ObjectiveTo investigate the risk factors for postpancreatectomy acute pancreatitis （PPAP） after minimally invasive pancreaticoduodenectomy （MIPD） and their association with major complications， to improve the understanding of PPAP and postoperative pancreatic fistula （POPF）， and to reduce the incidence rates of PPAP and POPF. MethodsA retrospective analysis was performed for the clinical data of 114 patients who underwent MIPD in Department of Hepatobiliary and Pancreatic Surgery， The First Affiliated Hospital of University of South China， from March 2015 to December 2023， and the definition of PPAP and its diagnostic criteria provided by the International Study Group of Pancreatic Surgery were used to determine the presence or absence of PPAP. The independent samples t-test or the Mann-Whitney U rank sum test was used for comparison of continuous data between groups， and the Kruskal-Wallis H test was used for comparison between multiple groups， and the Dunn-test was used for further comparison between two groups.； the chi-square test or the Fisher’s exact test was used for comparison of categorical data between groups.， and the Bonferroni-test was used for further comparison between two groups. The multivariate logistic regression analysis was used to identify the risk factors for PPAP after MIPD. ResultsOf all 114 patients undergoing MIPD， 27 （23.7%） experienced PPAP. The multivariate analysis showed that main pancreatic duct diameter ≤3 mm （odds ratio ［OR］=5.083， 95% confidence interval ［CI］： 1.703 — 15.172， P=0.004）， soft pancreatic texture （OR=5.925， 95%CI： 1.986 — 17.677， P=0.001）， and C-reactive protein ≥180 mg/L on day 1 after surgery （OR=5.419， 95%CI： 1.586 — 18.513， P=0.007） were independent risk factors for the onset of PPAP after MIPD. Clinical analyses showed that the patients with PPAP tended to have significantly higher incidence rates of POPF， peritoneal infection， Clavien-Dindo grade 3/4 complications， discharge with tube， and 90-day postoperative death （χ²=5.676， 5.460， 9.863， 5.439， and 4.207， all P<0.05）. ConclusionMain pancreatic duct diameter， pancreatic texture， and C-reactive protein on day 1 after surgery are closely associated with the onset of PPAP after MIPD， and PPAP can lead to other postoperative complications and even death.

The floating thrombus in the brachiocephalic artery is relatively rare and difficult to diagnose,and it is prone to be missed.This article reports a case of a patient with a floating thrombus in the brachiocephalic artery who underwent endovascular treatment via a combined radial artery and femoral artery approach.The patient presented with slurred speech,weakness in the left limbs,and dizziness.A cranial DWI examination revealed acute cerebral infarction in the right cerebral hemisphere and bilateral cerebellum.A neck CTA examination showed a floating thrombus in the brachiocephalic artery.Currently,there is no consensus on the treatment of floating thrombi in the brachiocephalic artery.The effect of conservative medical treatment for this patient was poor,and endovascular treatment was administered.The vertebral artery and carotid artery protection umbrellas were deployed via the radial artery approach to prevent intraoperative embolism events.A stent was deployed via the femoral artery approach to adhere to the thrombus.A follow-up neck CTA examination of the patient after the operation indicated that the stent was in a good position with complete thrombus apposition.

