2013年 · 第126卷第03期

The goals of future development of endovascular aortic stent grafting were towards extension of the proximal seal,preservation of vital branches,ease of deployment,and low profile delivery systems.Fenestrated aortic stent graft is a viable option for treating aortic aneurysms with short necks,and more than 5000 grafts have been implanted worldwide.The first device available,the Zenith fenestrated graft (Cook Medical,USA),involved placing a proximal tube fenestrated component,then accessing each target vessels from the contralateral side with a sheath,and bridging the connection with a covered stent.A bifurcated distal component is then placed to complete the endovascular repair。

Abstract：Background Conventional high ligation and stripping of the great saphenous vein (GSV) has a good curative effect but is highly traumatic with a considerable relapse rate.Subfascial endoscopic perforator surgery (SEPS) plus endovenous laser treatment (EVLT) could be applied as individual therapy.This study aimed to evaluate the feasibility of performing combined SEPS and EVLT without impacting GSV in the management of valvular insufficiency of the lower-limb venous perforators.Methods Placement of lower-limb venous perforator insufficiency was marked by ascending phlebography in 83 affected limbs from September 2010 to June 2011.After randomization,SEPS was performed on 41 limbs to address the insufficiency of the venous perforators under the deep fascia,in combination with EVLT to close the superficial varicose veins without impacting the GSV.The remaining 42 limbs were treated using traditional GSV phlebectomy as controls.Results Postoperatively,all varicose veins were resolved,with lightening of the pigmentation and healing of the ulcer.Within a follow-up period of 5-11 months,no symptoms had recurred.Compared with the control group,the operation time,the number of incisions sutured,and the in-hospital time decreased on average by 1.5 hours,4.7,and 6.8 days,respectively (P ＜0.01 in all cases).Conclusion Combined SEPS and EVLT for treatment of valvular insufficiency of the lower-limb venous perforators offer the advantages of microtrauma and rapid cure。

Abstract：Background Endovascular stent-graft with fenestration can improve proximal sealing in patients with juxtarenal abdominal aortic aneurysm (JAAA).The purpose of this study was to describe our primary experience and evaluate the safety and efficacy of fenestrated device for JAAA in high-risk patients.Methods Between March 2011 and May 2012,nine male patients (mean age,(79.6±8.6) years) with asymptomatic JAAAs underwent elective deployment of the Zenith fenestrated stent-grafts at a single institution.All patients were treated in the hybrid operating room under general anesthesia.Follow-up computed tomography angiography (CTA) was routinely performed before discharge,at 3,6,and 12 months and annually thereafter.Results Procedural success was achieved in all cases.Total sixteen small fenestrations,two large fenestrations and eight scallops were used.Intra-operative complications occurred in four patients,which included one proximal type Ⅰ endoleak,two type Ⅱ endoleaks,and one renal artery dissection.The mean hospital stay was (8.9±1.4) days,mean blood loss was (360.5±46.8) ml,and mean iodinated contrast volume was (230.6±58.3) ml.The mean follow-up time was (7.6±4.2) months.The visceral graft patency was 100％ until now.One patient had an increase of serum creatinine of more than 30％,but did not require dialysis.No patients died,no stent fractured,and migration were diagnosed during the follow-up.Conclusions The early results of fenestrated device for high-risk patients with complex JAAAs are satisfactory.However,long-term fenestrated graft durability and branch vessel patency remain to be determined。

