Endovascular aortic repair (EVAR) has been the main treatment means for abdominal aortic aneurysm.It has become an expert consensus that in the case of abdominal aortic aneurysm that is complicated by iliac aneurysm,the preservation of internal iliac artery is necessary because it can prevent the occurrence of gluteal muscle ischemnia,sigmoid ischemia,male sexual dysfunction and other complications.In recent years,with the continuous updating of the endovascular devices it has become possible to retain the internal iliac artery in the performance of EVAR.At present,the reconstruction of internal iliac artery in EVAR includes a variety of techniques,including intraluminal iliac branched device (IBD) technique,sandwich technique,common iliac artery covered-stent bell-bottom (BBT) technique,external iliac artery-internal iliac artery intraluminal shunt technique (reverse chimney technique),and spring coil embolism technique.This article aims to make a summary of all the above mentioned techniques.

Objective To investigate the efficiency of autologous transplantation of bone-marrow mononuclear cells for treatment of patients with diabetic lower limb ischemia. Methods Twenty patients of type 2 diabetes (22 legs) with diabetic lower limb ischemia were treated by autologous transplantation of bone-marrow mononuclear cells. Results All ischemic legs were preserved except three feet, which were amputated due to the previously existed foot gangrene in one and unsolved pain in two. The pain-alleviated rate was 85.0%. The amputation rate was 13.6%. The skin turned warm in all legs(100.0%). TcPO2 of the ischemic legs was elevated in 17 patients with 19 legs. Angiography showed a noticeable increase of visible collateral vessels in 7 patients with 8 limbs who had angiographic follow-up. Conclusion Autologous transplantation of bone-marrow mononuclear cells could be a simple, safe, and effective method to treat patients with diabetic lower limb ischemia.

Objective To explore the safety and feasibility of calf arterial stent angioplasty to treat severe lower limb ischemia. Methods Clinical data of 13 patients in our hospital during recent 3 years were retrospectively analysed and all these patients were followed up after discharge.Of these patients there were 10 males and 3 females; mean age was (73 ±7) years; mean disease course was (8 ±4) months.Severe claudication was reported in 5 patients,rest pain in 4 patients,toe ulcer in 2 patients,gangrene in 2 patients.Stent was placed in the tibioperoneal trunk artery in 5 patients ; in the proximal part of peroneal artery in 3 patients; in the tibioperoneal trunk and proximal peroneal artery in 2 patients; in the anterior tibial artery in 2 patients; in the posterior tibial artery in one patient.Simultaneous endovascular treatment of femoral/popliteal arterial disease was done in 11 patients. Results All the procedures were successful and the treated arteries kept patent on discharge of patients.Claudication distance increased to be above 500 meter in 5 patients; rest pain relieved in 4 patients ; toes ulcer reduced in 2 patients,feet gangrene kept dry till discharge in 2 patients.Postoperative ABI increased in all patients.Patients were followed-up of mean (6.9 ± 2.2) months.One patient with previous toe gangrene underwent amputation due to recurrent pain while the stent in anterior tibial artery kept patent after 6 months discharge.In the other patient gangrene toe had fallen off and the wound healed.Two patients with toe ulcer had a total recovery and patients with previous rest pain had no recurrent symptoms. Conclusions Below knee arterial stent angioplasty is a safe and effective method in the treatment of severe lower limb ischemia.