Objective To analyze the effects of intravenous tirofiban following endovascular treatment on the prognosis of patients with acute anterior circulation large vessel occlusion stroke who did not achieve successful recanalization.Methods This retrospective study included consecutive patients with acute anterior circulation ischemic stroke who underwent endovascular treatment but did not achieve successful recanalization.These patients were retrospectively enrolled from the Department of Neurology at Nanjing Jinling Hospital,Affiliated Hospital of Medical School,Nanjing University,the Second Affiliated Hospital of Soochow University,Wuhan No.1 Hospital,and Yijishan Hospital of Wannan Medical College(the First Affiliated Hospital of Wannan Medical College)between January 2015 and April 2023.Baseline and clinical data were collected including age,sex,medical history(hypertension,diabetes,atrial fibrillation,hyperlipidemia),personal history(smoking and drinking),National Institutes of Health stroke scale(NIHSS)score at admission,trial of Org 10172 in acute stroke treatment(TOAST)classification(large artery atherosclerosis,cardioembolism,or other types),Alberta stroke program early CT score(ASPECTS)on admission,intravenous thrombolysis,onset-to-puncture time(OTP),collateral circulation status(poor collaterals:American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology[ASTIN/SIR]score 0-2;good collateral:ASTIN/SIR score 3-4),procedure duration(from femoral or radial artery puncture to device removal),occlusion site,number of passes for thrombus retrieval,and post-procedural modified thrombolysis in cerebral infarction(mTICI)grade.Patients were divided into a tirofiban group and a non-tirofiban group based on whether they received post-procedural intravenous tirofiban.The primary outcome is a favorable functional outcome at 90-day since onset(modified Rankin scale[mRS]score ≤ 3).Safety outcomes included mortality at 90-day since onset(mRS score 6),any intracranial hemorrhage within 24 h post-procedure,and symptomatic intracranial hemorrhage within 24 h post-procedure.1∶1 propensity score matchings using the nearest neighbor method was performed based on variables with P＜0.05 in the comparison between the tirofiban and non-tirofiban groups.Differences in primary and safety outcomes between the matched groups were compared.Univariate and multivariate Logistic regression analyses were conducted with favorable outcomes at 90 days as the dependent variable to evaluate the effect of intravenous tirofiban administration after endovascular therapy on 90-day prognosis in patients without successful recanalization.Results A total of 356 patients without successful recanalization after endovascular treatment were included,comprising 195 males and 161 females,with a median age of 70(61,78)years(32-92 years).Among them,76 and 280patients were assigned to the tirofiban and non-tirofiban groups,respectively.At 90 days,114 patients had favorable outcomes,while 242 had unfavorable outcomes.(1)Before the 1∶1 propensity score matching,significant differences were observed between the tirofiban and non-tirofiban groups in terms of admission NIHSS score,ASPECTS,good collateral circulation,intravenous thrombolysis,and mTICI grade(all P＜0.05).After 1∶1 propensity score matching,66 matched pairs(132 patients)were obtained.No significant differences in the baseline and clinical characteristics were found between the two groups after matching(all P＞0.05).(2)After 1∶1 matching,a significant difference was observed in the rate of favorable outcomes at 90 days between the two groups(48.5％[32/66]vs.30.3％[20/66],P=0.033)after propensity score matching,while no significant differences were found in 90-day mortality,intracranial hemorrhage within 24h,or symptomatic intracranial hemorrhage within 24h(all P＞0.05).(3)Univariate analysis after 1∶1 matching indicated that age,atrial fibrillation,smoking history,admission NIHSS score,M2 segment middle cerebral artery occlusion,good collateral circulation,number of passes for thrombus retrieval,and tirofiban treatment were factors influencing favorable outcomes at 90 days.Multivariate Logistic regression analysis showed that younger age(aOR,0.942,95％CI 0.906-0.978,P=0.002),lower admission NIHSS score(aOR,0.855,95％CI 0.777-0.941,P=0.001),good collateral circulation(aOR,5.534,95％CI 2.141-14.301,P＜0.01),tirofiban treatment(aOR,2.774,95％CI 1.092-7.046,P=0.032),and M2 segment MCA occlusion(reference:internal carotid artery occlusion;aOR,4.874,95％CI 1.428-16.632,P=0.011)were independent predictors of favorable outcomes at 90 days.Conclusions Intravenous tirofiban administration after endovascular therapy may improve 90-day neurological outcomes in patients with acute anterior circulation large vessel occlusion stroke who did not achieve successful recanalization without increasing the risk of hemorrhage.Further large-scale randomized controlled trials are warranted to validate these findings.