Abstract：Background Peripheral artery disease accounts for more than 400 000 hospitalizations in the USA and results in symptoms ranging from claudication to gangrene.Recent advances in endovascular techniques have led to a more aggressive approach for treating peripheral artery disease.The aim of this retrospective study was to evaluate the outcomes of endovascular interventions on TransAtlantic InterSociety Consensus (TASC) Ⅱ C and D femoropopliteal occlusive disease.Methods Data for all patients undergoing endovascular interventions for femoropopliteal occlusive disease from December 2007 through December 2010 were reviewed.Demographic data,risk factor data,preprocedural and postprocedural ankle-brachial indices,technical success rates,and complication rates were obtained.Primary,assisted primary,and secondary patency were determined by Kaplan-Meier survival analysis.Univariate and multivariate analyses were performed to identify factors adversely affecting primary patency.Results The study group included 52 TASC Ⅱ C and 106 TASC Ⅱ D limbs in 126 patients (mean age,(68.0±18.0) years).The technical success rate was 91.1％.Complications occurred in 19 limbs (12.0％),including 8 (5.1％) major complications.The mean follow-up period was (17.6±5.1) months (range,12.0-48.0 months).Primary patency rates at 1,2,3,and 4 years were 95％,78％,74％,and 74％ in TASC Ⅱ C lesions and 89％,62％,52％,and 52％ in TASC Ⅱ D lesions,respectively.Secondary patency rates at 1,2,3,and 4 years were 97％,94％,94％,and 94％ in TASC Ⅱ C lesions and 97％,95％,83％,and 83％ in TASC Ⅱ D lesions,respectively.It is significantly different between primary patency rates (P ＜0.05) but not secondary patency rates of TASC Ⅱ C and D groups (P ＞0.05).Predictors of restenosis/occlusion included hyperlipidemia,lesion length,and popliteal artery involvement.Conclusions Endovascular treatment of TASC Ⅱ C and D femoropopliteal artery occlusion has a high technical success rate with favorable mid-term secondary patency rate.Hyperlipidemia,lesion length,and popliteal artery involvement were independent risk factors for in-stent restenosis。

Abstract：Background Endovenous laser ablation (EVLA) is an improved method to treat varicose great saphenous veins (GSV)with a high satisfactory rate.This study aimed to evaluate the efficiency and safety of treatment by EVLA procedures with ultrasound-guided perivenous tumescence.Methods Thirty-one patients (31 limbs) with symptomatic varicose vein primary to chronic venous insufficiency (CVI) treated with EVLA were prospectively studied.The entire procedure was performed under ultrasound-guided tumescent local anesthesia.The patients were evaluated with a 18 month follow-up postoperation using clinical examination and venous duplex ultrasonography.Pain scores and quality of life (QOL) were recorded using visual analog scale (VAS) and the chronic venous insufficiency questionnaire (CIVIQ) at 1 week,1 month,and 12 months after operation.Results All patients tolerated EVLA procedure well.The overall success occlusion rates of GSV were 92％,94％,and 94％ at 1,12,and 18 months follow-up,respectively.The score of CIVIQ one week preoperation was 69.14±11.44 while that of CIVIQ one month postoperation was 85.32±4.89.The life quality has significantly improved after the operation of EVLA (t=12.71,P ＜0.05).The VAS one month after treatment was lower than 1 week before therapy (t=8.048,P ＜0.05).Major complications such as deep vein thrombosis and skin bums were not found.Most of the complications were minor and improved quickly.Conclusions This refinement type of EVLA procedure is a safe and effective treatment with a high satisfaction rate; it displayed noteworthy features including shortening hospitalization,early ambulant activity,and preferable occlusion rates。

Abstract：Background Central venous stenosis and obstruction (CVD) is a serious and prevalent challenge to both resolve the venous hypertension symptoms and maintain the pantency of the ipsilateral hemodialysis access in hemodialysis patients.This study aimed to summarize our experience of the endovascular management of the central venous stenosis or obstruction in hemodialysis patients.Methods Twenty-four haemodialysis cases of central vein stenosis or obstruction with ipsilateral functional vascular access in our hospital between July 2006 and February 2012 were treated by interventional therapy and the data were analyzed retrospectively.Results Eighteen males and six females with mean age of (66.4±13.8) years and manifesting with arm swelling and venous hypertension were enrolled; 62.5％ of them had a history of catheterization.Venography showed stenotic lesion in 10 cases including eight cases of brachiocephalic vein stenosis and two cases of subclavian vein stenosis and 14 cases of obstruction lesions including seven cases of short brachiocephalic obstruction and seven cases of long segment obstruction.Interventional therapy was performed and the technique success rate was 83.3％.Percutaneous transluminal angioplasty (PTA) was performed in nine cases and stent was performed in 11 cases firstly.The symptoms of venous hypertension were resolved after intervention in all the cases.There was no major complication and death perioperatively.During follow-up,reintervention was done,the primary patency rates were (88.9±10.5)％,(64.8±10.5)％ and (48.6±18.7)％ at 3 months,6 months and 1 year after treatment in the PTA group; (90.0±9.5)％ and (77.1±14.4)％ at 6 months and 1 year after treatment in the stent group,respectively.The secondary patency rates were (48.6±18.7)％ in the PTA group and (83.3±15.2)％ in the stent group 1 year after treatment,respectively.There was no significant difference between the two groups (primary patency,P=0.20; secondary patency,P=0.10).Conclusions The endovascular intervention is a safe and effective method for CVD in short term; enhanced follow-up and repeated interventions are required to maintain patency for long term.The prevention is most important.Avoiding and minimizing the placement of the central venous catheter may be the key point for the prevention。

