% vs. 23.08%, p<0.05). The total perioperative mortality was 25.00% (6 patients with stump blowouts). The perioperative survival rates between these two aortic stump management approaches were 72.72% and 76.92% (ASC vs. p-graft ISSR, p<0.05). In total, 18 patients were followed up (3-180 months). There were 3 aorta-related deaths during the late follow-up period (including both of the 2 stump-blowout-related deaths just treated with ASC).

CONCLUSIONS

If the condition of the aorta and peri-aortic tissue are suitable for a prosthetic graft bypass, the p-graft ISSR is highly recommended for OSC patients after EVAR.

Anticoagulant therapy and TEVAR in a patient with antiphospholipid syndrome presenting with pulmonary embolisms and multiple arterial embolisms due to thoracic aortic mural thrombosis

We often observe patients with antiphospholipid syndrome (APS) presenting with both venous and arterial thrombi. Anticoagulant therapy is effective for venous and peripheral arterial embolisms in these patients; however, it has opposite effects when applied for thoracic aortic mural thrombosis because of the risk of new arterial embolisms. Recently, thoracic endovascular aortic repair (TEVAR) has been used to prevent arterial embolisms due to aortic thrombosis. However, we generally hesitate to implant artificial materials in patients in a hypercoagulable state because this can cause new thrombi to develop. Here, we present a case of successful treatment by anticoagulant therapy and TEVAR in an APS patient presenting with pulmonary embolisms (PEs) and multiple arterial embolisms due to thoracic aortic mural thrombosis.

A 46-year-old man was referred to our hospital due to dyspnea and leg pain. Since contrast-enhanced computed tomography revealed PEs, thoracic aortic mural thrombosis, and lower limb arterial embolisms, we administered anticoagulation therapy. Three days later, contrast-enhanced computed tomography revealed new arterial embolisms in the right kidney. To prevent further arterial embolisms due to thoracic aortic mural thrombosis, we performed emergent TEVAR in addition to anticoagulant therapy. Thereafter, no venous or arterial embolisms recurred during the 13-month follow-up period.

<Learning objective: An optimal therapy has not been established for patients in a hypercoagulable state who are threatened by venous thrombi and multiple arterial embolisms due to thoracic aortic mural thrombosis. In such patients, in addition to anticoagulant therapy, thoracic endovascular aortic repair for thoracic aortic mural thrombosis can be a promising option to prevent further arterial embolisms.>

Thoracic Endovascular Aortic Repair With Single/Double Chimney Technique for Aortic Arch Pathologies

Purpose: To summarize a single-center experience using the single/double chimney technique in association with thoracic endovascular aortic repairs (TEVAR) for aortic arch pathologies. Methods: From November 2007 to March 2016, 122 patients (mean age 50.4±12.7 years, range 29–80; 92 men) with aortic arch pathologies underwent TEVAR combined with single (n=101) or double (n=21) chimney grafts to reconstruct the supra-aortic branches: 21 innominate arteries, 114 left common carotid arteries, and 8 left subclavian arteries (LSA). Pathologies included type B aortic dissection (n=47), aortic arch dissection (n=49), retrograde type A aortic dissection (n=8), thoracic aortic aneurysm (n=7), penetrating aortic arch ulcer (n=9), and post-TEVAR type I endoleak (n=2). Follow-up examinations included computed tomography at 0.5, 3, 6, and 12 months and yearly thereafter. Results: The aortic stent-grafts were deployed in zone 0 (n=21), zone 1 (n=93), and zone 2 (n=8). One (0.8%) of the 122 patients died at 4 days due to a perforated peptic ulcer. Type Ia endoleaks were found intraoperatively in 13 (10.7%) patients, including 3 with the double chimney technique. Type II endoleaks occurred in 6 (4.9%) patients; 3 were treated with duct occluders in the LSA. Postoperative chimney graft migration occurred in 1 (0.8%) patient with double chimneys; additional stent-grafts were deployed in both chimneys. Median follow-up was 32.3 months, during which 1 (0.8%) patient died after a stroke at 3 months. Chimney stent-graft patency was observed in the remaining 120 patients. Two (1.7%) secondary TEVARs were performed for distal aortic dissection. Nine asymptomatic type Ia endoleaks and 1 type II endoleak persisted in follow-up; a type II endoleak in 1 patient with Marfan syndrome sealed in 52 months. Conclusion: TEVAR with the chimney technique provides a safe, minimally invasive alternative with good chimney graft patency and low postoperative mortality during midterm follow-up. The double chimney technique should be used judiciously owing to its potential complications.

Comparison of gene expression profiles in aortic dissection and normal human aortic tissues

The aim of the present study was to compare the gene expression profiles in aortic dissection (AD) and healthy human aortic tissue samples by DNA microarray analysis in order to screen the differential genes. In total, five AD and four healthy aortic specimens were selected; the total RNA was extracted and reverse transcribed into cDNA and in vitro transcribed into aRNA, followed by microarray hybridization for analysis. Thereafter, the transcription levels of six differential genes, myosin light chain kinase (MYLK), polycystin 1, transient receptor potential channel interacting (PKD-1), myosin heavy chain 11 (MYH11), superoxide dismutase 3, extracellular (SOD3), filamin A (FLNA), and transgelin (TAGLN), screened from the expression profiles were quantitatively verified. Compared with the healthy aortic specimens, a total of 1,661 genes in the AD group demonstrated more than 2-fold differential expression, of which 997 genes were upregulated and 664 genes were downregulated. Thereafter, six AD-associated genes that showed downregulation in the microarray assay were selected for quantitatively verifying the gene transcription level using reverse transcription-quantitative polymerase chain reaction (RT-qPCR), which confirmed their downregulation compared with the healthy aortic tissue genes; of the six genes, the expression levels of MYLK, PKD-1, MYH11, SOD3 and TAGLN were significantly downregulated (P<0.05), while the expression of FLNA was not significantly downregulated (P>0.05). Thus, whole genome microarray may be used to screen differentially expressed genes between AD and healthy aortic tissues. When used in combination with RT-qPCR validation, this method may provide novel strategies for investigating AD.