The floating thrombus in the brachiocephalic artery is relatively rare and difficult to diagnose,and it is prone to be missed.This article reports a case of a patient with a floating thrombus in the brachiocephalic artery who underwent endovascular treatment via a combined radial artery and femoral artery approach.The patient presented with slurred speech,weakness in the left limbs,and dizziness.A cranial DWI examination revealed acute cerebral infarction in the right cerebral hemisphere and bilateral cerebellum.A neck CTA examination showed a floating thrombus in the brachiocephalic artery.Currently,there is no consensus on the treatment of floating thrombi in the brachiocephalic artery.The effect of conservative medical treatment for this patient was poor,and endovascular treatment was administered.The vertebral artery and carotid artery protection umbrellas were deployed via the radial artery approach to prevent intraoperative embolism events.A stent was deployed via the femoral artery approach to adhere to the thrombus.A follow-up neck CTA examination of the patient after the operation indicated that the stent was in a good position with complete thrombus apposition.

Hilar cholangiocarcinoma(HCCA)is a common malignant tumor of the biliary system.Radical HCCA resection with combined vascular resection and reconstruction can help achieve R0 resection,improve tumor resectability,and enhance patient outcomes.With the increasing popularity of minimally invasive surgical techniques such as laparoscopy and robotic surgery,more and more centers are beginning to experiment with minimally invasive HCCA resection with combined vascular resection and reconstruction.However,due to the complex anatomy of the hilum and the limitations of minimally invasive techniques,completing HCCA revascularization and reconstruction under minimally invasive conditions is particularly challenging.The author has accumulated considerable experience in minimally invasive HCCA vascular resection and reconstruction.This article will discuss the technical challenges of minimally invasive HCCA vascular resection and reconstruction,indication selection,established revascularization techniques,reconstructive skills,and remedial measures after reconstruction failure.

Objective:To investigate the association between short-term blood pressure variability(BPV)and all-cause mortality in elderly patients with early sepsis-associated acute kidney injury(SA-AKI).Methods:A retrospective study was conducted on elderly patients with early SA-AKI from the Medical Information Mart for Intensive Care Ⅳ(MIMIC-Ⅳ)database between 2008 and 2022.All patients were divided into four groups(Q1-Q4)according to the quartiles of the 24-hour systolic blood pressure coefficient of variation(SBPCV): Q1(SBPCV<8.69%), Q2(8.69%≤SBPCV<10.84%), Q3(10.84%≤SBPCV<13.64%), Q4(SBPCV≥13.64%). Cox regression analysis was used to assess the association between SBPCV and one-year all-cause mortality.Restricted cubic spline regression was used for non-linear testing, and threshold effect analysis was further performed for non-linear relationships.Results:A total of 5 955 elderly patients were included in the study, and 2 746(46.11%)patients died within one year following the diagnosis of early SA-AKI.Patients in groups Q1 to Q4 had one-year all-cause mortality rates of 46.34%(690/1 489), 45.56%(678/1 488), 42.47%(632/1 488), and 50.07%(746/1 490), respectively.After adjusting for relevant confounding variables, Cox regression analysis showed that the Q1 group and Q4 group had a 26%( HR=1.26, 95% CI: 1.13-1.41, P<0.001)and 12%( HR=1.12, 95% CI: 1.01-1.24, P=0.047)higher risk of one-year mortality compared to the Q3 group, respectively.SBPCV and one-year all-cause mortality showed a U-shaped non-linear manner( P for nonlinear<0.001). Threshold effect analysis indicated that when SBPCV<13.07%, each standard deviation increase in SBPCV was associated with a 15% reduction in mortality risk( HR=0.85, 95% CI: 0.78-0.92, P<0.001); conversely, when SBPCV>13.07%, each standard deviation increase in SBPCV was associated with an 11% increase in mortality risk( HR=1.11, 95% CI: 1.03-1.21, P=0.011). Conclusions:Short-term BPV may be associated with long-term all-cause mortality in elderly patients with early SA-AKI in a U-shaped manner.However, these findings require further confirmation through high-quality prospective studies.