Abstract：Background Acute kidney injury (AKI) is considered as a common and significant complication following abdominal aortic aneurysm (AAA) repair.This study aimed to assess the associated risk factors of AKI in the critically ill patients undergoing AAA repair and to evaluate the appropriate AKI management in the specific population.Methods We retrospectively examined data from all critically ill patients undergoing AAA repairs at our institution from April 2007 to March 2012.Multivariable analysis was used to identify factors associated with postoperative AKI,which was defined by risk,injury,failure,loss and end-stage (RIFLE) kidney disease criteria.The goal-directed hemodynamic optimization (maintenance of optimal hemodynamics and neutral or negative fluid balance) and renal outcomes were also reviewed.Results Of the 71 patients enrolled,32 (45.1％) developed AKI,with 30 (93.8％) cases diagnosed on admission to surgical intensive care unit (SICU).Risk factors for AKI were ruptured AAA (odds ratio (OR)=5.846,95％ confidence interval (Cl):1.346-25.390),intraoperative hypotension (OR=6.008,95％ CI:1.176 to 30.683),and perioperative blood transfusion (OR=4.611,95％ CI:1.307-16.276).Goal-directed hemodynamic optimization resulted in 75.0％ complete and 18.8％ partial renal recovery.Overall in-hospital mortality was 2.8％ AKI was associated with significantly increased length of stay ((136.9±24.5) hours vs.(70.4±11.3) hours)in Surgical Intensive Care Unit.Conclusions Critically ill patients undergoing AAA repair have a high incidence of AKI,which can be early recognized by RIFLE criteria.Rupture,hypotension,and blood transfusion are the significant associated risk factors.Application of goal-directed hemodynamic optimization in this cohort appeared to be effective in improving renal outcome。

Abstract：Background The pathological characteristics of abdominal aortic aneurysm (AAA) involved the regression of extracellular matrix (ECM) in aortic walls,especially elastic structure in medial layer.As the major structural protein of aorta,elastin contributes to the extensibility and elastic recoil of the vessels.We hypothesized that overexpression of elastin in vessel walls might regenerate the elastic structure of ECM,restore the elastic structure of the aneurysmal wall,and eventually lead to a reduction of aortic diameters (ADs) in an experimental model of AAA.Methods Tropoelastin (TE) of Sprague Dawley (SD) rat was synthesized by reverse transcription polymerase chain reaction and used to construct adneviral vectors containing elastin precursor protein (AdTE-GFP).Cultured vascular smooth muscle cells (VSMCs) from aortas of male SD rats were transfected with AdTE-GFP,AdGFP,adenoviral vector (AdNull),and phosphate buffered saline (PBS).Immunofluorescence staining was performed to determine the expression of elastin in transfected cells.The expression of elastic fibers in ECM of VSMCs transfected with AdTE-GFP were detected by fluorescence microscopy and transmission electron microscopy (TEM) at 1,3,and 5 days following gene transfer.The AAA vessel walls were infused with AdTE-GFP or an empty AdNull,or PBS directly into the aneurysmal lumen.ADs of the aneurysms were compared in infused aortas.Formation of new elastic fibers in vivo was assessed by hematoxylin and eosin,and elastic von-Giesson staining.Recombinant elastin-GFP in vivo was identified by immunohistochemical staining.Results Elastic fibers were increased both in ECM of VSMC and in vessel walls after gene transfer.Histological studies revealed that the AdTE-GFP-transduced aortas had elastic fiber regeneration in the aneurysmal walls.The AdTE-GFP-transduced aortas showed a decreased AD (23.04％±14.49％,P ＜0.01) in AAA vessel walls.Conclusions Elastic fibers have been successfully overexpressed both in vitro and in a rat model of AAA by a technique of gene transfer.The overexpression of elastic fibers within the aneurysmal tissue appeared to reverse the aneurysm dilatation in this model。