Objective To investigate the effect and safety of autologons bone margow-mononuclear cell (BM-MNC)transplantation after the bone marrow stimulation in patients with thromboangiitis obliterans (TAO).Methods The bone marrows of 12 patients were stimulated by an injection of the recombinant human granuloeyte-macmphage colony-stimulatory factor(GCSF)for 3-5 days.150-200 ml bone marrow was drown from the iliac spine and the autologous BM-MNC were obtained in each patients.Fifteen lower limbs of 12 patients received implantation of the autologous BM-MNC by an intramuscular iniecdon.A series of subjective indexes(including improvement of pain and cold sensation)and objeetive indexes [including increase of ankle braehial index(ABI),transcutaneons oxygen pressure(TcPO2)and improvement of foot skin ulcer] were used to evaluate the effects.Results The outcomes were evaluated after 2 months of transplantation.The pain-relief rate and the cold feeling improvement rate were 86.7%(13/15)and 93.3%(14/15)respectively.The ABI were 0.38 ±0.05 vs.0.61 ±0.14(P<0.05)before transplantation and 2 months after transplantation respectively.increased in 66.7%(10/15)limbs.The TcPO2 of the ischemic legs increased from(27.47±2.85)mm Hg to(43.53 ±8.38)mm Hg(t=-7.03,P<0.05)after the transplantation,and the improvement rate of TcPO2 was 93.3%(14/15).Skin ulcers in improved in 8/9 limbs.Twelve patients were followed up for all average period of 10 months.The patients'symptoms improved in 80.0%(12/15)limbs,as to the objective index the ABI was0.57±0.13,TcPO2 was(42.07 ±7.81)mm Hg,which improved significandy compared to before treatment(t=-5.33,-7.80,Ps<0.05).skin ulcer healing rate was 66.7%(6/9).The ischemic symptoms in 2 patients were not relieved.There WBS no mortality and high level amputation in all subjects.The complications,such as proliferative retinopathy,malitpmnt tumor,myocardial infarction,stroke or hemangioma were not found in any patients.Conclusion In patients with TAO,intramuscular transplantation of autologous BM-MNC after the bone marrow stimulation has advantages of less bone marrow aspiration,more mononuclear cell content and relatively high safety.It may be a new and effective method to alleviate symptoms and accelerate the healing of skin ulcer.

Objective To evaluate the efficiency and safety of infrainguinal arterial bypass in diabetic ischemia of the lower extremities. Method Eighty-two consecutive patients undergoing lower extremity arterial reconstruction from 2002 to 2005 were divided into diabetes group (DM) and nondiabetes group ( NDM ) . Graft patency, limb salvage, and perioperative complications were compared between the two groups. Results There were 82 patients receiving 86 grafts, 44 grafts (51. 2% ) in patients with diabetes (DM group) and 42 (48. 8% ) in nondiabetic patients (NDM group). Average age of the DM group was (68?10) years, vs. (63?12) years of NDM group (P=0.025). In-hospital perioperative mortality was 3. 7% ( DM group 4. 8% vs. NDM 2. 5% ,P = 1. 000). Cumulative primary and secondary graft patency in 4 year was 44% in DM group and 64% in NDM group, P =0. 112 and 69% in DM group, 66% in NDM group, P = 0. 083) , respectively. The 4 year overall limb salvage rate was not statistically defferent ( DM group, 68%; NDM group, 66%; P =0.114). Conclusions Diabetes mellitus does not influence perioperative mortality, graft patency, or limb salvage rates after lower extremity arterial bypass.

Objective To evaluate the feasibility of endovascular aortic repair (EVAR) under local anesthesia without using any contrast agent for abdominal aortic aneurysm in patients with high allergic risk to contrast agent.Methods Under local anesthesia and with no use of any contrast,percutaneous EVAR was performed in a patient with abdominal aortic aneurysm who carried high allergic risk to contrast agent.Results Percutaneous EVAR was successfully accomplished.Postoperative follow-up MRI examination showed that the abdominal aortic aneurysm was completely isolated with no endoleak.The blood flow was unobstructed in the covered stent,and bilateral renal arteries were well visualized.Conclusion For the treatment of abdominal aortic aneurysm in patients who are highly allergic to contrast agent and who have contraindications to general anesthesia,percutaneous EVAR performed under local anesthesia and using no contrast agent is safe and effective.Strict observation of indications and sufficient preoperative evaluation of clinical conditions is the key to ensure a successful operation.

Objective To explore the indications of axillary artery approach in endovascular treatment and to analyze complications associated with axillary artery puncture.Methods In 111 cases endovaccular treatment via axillary artery approach by Seldinger technique was performed.The indications of axillary artery approach and the complications associated with axillary artery punture were respectively analyzed.Results The success rate of angiography was 100％,and the success rate of angioplasty was 90.8％ by axillary artery approach.The total incidence of complications was 10.3％.The incidence of local hematomas was 4.8％,nerve injury was 3.2％,pseudoaneurysm was 0.8％,acute thrombosis of the axillary artery was 0.8％,acute thrombosis of the axillary vein was 0.8％.The main factors affecting complications include vascular conditions,perioperative medication,anatomy of the axillary artery,location of puncture point,the success rate of first attempt,and pressure of bandage.Conclusions The axillary artery approach increases the success rate of endovascular treatment.Reasonable choice of axillary artery appruch,meticulous perioperative management and fully understanding the anatomical characteristics of the axillary artery can decrease the complications of axillary artery puncture.

