Xuemin Zhang

Background/Objectives: Characterizing factors associated with intensive care unit (ICU) admission among hospitalized patients with pulmonary embolism (PE) is clinically relevant, particularly when established risk-stratification variables are incompletely documented in routine electronic medical records. The D-dimer-to-albumin ratio (DAR) combines a marker of fibrin turnover with serum albumin, a marker of systemic vulnerability; however, whether DAR provides clinically meaningful information beyond D-dimer alone remains uncertain. We evaluated the association between peri-diagnostic DAR and ICU admission and compared DAR with its component biomarkers. Methods: This single-center retrospective cohort study used electronic medical record data from 2009 to 2024. Candidate PE-related hospitalizations were identified from diagnostic records and clinically reviewed to verify a current acute PE event. Patients were eligible when DAR were measured within ±48 h of the PE diagnosis timestamp in the electronic medical record; the first eligible hospitalization per patient was retained. The primary outcome was ICU admission. Logistic regression models were adjusted for age, sex, recorded malignancy, and concomitant deep vein thrombosis (DVT). Results: Among 159 clinically reviewed patients with current acute PE, 143 (89.9%) had documented objective imaging confirmation, and 22 (13.8%) were admitted to the ICU. Each 1-unit increase in log-DAR was associated with greater odds of ICU admission (odds ratio [OR], 2.02; 95% confidence interval [CI], 1.43–2.86; p < 0.001), and the highest DAR quartile (Q4) was associated with greater odds than Q1–Q3 (OR, 6.78; 95% CI, 2.52–18.20; p < 0.001). However, in a temporally restricted analysis including 145 patients and 8 subsequent ICU admissions, the associations were attenuated and no longer statistically significant. Log-DAR was almost perfectly correlated with log-D-dimer (Spearman ρ = 0.995) and did not materially improve discrimination (area under the receiver operating characteristic curve [AUC], 0.788 vs. 0.785; ΔAUC, 0.003; p = 0.471; optimism-corrected AUC, 0.738 vs. 0.737). Conclusions: Peri-diagnostic DAR was associated with ICU admission in the primary analysis, but the temporally restricted analysis did not support prospective prediction of subsequent ICU admission. Its incremental value beyond D-dimer appeared limited, and DAR should be considered an exploratory adjunct rather than a replacement for established PE risk-stratification tools.

Background: Type II endoleak (T2EL) remains a significant cause of reintervention after endovascular aneurysm repair (EVAR). Current strategies for T2EL management remain suboptimal with low long-term efficacy. Thus, this study aimed to evaluate the feasibility and outcomes of laparoscopic transperitoneal branch artery ligation for T2EL management. Methods: This study included 6 patients with persistent T2EL and aneurysm sac expansion who underwent laparoscopic ligation of the culprit vessels, including the inferior mesenteric, lumbar, and median sacral arteries, at our center between January 2021 and January 2024. Preoperative basic clinical characteristics, operative data, postoperative outcomes, and complications of the patients were recorded and analyzed. Results: The median operative time was 225 minutes (range: 120–360 min) with blood loss of 300 mL (range: 50–500 mL). All patients achieved complete ligation of targeted vessels (median of 5 vessels per patient), with 100% success for the inferior mesenteric artery (IMA) and 50% for the median sacral artery. One patient developed a lymphatic fistula that was managed conservatively. At a median follow-up of 13.5 months (range: 4–54 months), all patients exhibited sac regression (median reduction: 3.5 mm; range: 1–8 mm). Complete endoleak resolution was observed in 4 cases (66.7%), while 2 had asymptomatic persistent T2EL without expansion. No reinterventions or mortality occurred. Conclusions: Laparoscopic transperitoneal branch artery ligation represents a promising, albeit preliminary, option for managing embolization-refractory T2EL. Our findings suggest that laparoscopic T2EL repair may provide durable sac stabilization in selected patients; however, the limited sample size underscores the need for larger studies to clarify patient selection criteria and long-term durability.