Abstract：Background The traditional approach to blunt aortic injury (BAI) has been emergent intervention.This study aimed to utilize a modified imaging grading system that may allow us to categorize these injuries as needing emergent,urgent,or non-operative management.Methods From January 2003 to December 2011,28 patients with BAI were managed at our institution.Imaging and medical records were reviewed retrospectively.BAI was classified into 4 grades based on imaging studies.Grade la:intimal tear,Grade Ⅰb:intramural hematoma; Grade Ⅱ:intimal injury with periaotic hematoma; Grade lia:aortic transection with pseudoaneurysm,Grade Ⅲb:multiple aortic injuries; and Grade Ⅳ:free rupture.Progression and clinical outcomes of ABI were analyzed.Results Of the 28 patients,22 were males and 6 were females with mean age of 38 (range,7--69) years.Twenty-five (89.3％) had descending thoracic aortic injury,two (7.1％) had abdominal aortic injury and one (3.6％) presented with multiple aortic injuries.Three patients (10.7％) with Grade Ⅰ,1 (3.6％) Grade Ⅱ,22 (78.6％) Grade Ⅲ,and 2 (7.1％) Grade Ⅳ injuries.Twenty-five patients underwent thoracic endovascular aortic repair and 3 were managed medically.Median time between injury and surgical intervention was (2±1) days.One (3.6％) patient developed paraplegia after thoracic endovascular aortic repair (TEVAR).One Type 2 endoleak spontaneously sealed within 1 month,and another patient died from ruptured Type 1 endoleak 3 years later.Median follow-up time was 16 (range,1-96) months.Perioperative 30-day mortality rate was 3.6％.Conclusions This study based on our modified BAI grading system indicated that Grade Ⅰ BAI can be managed conservatively.Grade Ⅱ injury requires close observation and repeated computerized tomography angiogram (CTA)within 48-72 hours.If injury appears worse on follow up imaging,surgery should be performed.Delayed repair of Grade Ⅲ BAI is acceptable if associated life threatening traumatic injuries need to be addressed first。

Abstract：Background Repeat percutaneous coronary intervention (PCI) is associated with unfavorable prognosis in patients with coronary artery disease,but there is a current lack of related systematic cross-sectional studies in China.The survey was to investigate a real world of repeat PCIs and their associated factors during the drug eluting stent era in a Beijing high volume center.Methods A comprehensive review of the institution's database between January 2006 and July 2009 was conducted.Demographic information,concomitant diseases,peri-procedure laboratory examinations and angiographic features were collected consecutively.Multivariate Logistic regression analysis was undertaken to explore the risk factors associated with repeat PCIs.Results A total of 13404 patients were included in the analysis.Of which,1946 patients (14.5％) had prior PCI procedure.More males patients had previous PCI than the females (15.7％ vs 10.9％,P ＜0.001).After adjustment for age,gender,concomitant diseases,angiographic and procedural factors,a multivariate model showed that male,diabetes,hyperlipidemia and previous myocardial infarction,left main disease were identified as independent risk factors of repeat PCIs.Of which,previous myocardial infarction (odds ratio:2.58,95％ confidence interval:2.27-2.92)was highly related with repeat PCIs.Conclusion The frequency of repeat PCIs was 14.5％ in this cross-sectional investigation,and their associated factors included male,diabetes,hyperlipidemia and previous MI and left main disease during drug eluting stent era。

Abstract：Background The hybrid procedure for coronary heart disease combines minimally invasive coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) and is an alternative to revascularization treatment.We sought to assess the predictive value of four risk-stratification models for risk assessment of major adverse cardiac and cerebrovascular events (MACCE) in patients with multivessel disease undergoing hybrid coronary revascularization.Methods The data of 120 patients were retrospectively collected and the SYNTAX score,EuroSCORE,SinoSCORE and the Global Risk Classification (GRC) calculated for each patient.The outcomes of interest were 2.7-year incidences of MACCE,including death,myocardial infarction,stroke,and any-vessel revascularization.Results During a mean of 2.7-year follow-up,actuarial survival was 99.17％,and no myocardial infarctions occurred.The discriminatory power (area under curve (AUC)) of the SYNTAX score,EuroSCORE,SinoSCORE and GRC for 2.7-year MACCE was 0.60 (95％ confidence interval 0.42-0.77),0.65 (0.47-0.82),0.57 (0.39-0.75) and 0.65 (0.46-0.83),respectively.The calibration characteristics of the SYNTAX score,EuroSCORE,SinoSCORE and GRC were 3.92 (P=0.86),5.39 (P=0.37),13.81 (P=0.32) and 0.02 (P=0.89),respectively.Conclusions In patients with multivessel disease undergoing a hybrid procedure,the SYNTAX score,EuroSCORE,SinoSCORE and GRC were inaccurate in predicting MACCE.Modifying risk-stratification models to improve the predictive value for a hybrid procedure is needed。