Hilar cholangiocarcinoma(HCCA)is a common malignant tumor of the biliary system.Radical HCCA resection with combined vascular resection and reconstruction can help achieve R0 resection,improve tumor resectability,and enhance patient outcomes.With the increasing popularity of minimally invasive surgical techniques such as laparoscopy and robotic surgery,more and more centers are beginning to experiment with minimally invasive HCCA resection with combined vascular resection and reconstruction.However,due to the complex anatomy of the hilum and the limitations of minimally invasive techniques,completing HCCA revascularization and reconstruction under minimally invasive conditions is particularly challenging.The author has accumulated considerable experience in minimally invasive HCCA vascular resection and reconstruction.This article will discuss the technical challenges of minimally invasive HCCA vascular resection and reconstruction,indication selection,established revascularization techniques,reconstructive skills,and remedial measures after reconstruction failure.

Objective To analyze the effects of intravenous tirofiban following endovascular treatment on the prognosis of patients with acute anterior circulation large vessel occlusion stroke who did not achieve successful recanalization.Methods This retrospective study included consecutive patients with acute anterior circulation ischemic stroke who underwent endovascular treatment but did not achieve successful recanalization.These patients were retrospectively enrolled from the Department of Neurology at Nanjing Jinling Hospital,Affiliated Hospital of Medical School,Nanjing University,the Second Affiliated Hospital of Soochow University,Wuhan No.1 Hospital,and Yijishan Hospital of Wannan Medical College(the First Affiliated Hospital of Wannan Medical College)between January 2015 and April 2023.Baseline and clinical data were collected including age,sex,medical history(hypertension,diabetes,atrial fibrillation,hyperlipidemia),personal history(smoking and drinking),National Institutes of Health stroke scale(NIHSS)score at admission,trial of Org 10172 in acute stroke treatment(TOAST)classification(large artery atherosclerosis,cardioembolism,or other types),Alberta stroke program early CT score(ASPECTS)on admission,intravenous thrombolysis,onset-to-puncture time(OTP),collateral circulation status(poor collaterals:American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology[ASTIN/SIR]score 0-2;good collateral:ASTIN/SIR score 3-4),procedure duration(from femoral or radial artery puncture to device removal),occlusion site,number of passes for thrombus retrieval,and post-procedural modified thrombolysis in cerebral infarction(mTICI)grade.Patients were divided into a tirofiban group and a non-tirofiban group based on whether they received post-procedural intravenous tirofiban.The primary outcome is a favorable functional outcome at 90-day since onset(modified Rankin scale[mRS]score ≤ 3).Safety outcomes included mortality at 90-day since onset(mRS score 6),any intracranial hemorrhage within 24 h post-procedure,and symptomatic intracranial hemorrhage within 24 h post-procedure.1∶1 propensity score matchings using the nearest neighbor method was performed based on variables with P＜0.05 in the comparison between the tirofiban and non-tirofiban groups.Differences in primary and safety outcomes between the matched groups were compared.Univariate and multivariate Logistic regression analyses were conducted with favorable outcomes at 90 days as the dependent variable to evaluate the effect of intravenous tirofiban administration after endovascular therapy on 90-day prognosis in patients without successful recanalization.Results A total of 356 patients without successful recanalization after endovascular treatment were included,comprising 195 males and 161 females,with a median age of 70(61,78)years(32-92 years).Among them,76 and 280patients were assigned to the tirofiban and non-tirofiban groups,respectively.At 90 days,114 patients had favorable outcomes,while 242 had unfavorable outcomes.(1)Before the 1∶1 propensity score matching,significant differences were observed between the tirofiban and non-tirofiban groups in terms of admission NIHSS score,ASPECTS,good collateral circulation,intravenous thrombolysis,and mTICI grade(all P＜0.05).After 1∶1 propensity score matching,66 matched pairs(132 patients)were obtained.No significant differences in the baseline and clinical characteristics were found between the two groups after matching(all P＞0.05).(2)After 1∶1 matching,a significant difference was observed in the rate of favorable outcomes at 90 days between the two groups(48.5％[32/66]vs.30.3％[20/66],P=0.033)after propensity score matching,while no significant differences were found in 90-day mortality,intracranial hemorrhage within 24h,or symptomatic intracranial hemorrhage within 24h(all P＞0.05).(3)Univariate analysis after 1∶1 matching indicated that age,atrial fibrillation,smoking history,admission NIHSS score,M2 segment middle cerebral artery occlusion,good collateral circulation,number of passes for thrombus retrieval,and tirofiban treatment were factors influencing favorable outcomes at 90 days.Multivariate Logistic regression analysis showed that younger age(aOR,0.942,95％CI 0.906-0.978,P=0.002),lower admission NIHSS score(aOR,0.855,95％CI 0.777-0.941,P=0.001),good collateral circulation(aOR,5.534,95％CI 2.141-14.301,P＜0.01),tirofiban treatment(aOR,2.774,95％CI 1.092-7.046,P=0.032),and M2 segment MCA occlusion(reference:internal carotid artery occlusion;aOR,4.874,95％CI 1.428-16.632,P=0.011)were independent predictors of favorable outcomes at 90 days.Conclusions Intravenous tirofiban administration after endovascular therapy may improve 90-day neurological outcomes in patients with acute anterior circulation large vessel occlusion stroke who did not achieve successful recanalization without increasing the risk of hemorrhage.Further large-scale randomized controlled trials are warranted to validate these findings.