To evaluate the feasibility and safety of the suture-mediated vascular closure device in the closure of the left brachial artery access site after thoracic endovascular aortic repair (TEVAR). Data from 91 patients receiving TEVAR with left brachial artery puncture from January 2021 to May 2023 were retrospectively collected and analyzed. In 27 cases whose brachial artery was over 5 mm, a suture-mediate vascular closure device (Perclose ProGlide, Abbott) was used to deal with the left brachial artery access, and in the other 64 cases with brachial artery < 5 mm, manual compression was used. The primary outcomes were the incidence of perioperative access-related complications and long-term outcomes. In the suture-mediate device group, the access-site compression time was significantly reduced than that in the manual compression group (P < 0.001). The proportion of discomforts, such as numbness, pain, and swelling of the compression-related limbs was significantly lower than that in the compression-alone group (3.70% vs. 42.19%, P < 0.001). One case with brachial artery access-related complications occurred in the suture-mediate device group during hospitalization, which was acute brachial artery occlusion and required reinterventions. In the manual compression group, 4 cases of brachial artery puncture point complications occurred during hospitalization, including 3 cases of pure hematoma with conservative management and 1 case of pseudoaneurysm requiring reintervention. There was no significant difference in the incidence of early puncture point complications between the two groups (3.70% vs. 6.25%, P=0.625). During an average follow-up of (14±6) months, no access-related complications of the left brachial artery occurred. It is effective to use the suture-mediated vascular closure in the left brachial artery access site after TEVAR, and the long-term effect is satisfactory. For patients with >5 mm brachial artery, it is reasonable to use suture-mediated vascular devices to deal with brachial artery access.

Isolated distal deep vein thrombosis (IDDVT) is the most prevalent form of deep vein thrombosis (DVT), comprising up to 50% of all DVT cases. The incidence of IDDVT varies depending on cancer type, patient-specific characteristics, and cancer treatment factors. Cancer-associated isolated distal deep vein thrombosis (CA-IDDVT) is a specific form of IDDVT, which has serious clinical outcomes, including death, VTE recurrence, and major bleeding. Despite its clinical importance, few studies have focused on the management of CA-IDDVT. Emerging evidence supports an individualized anticoagulation strategy, and extended-duration therapy is recommended. Notably, the ONCO-DVT trial demonstrates that extended treatment with edoxaban significantly reduces thrombotic risk without increasing major bleeding, highlighting its potential in CA-IDDVT management. This article reviews recent advances in the clinical factors, manifestations, and treatment strategies for CA-IDDVT, providing new insights to guide its effective management.

Thoracoabdominal aortic aneurysm (TAAA) involves both the thoracic and abdominal aorta and surgical treatment requires reconstructing several important visceral branch arteries. Open surgery is considered the standard treatment for TAAA, but it carries high risks and many complications. With the advancement of endovascular techniques, endovascular repair of TAAA has gradually become a new trend in treatment. This article presents a case of a 61-year-old female with TAAA. The patient underwent a follow-up thoracoabdominal CTA after teratoma surgery, which revealed a thoracoabdominal aortic aneurysm (Crawford Type III) extending from the sixth intercostal space to 5 cm below the renal arteries. The challenge in treating this case lay in reconstructing the visceral arteries. The octopus technique, a type of parallel stenting, offers advantages but has inherent technical limitations, such as multiple access routes for simultaneous stent placement, the potential risk of gutter endoleaks, and mutual compression among parallel stents. To avoid these drawbacks, modifications to the octopus technique are necessary. We connected multiple small stent grafts side-by-side and end-to-end to a single branch of the main aortic stent graft. This improved design effectively circumvented the gutter endoleaks and stent compression issues, allowing for sequential visceral artery reconstruction through single upper limb access. This modified octopus technique closely aligns with the design concept of branched stents. This article aims to describe a case of complete endovascular reconstruction of TAAA using the modified octopus technique combined with the external branch technique, providing an in-depth analysis of the specific procedural steps and their clinical application value.

Thoracoabdominal aortic aneurysm (TAAA) involves both the thoracic and abdominal aorta and surgical treatment requires reconstructing several important visceral branch arteries. Open surgery is considered the standard treatment for TAAA, but it carries high risks and many complications. With the advancement of endovascular techniques, endovascular repair of TAAA has gradually become a new trend in treatment. This article presents a case of a 61-year-old female with TAAA. The patient underwent a follow-up thoracoabdominal CTA after teratoma surgery, which revealed a thoracoabdominal aortic aneurysm (Crawford Type III) extending from the sixth intercostal space to 5 cm below the renal arteries. The challenge in treating this case lay in reconstructing the visceral arteries. The octopus technique, a type of parallel stenting, offers advantages but has inherent technical limitations, such as multiple access routes for simultaneous stent placement, the potential risk of gutter endoleaks, and mutual compression among parallel stents. To avoid these drawbacks, modifications to the octopus technique are necessary. We connected multiple small stent grafts side-by-side and end-to-end to a single branch of the main aortic stent graft. This improved design effectively circumvented the gutter endoleaks and stent compression issues, allowing for sequential visceral artery reconstruction through single upper limb access. This modified octopus technique closely aligns with the design concept of branched stents. This article aims to describe a case of complete endovascular reconstruction of TAAA using the modified octopus technique combined with the external branch technique, providing an in-depth analysis of the specific procedural steps and their clinical application value.