Abstract：Background Atherosclerosis is the primary cause of cardiovascular disease,carotid artery disease,and peripheral vascular disease.However,it is hard to obtain human arterial tissue at different stages of atherosclerosis for a systematic study.The ApoE-deficient (ApoE 1-) mice predictably develop spontaneous atherosclerotic plaques with numerous features similar to the human lesions and contain nearly the entire spectrum of lesions observed during atherogenesis in humans.MicroRNA expression profiles at different stages of atherosclerosis in ApoE-deficient mice were screened to find out the differentially expressed microRNAs.Methods ApoE-deficient mice were euthanized at 4,8,and 20 weeks of age and divided into three groups according to the three time points,including groups A4 (fed a Western-type diet for 0 week),A8 (fed a Western-type diet for 4 weeks),and A20 (fed a Western-type diet for 16 weeks).Atherosclerotic lesions were analyzed.Fifteen aortas were collected and combined into three pools (five aortas in one pool) in each group.MicroRNA microarray analysis was replicated thrice in each group.The threshold of fold change ≥2.0 was used to screen up or down-regulated microRNAs.Differentially expressed microRNAs were subsequently verified with quantitative real-time polymerase chain reaction.Those increasingly up or down-regulated microRNAs during the progression of atherosclerosis were selected.Results Atherosclerotic lesions first appeared in the aortic arch in group A8.Severe atherosclerotic lesions were observed in group A20.In group A8,seven MicroRNAs were up-regulated while two were down-regulated.In group A20,15 microRNAs were up-regulated while two were down-regulated.miR-34a-Sp and miR-497-5p were increasingly up-regulated,while miR-434-3p was progressively down-regulated when atherosclerosis progressed.Conclusions In this study,we described that microRNAs are differentially expressed at different stages of atherosclerosis in ApoE-deficient mice.Those increasingly up or down-regulated microRNAs during the progression of atherosclerosis may play an important role in the pathogenesis of atherosclerosis and provide us opportunities for investigating atherosclerosis from early to advanced stages。

Abstract：Background Carotid stenosis is one of the common reasons for patients with ischemic stroke,and the two invasive options carotid endarterectomy (CEA) and carotid artery stenting (CAS) are the most popular treatments.But the relative efficacy and safety of the methods are not clear.Methods About 521 articles related to CAS and CEA for carotid stenosis published in 1995-2011 were retrieved from MEDLINE,Cochrane Library (CL),and China National Knowledge Infrastructure (CNKI) China Journal Full-Test database.Of them,eight articles were chosen.Meta-analysis was used to assess the relative risks.Results The eight studies included 3873 patients with symptomatic carotid artery stenosis,including 1941 cases in the carotid stent angioplasty group,and 1932 cases in the carotid endarterectomy group.Fixed effect model analysis showed that within 30 days of incidence of all types of strokes,surgery was significantly highly preferred in CAS patients (CAS group) than the CEA patients (CEA group),and the difference was statistically significant (relative ratio (RR)=1.80,95％ confidence interval (CI):1.380-2.401,P ＜0.0001).But the incidence of death in the two groups is not showed and is not statistically significant after 30 days (RR=1.52,95％ CI:0.82-2.82,P=0.18).The rate of cranial nerve injury in the CAS group is lower than the CEA group (RR=0.14,95％ CI:0.05-0.43,P=0.0005).The incidence of CAS patients with myocardial infarction is lower than the CEA group after 30 days,but statistically meaningless (RR=0.22,95％ CI:0.05-1.02,P=0.05).The stroke or death in CAS patients were higher than the CEA group after 1 year of treatment (RR=2.58,95％ CI:1.03-6.48,P=0.04).Conclusions Compared to CAS,carotid endarterectomy is still the preferred treatment methodology of symptomatic carotid artery stenosis.Future meta-analyses should then be performed in long-term follow-up to support this treatment recommendation。