Objective To evaluate the role of transcranial Doppler (TCD) in carotid endarterectomy and the effect of carotid endarterectomy on extracranial carotid artery stenosis.Methods From January 2002 to December 2008, fifty eight patients (40 males and 18 females)with mean age of 64.5 years were treated in our hospital. Of these patients, forty had symptoms of cerebral ischemia, eighteen were asymptomatic. All the patients had 70% and up carotid artery stenosis. Forty one patients underwent simple suture closure of the arterial incision while nine patients had angioplasty with arterial patch (polyester) and eight with autologous great saphenous vein. TCD monitoring was used in the surgery of 32 patients excluding two patients using arterial shunt. Results Surgery was successful in all 58 cases except for deflected tongue-protrusion in five patients after operation, of which three recovered conservatively and two recovered after administration of cortical steroids for two weeks. Cerebral ischemic symptoms improved to a certain degree in all the 40 preoperative symptomatic patients. Cerebral hyperperfusion occurred in five of no TCD-monitoring patients ( 19.2% ), no hyperperfusion was found in TCD-monitored patients. Fifty three patients were followed up for a mean time of 42.5 months. Five patients died and three patients had carotid artery restenosis, of which two underwent PTA and stenting, one is still under surveillance.Conclusions Carotid endarterectomy is a safe and effective procedure for treating extracranial carotid artery stenosis. TCD monitoring is valuable for determining the use of arterial shunt and preventing postoperative cerebral hyperperfusion.

Objective To investigate the safety and feasibility of carotid endarterectomy (CEA) combined with carotid artery stent angioplasty (CASA) in treating tandem stenosis of carotid artery. Methods The clinical data of 9 patients with tandem stenosis of carotid artery, who were treated at authors' hospital during the period from January 2013 to October 2014, were retrospectively analyzed. The patients included 7 males and 2 females, with a mean age of (66.0 ±4.2) years. The disease course ranged from 2 months to 36 months, with a mean of 7 months. Clinically, all patients had cerebral ischemia symptoms. Transient ischemia attack was seen in 5 patients and history of cerebral infarction was present in 2 patients. Coronary artery disease was found in 2 patients, hypertension in 6 patients and lower limb ischemia in one patient. After receiving adequate antiplatelet therapy, CEA and CASA were carried out in all patients. Results The technical success rate was 100%, postoperative residual stenosis was less than 30%, no death occurred in perioperative period. After the treatment, the clinical symptoms were improved in all 9 patients;no new stroke or cerebral hemorrhage occurred. After the treatment, 2 patients developed cerebral hyperperfusion-related symptoms such as headache and dizziness, which were much relieved at the time of discharge. The patients were followed up for 4-19 months, with a mean of (10.5±6.2) months. No recurrence of symptoms was observed . In one patient , transcranial Doppler ultrasound performed at 6 months after treatment showed that the carotid artery became moderate restenosis (50%-70%). No death occurred. Conclusion For the treatment of tandem stenosis of carotid artery, CEA combined with CASA is safe and effective, although larger sample and long-term follow-up studies are still needed to further confirm the effect.

Objective To discuss the methods, advantages and indications of multipoint puncturing in performing endovascular therapy for complex lower extremity arterial occlusive diseases. Methods During the period from Oct. 2011 to Oct. 2013, a total of 46 patients with complex lower extremity arterial occlusive diseases were treated with endovascular therapy by using multipoint puncturing technique. The puncturing type, the advantages of multipoint puncturing technique and the success rate of this technique were analyzed. Results The multipoint puncturing was divided into three types: type Ⅰ : puncturing from the opposite direction to deal with the same target vessel; type Ⅱ: direct puncturing of the target vessel; and type Ⅲ:using the same puncturing direction to deal with different target vessels. The success rate of endovascular treatment was 80.4%. Conclusion Multipoint puncturing technique helps improve endovascular treatment success rate for lower extremity arterial occlusive diseases. Full understanding of the advantages of multipoint puncturing technique, perfect preoperative planning, precise puncturing technique and proper interventional equipments are helpful to ensure a successful treatment.