Incidence of branching patterns variations of the arch in aortic dissection in Chinese patients

Several authors have described anatomic variations of the aortic arch in 13% to 20% of the patients who do not have aortic disease. However, few studies have evaluated these patterns in the thoracic aortic dissection (TAD). In the authors' knowledge, this is the first survey that specifically investigates the frequency of these variations in a broad, nonselected group of Chinese patients with aortic dissection. Furthermore, it compares this group with a group of patients without aortic disease.The objective of this study was to define the variation frequency of the aortic arch branches pattern using the tomographic studies of 525 Chinese patients with a diagnosis of TAD. The Stanford classification was used to set the site of the initial tear of the dissection. In addition, we performed an epidemiological analysis of the aortic arch anatomic variations in TAD, and its possible implications for surgical or endovascular treatment. The general hypothesis proposal asserted that Chinese patients with dissection of the aorta have a similar incidence of variations of the aortic arch to the patients without aortic disease.A retrospective study of cases and controls was carried out using the tomographic studies (CT) of all patients admitted to the First Affiliated Hospital of Zhengzhou University, located at Henan-China, with a confirmed diagnosis of aortic dissection from January 2012 until December 2014. The group of cases consisted of 525 patients: 374 men and 151 women, with a mean age of 52.27 years (range, 20-89). The average age of the patients with Stanford A and B aortic dissection was 49.46 and 53.67, respectively. The control group consisted of 525 unselected patients without TAD who underwent a CT scan of the chest due to other indications. This group consisted of 286 men and 239 women, with a mean age of 53.60 years (range, 18-89). All the patients with aneurysm or dissection were excluded from the control group. We performed a statistical analysis of demographic data.The study found 7 different patterns of the aortic arch on both groups of cases and controls. Within the 525 patients with TAD were observed 85 (16.19%) anatomical variations, while the control group showed 112 variations (21.33%); P = 0.033. The most common anatomical variant was the bovine arch, found in 62 (11.80%) cases of TAD compared with 77 (14.66%) in the control group; P = 0.172. Anatomical variations were observed in 14.32% of the patients with Stanford A dissection and 17.09% of the patients with Stanford B dissection; P = 0.425. Patients with Stanford A dissection showed the pattern of bovine arch in 23 (13.21%) of 174 cases. In contrast, the patients with Stanford B dissection showed it in 39 (11.11%) of 351 cases; P = 0.481. The anatomical variant defined as vertebral artery of direct origin of the aortic arch was more frequent in the patients with Stanford B dissection (5.12%). The patients with Stanford A dissection presented this pattern in 1.14% of the cases; P = 0.025. This study observed an increased frequency of aortic dissection in the subgroup from 41 to 60 years old. In the subgroup from 41 to 60 years old without TAD, a greater frequency of anatomical variations were found than in the patients with TAD (20.81% vs 14.23%; P = 0.050). The same fashion was seen in patients older than 80 years (27.27% vs 0%; P = 0.030). The anatomical variations of the aortic arch with TAD occurred in 14.97% of the male patients and 19.20% of the female patients compared to 21.67% to 20.92% in the control group; P = 0.026 and P = 0.681, respectively.The aortic arch variations were found less frequently in the TAD group than in the control group in the present Chinese series. The bovine arch was considered the variant pattern of the major frequency in the patients with TAD and the control group. The anatomical variant of 4 branches, defined as vertebral artery of direct origin of the aortic arch, was more frequent in patients with Stanford B aortic dissection than in the patients with Stanford A.This finding might show an association between the geometry of the aortic arch and the site of onset of first intimal tear of dissection.

Ursolic acid inhibited growth of hepatocellular carcinoma HepG2 cells through AMPKα-mediated reduction of DNA methyltransferase 1

Hepatocellular carcinoma (HCC), the major histological subtype of primary liver cancer, remains one of the most common malignancies worldwide. Due to the complicated pathogenesis of this malignancy, the outcome for comprehensive treatment is limited. Chinese herbal medicine (CHM) is emerging as a promising choice for its multi-targets and coordinated intervention effects against HCC. Ursolic acid (UA), a natural pentacyclic triterpenoid carboxylic acid found in CHM, exerts anti-tumor effects and is emerging as an effective compound for cancer prevention and therapy. However, the molecular mechanisms underlying the action of UA remain largely unknown. In this study, we showed that UA inhibited the growth of HCC cells and induced apoptosis in the dose- and time-dependent fashion. Furthermore, we found that UA induced phosphorylation of AMP-activated protein kinase alpha (AMPKα) and suppressed the protein expression of DNA methyltransferase 1 (DNMT1) in the dose-dependent manner. The inhibitor of AMPK, compound C blocked, while an activator of AMPK, metformin augmented the effect of UA on DNMT1 expression. In addition, UA suppressed the expression of transcription factor Sp1. Conversely, overexpression of Sp1 reversed the effect of UA on DNMT1 expression and cell growth. Collectively, our results show for the first time that UA inhibits growth of HCC through AMPKα-mediated inhibition of Sp1; this in turn results in inhibition of DNMT1. This study reveals a potential novel mechanism by which UA controls growth of HCC cells and suggests that DNMT1 could be novel target for HCC chemoprevention and treatment.