Abstract：Objective To review the recent progress of multilayer stents in treating arterial aneurysms and to draw an initial conclusion about its paradigm.Data sources PubMed database and ELSEVIER database were searched with the keywords "cardiatis" or "multilayer stent" for relevant articles from January 2008 to September 2012.Relevant websites (provided by Cardiatis) were also involved in the review process.Study selection Well-controlled,relatively large-scale,retrospective studies as well as meaningful individual cases were all selected as materials.Results A total of 23 articles were involved in this review.The newly introduced Cardiatis multilayer stent aims at creating an active flow-modulating barrier between normal blood flow and aneurismal sac,which can induce thrombosis within aneurismal sac and preserve collateral circulation at the same time.Currently,it has been applied for complicated aneurysms located in different segments of the arterial system.Conclusion This new concept of multilayer uncovered stent offers a promising alterative in the treatment of arterial aneurysms.However,a further large-scale clinical and hemodynamic study is required to evaluate the long-term effects。

Abstract：Objective To review the mechanisms and current clinical application of pharmacological interventions for phantom limb pain.Data sources Both Chinese and English language literatures were searched using MEDLINE (1982-2011),Pubmed (1982-2011) and the Index of Chinese Language Literature (1982-2011).Study selection Data from published articles about pharmacological management of phantom limb pain in recent domestic and foreign literature were selected.Data extraction Data were mainly extracted from 96 articles which are listed in the reference section of this review.Results By reviewing the mechanisms and current clinical application of pharmacological interventions for phantom limb pain,including anticonvulsants,antidepressants,local anaesthetics,N-methyl-D-aspartate receptor antagonists,non-steroidal anti-inflammatory drugs,tramadol,opioids,calcitonin,capsaicin,beta-adrenergic blockers,clonidine,muscle relaxants,and emerging drugs,we examined the efficacy and safety of these medications,outlined the limitations and future directions.Conclusions Although there is lack of evidence-based consensus guidelines for the pharmacological management of phantom limb pain,we recommend tricyclic antidepressants,gabapentin,tramadol,opioids,local anaesthetics and N-methyl-D-aspartate receptor antagonists as the rational options for the treatment of phantom limb pain。

For over a decade,there has been a paradigm shift to an endovascular,minimally invasive approach whilst treating diseases of the aorta and its branches,with clear advantages in terms of morbidity and mortality in certain vascular beds,especially in patients with multiple co-morbidities that would otherwise be deemed unsuitable for traditional open surgical approaches.Endovascular intervention however,has certain morphological and anatomical constraints.Difficult anatomical targets may lead to prolonged endovascular instrumentation carrying significant risks to the patient such as distal embolization and vessel trauma,with increased fluoroscopic exposure and long overall procedure times.Visualization and control of wire and catheter manipulation become less intuitive and less predictable as case complexity increases.Furthermore,complex endovascular tasks require a refmed set of operator skills and technical finesse that is usually acquired after years of experience and standardized training.Conventional endovascular catheter technology contributes to these technical limitations;with a limited repertoire of shapes and sizes,they are difficult to steer and lack active maneuverability of the tip.This manual control can hinder overall stability and control at key target areas necessitating frequent catheter changes and risking loss of wire position in challenging cases.Catheter movement in itself consists of a series of interactions,which occur between the catheter,the guidewire and the vessel wall.Although effective,it is this wall interaction,which is responsible for many of the complications reported,as repeated instrumentation especially in the presence of vessel thrombus or calcification,increases the risk vessel dissection,perforation and distal embolization.Endovascular flexible robotic technology presents itself as an attractive option,with enhanced active maneuverability,catheter tip control and the promise of "off the wall",center-line navigation remotely and away from the radiation source。

Restenosis and occlusion after endovascular intervention of lower limb arteries remain the main problem in obtaining better results for patients with critical limb ischemia (CLI) and claudication.Improved angioplasty balloons,catheters,guide-wires,and operator skill have enabled ＞90％ of stenotic and ＞80％ of occluded arteries to be successfully cleared.However,percutaneous transluminal angioplasty (PTA) rarely results in sustained patency with most studies showing a ＜50％ patency at 12 months.1,2 Drug eluting stents (DES)were originally designed to reduce the risk of restenosis in coronary arteries.While there has been concern about acute thrombosis in the medium term follow-up,DES has clearly been shown to reduce the risk of restenosis compared with similar bare metal stents (BMS) by over 50％ at 12 months and later.4