Tumor microenvironment is the result of dynamic interactions between different cellular and non-cellular components,including cancer cells themselves,extracellular matrix,immune cells and various non immune cells.Microenvironment is closely related to the growth,metastasis and prognosis of breast cancer,and is closely related to the current popular targeted therapy and immunotherapy.Radiomics is a new field of translational medicine based on extracting high-dimensional data from images to obtain reliable models that can be applied to clinical practice.In this review,the latest advances in the application of radiomics to the tumor microenvironment of breast cancer are discussed.

Objectives:To explore the feasibility of zero-ray radiofrequency catheter ablation for paroxymal atrial fibrillation under the guidance of transthoracic echocardiography combined with three-dimensional mapping system.Methods:This is a single-center prospective observational study.A total of 12 patients with paroxysmal atrial fibrillation who underwent radiofrequency catheter ablation in Fuwai Hospital,Chinese Academy of Medical Sciences from June 1,2024 to September 30,2024 were included.All patients underwent successful percutaneous puncture,atrial septal puncture under the guidance of transthoracic echocardiography,and all patients underwent left atrial modeling and discharge ablation under the guidance of transthoracic echocardiography combined with three-dimensional mapping system.The disappearance of pulmonary vein potential was confirmed after the ablation operation and as the ablation endpoint and successful ablation marker.The operation results and 1-month and 3-month follow-up results of the patients were observed.Results:There were 12 patients with paroxysmal atrial fibrillation,9 males and 3 females,aged(56.8±11.2)years,with a history of paroxysmal atrial fibrillation(4.2±2.3)years.The mean left atrial diameter was(36.5±2.5)mm,the left ventricular end-diastolic diameter was(47.8±4.1)mm,and the left ventricular ejection fraction was 55%-65%.The mean overall operation time was(102.25±14.51)min,the ultrasound operation time was(29.58±6.23)min,and the catheter operation time was(33.08±4.10)min.All patients completed circumferential pulmonary vein isolation without intraoperative complications.The hospitalization time was 2-6 days.At the 1-month follow-up after ablation,all patients showed sinus rhythm on 24-hour ambulatory electrocardiogram,and 2 patients had occasional atrial premature contractions without recurrence of atrial fibrillation.At the 3-month follow-up,two patients had occasional premature atrial contractions,and no recurrence of atrial fibrillation was recorded on the electrocardiogram of all patients.Conclusions:It is feasible to complete radiofrequency catheter ablation of paroxysmal atrial fibrillation under the guidance of transthoracic echocardiography combined with three-dimensional mapping system.