Situs inversus totalis (SIT) is a rare congenital condition characterized by mirror image transposition of thoracic and abdominal organs. The coexistence of SIT and abdominal aortic aneurysm presents unique anatomical and surgical challenges. We reported a case of a 60-year-old male with SIT and a history of endovascular aneurysm repair who developed multiple endoleaks (T1bEL, T2EL, and T3EL). A hybrid procedure combining open surgical repair and endovascular techniques was successfully employed to address the complex endoleaks (ELs). The procedure included ligation of collateral vessels, stent–graft extension, and preservation of the right internal iliac artery using an artificial vessel. This case highlights the feasibility of a hybrid approach for managing ELs in patients with SIT and underscores the importance of tailored surgical strategies.

Purpose Vascularized pedicled bone-grafting from the cuboid to the talus provides low donor site morbidity and satisfactory outcomes in patients with early-stage talar avascular necrosis. We investigated the anatomy of the rotational vascularized pedicled bone graft from the cuboid. Methods 15 embalmed cadaver specimens were perfused with red latex via the popliteal artery. The lateral malleolus was dissected. The course of the lateral tarsal artery and the vascular territory in the cuboid supplied by the lateral tarsal artery were observed. Vessel diameters were measured. Results The course of the lateral tarsal artery to the cuboid was consistent, and a vascularized pedicle of the lateral tarsal artery was present in all specimens. Mean diameter of the lateral tarsal artery was 1.40 ± 0.12 mm (range 1.67–1.25). Mean length of the vascularized pedicle was 67.15 ± 3.18 mm (range 62.43–74.36). The pedicle bone graft was long enough to reach the bony border of both the lateral and medial malleolus. Conclusion A vascularized pedicled cuboid bone graft based on the lateral tarsal artery has clinical utility for early-stage talar avascular necrosis.

Peripheral arterial disease is one part of systematic atherosclerosis, becoming a heavy burden of human health. Patients in end stage of peripheral arterial disease manifest critical limb ischemia with severe rest pain and refractory ulcer. Surgical revascularization is the optimal option for patients with critical limb ischemia to avoid major amputation and improve quality of life. However, some of them contraindicate surgical revascularizations owing to coexisting morbidities. Spinal cord stimulation is reported to be effective and minimally invasive in pain relief and limb salvage for patients with limb ischemia. Here, we reported one case with chronic critical limb ischemia and gangrene of foot who underwent spinal cord stimulation, which was, as we knew, the first case in China. He was diagnosed with Burger disease and accompanied with history of stroke, chronic obstructive pulmonary disease and Castleman's disease. It showed totally occlusive lesions of external iliac and femoropopliteal artery and no outflows below the knee in the computed tomography angiography. Given the complexity of lesions and weakness of the patient, spinal cord stimulation was indicated for control of rest pain and limb salvage. As specified, we implanted the temporary neurostimulator as the first step. After 2 weeks from temporary neurostimulator implantation, the patient achieved significant relief in intensity of pain, and acquired 20% improvement of transcutaneous oxygen pressure. The satisfactory results indicated probable effectiveness of spinal cord stimulation, thus we performed the permanent neurostimulator implantation 1 month later. During 2 months of follow-up, the patients stabilized at Fountain III with pain relief with one kind of nonsteroidal anti-inflammatory drug. In our case, we confirmed the significant validity of spinal cord stimulation for pain control and consequent improvement of quality of life in non-reconstructable chronic critical limb ischemia. Furthermore, we reviewed that a number of published studies suggested that spinal cord stimulation be a reasonable option for patients with critical rest pain, especially who contraindicated surgical revascularization. The application of spinal cord stimulation in pain relief for non-reconstructable chronic critical limb ischemia was approved by related guidelines released by European Society of Cardiology and Trans-Atlantic Inter-Society Consensus. Further investigations are required for assessing the long-term outcome in limb salvage.