The metamorphosis of abdominal aortic aneurysm (AAA) repair from open surgical to endovascular means has evolved substantially over the past 2 decades.Today,endovascular abdominal aneurysm repair (EVAR)is considered as the first choice of therapy for treatment of infrarenal AAA in patients with favorable morphology.Furthermore,in "real world" clinical scenarios,with increasing physician experience and ability,the indications of EVAR have expanded from treatment of elective to emergent aneurysms and from favorable morphology to sometimes complex and unfavorable anatomy,particularly in high-risk patients.1-4 When considering these endovascular techniques for treating ruptured AAA,one has to prepare for the challenges of streamlining patient care from the emergency room to the operating room and subsequent endovascular procedure that often requires a multidisciplinary approach and a change in paradigm and local cultures.This paper will focus on a comprehensive and standardized technical approach for treating patients presenting with ruptured AAA by endovascular means that can maximize our ability to offer this treatment of most patients and optimize outcomes。

Stroke is one of the most common causes of permanent disability in industrialized countries and become increasingly prevalent in developing countries.Management of stroke consumes $45 billion annually,and is responsible for greater than one million hospital admissions each year in the U.S.Neurologic sequelae related to cerebral vascular accidents (CVA) severely limit a patient's ability to carry out activities of daily living and invariably create an enormous burden on health care costs.As a result,the prevention of CVA with safe treatment of extra-cranial carotid occlusive disease remains an important health care goal。

Organ transplant is an advanced medical technology brought to China from the West in the latter half of the 20th century.Thanks to the strenuous efforts of generations,it has become a mature clinical practice,having saved the lives of a great number of patients suffering from end-stage organ failure.Different from other medical technologies,an organ transplant requires a donated transplantable organ,and the donation and allocation are embedded in social issues such as culture,tradition,ethics,and law.Therefore,the government should play a leading role in the extensive application of transplant technology to build a managing system in line with social ethics,to motivate the public to register for gratuitous organ donations,to assure the donors of their legitimate interests and benefits through reasonable donation procedures and regulations,and to guarantee the just allocation and reasonable utilization of organs.While developing organ transplant technology,the western countries have established a complete legal management framework.For instance,in the United States,National Organ Transplant Act was promulgated in 1984,and institutions such as Organ Procurement and Transplantation Network (OPTN),Organ Procurement Organization (OPO),and United Network for Organ Sharing (UNOS) were set up accordingly to ensure the rationality and legality of transplant services。

With the rapidly rising incidence of diabetes,one of its complications,diabetic nephropathy (DN) is becoming one of the most common causes of end-stage renal disease in many countries.Reliable animal models of DN are a valuable tool for identifying the molecular mechanisms responsible for this disease and preclinical development of new therapeutic strategies.Various types of animal models have been used in the past;the induced methods and characteristics of these commonly used animal models were summarized in this review。

Islet transplantation has recently emerged as one of the most promising therapeutic approaches to improving glycometabolic control in diabetic patients.The Edmonton trials demonstrated a marked improvement in the short-term rate of success of islet transplantation,with an 80％ rate of insulin-independence being at 1 year after transplantation,as reported by several institutions worldwide.Unfortunately,this rate consistently decreases to 10％ by 5 years post-transplantation.1 Other data reported that less than half of the patients achieved insulin independence at 1 year and ＜15％ remained insulin independent at 2 years.2It is not clear whether this decline in insulin independence is the result of islet loss.Also unclear are the mechanisms that underlie the deterioration of graft function,though possibilities include auto or alloimmune destruction,immunosuppressant toxicity,or a progressive disruption of insulin secretion.Several questions with respect to islet transplantation remain regarding why and when insulin independence is attained,the effective volume of marginal islet mass,and the mechanism of loss of islet mass following transplantation.As such,there is an urgent need for efficient monitoring tools to label and track islets,detect graft damage,and monitor the long-term function and survival of transplanted islets.Furthermore,because complications of islet transplantation may be either immediate or delayed as a consequence of the migration of engrafted islets to the liver or as a side effect of immunosuppressive therapy,routine post-transplantation imaging is important to detect complications that are not apparent with clinical or laboratory examinations.3 Successful monitoring of the stability and function of the graft and graft-related complications will assist in the evaluation of various immunosuppressive regimens and islet delivery strategies and ultimately assist in optimizing the islet transplantation procedure.In this article,we summarize the recent advances in the monitoring of islet post-transplantation,as shown in Table 1。

To the editor:I read with great interest the recent article by Liu et al.1 The article provided highly interesting data on the mitigating effect of flurbiprofen on ischemia related injury.Interestingly,besides affording neuroprotection by activation of cerebral peroxisome proliferator activated receptor gamma,flurbiprofen also affords cerebral protection after ischemia/reperfusion injury by modulating the Akt/GSK-3β pathway.2 It also up regulates Bcl-2 expression.At the same time it doewnregulates the expression of Bax.3 As a result,there is a marked decrease in neurological deficit scores.P-Akt levels are also accentuated markedly.As a result intra cerebral apoptosis is markedly attenuated resulting in a decrease in infarct volume.Flurbiprofen is also an acid sensing ion channel protein (ASICla)inhibitor.4 As a result,it attenuates ischemic associated increases in malondialdehyde (MDA) levels as well has a mitigatory effect on calpain mediated increase in spectrin breakdown products (SBDPs).The neuro-protection afforded by flurbiprofen is further augmented by using agents such as ifenprodil in conjunction with flurbiprofen.5 Ifenprodil is an NR2b selective N-methyl-D-aspartate receptor (NMDAR) antagonist and further reduces the infarct size.The advantage of flurbiprofen is that the therapeutic time window can be as long as 24 hours。

To the editor:Tuberculosis of the central nervous system (CNS) is not commonly encountered compared to the involvement of other systems.Radiological diagnosis of a brain tuberculoma is difficult because the imaging presentation is varied and can be non-specific.We present a case of tuberculoma mimicking a high-grade glial tumor on magnetic resonance imaging (MRI) and clinical presentation。

Carotid body tumour (CBT) is a rare neoplasm arising from paraganglion cells of the carotid body.1 Surgical resection of the CBT is considered the primary treatment option,and the only one which can allow a definitive cure.1-3 The resection is particularly difficult because the tumour is adherent to the carotid adventitia,is highly vascularized,often involves the cranial nerves,and is in a limited field for exposure,consequently,the intervention is associated with high morbidity due to risk of nervous injuries,stroke,was well as hemorrhage shock.1-3

Cystic adventitial disease (CAD) is a rare condition characterized by cystic lesions of the non-axial blood vessels adjacent to joints;1 the majority of cysts are in the lower limb,with popliteal artery predominance.Here,we report a case of cystic adventitial disease in a 47-year-old man who was misdiagnosed and performed percutaneous transluminal angioplasty (PTA) in other hospital.He was eventually treated successfully with incision and evacuation of the popliteal cyst and ligation of communicating channels to the knee joint and remains asymptomatic 1 year later。

Echinococcosis is a human parasitic disease common in sheep-rearing regions.It is caused by the larval stage of Echinococcus granulosus.In humans,the most frequent locations of the hydatid cysts are the liver and lungs;1 pericardial echinococcosis is extremely rare.2Only 8 cases of pericardial echinococcosis occurred in approximately 7000 cardiac operations during 31 years in our hospital.We herein reported our surgical treatment experience and provide diagnostic and therapeutic recommendations for pericardial echinococcosis。

Acute basophilic leukemia (ABL) is a rare subtype of acute myeloid leukemia (AML),accounting for 4％-5％ of AML and less than 2％ of all hematopoietic malignancies.It is usually characterized by a very rapid clinical course,symptoms of hyperhistaminemia,peptic ulceration,gastrointestinal cerebrovascular bleeding and resistance to therapy.1 However,the clinical outcome of ABL remains disappointing.Most patients died within 1 year after diagnosis.We reported a de novo ABL case in a 70-year-old patient treated with single-agent arsenic trioxide (ATO).And prolonged survival was observed。

Aortic dissection (AD) is a catastrophic disease involving the aorta.Most intimal tears are located in the ascending aorta or the first portion of the descending aorta.1 It is a rare case that the proximal tear originates from the left subclavian artery (LSA).Virtual endoscopy (VE) technology could provide us a specific perspective to see from intraluminal to the outside and was especially helpful to look for and indentify complicated intimal tears.2 Vascular occluder is a useful device to treat vessel diseases alone or combined with other appratus.3 In the present report,we described one case of type BAD with a proximal tear located at the root of LSA.This tear was indentified by VE,confirmed by balloon inflation blocking and sealed with an occluder,while the second tear was repaired with one stent graft (SG)。

Takayasu arteritis (TA) is a chronic inflammatory disease of the large elastic arteries that primarilyaffects the aorta and its major branches,resulting in luminal stenosis and aneurysmal changes in the large vessels.1 Cerebral aneurysms and accompanying subarachnoid hemorrhage (SAH) are rare;no case from China has been reported.We herein report two cases of TA with cerebral aneurysms that were successfully treated with coil embolization。