Professor Jing Zaiping talks about minimally invasive treatment of vascular diseases Vascular diseases are on the rise, but both patients and doctors in general are still at the time of “getting to know the true face of the mountain” and are in urgent need of modern medical knowledge update and public knowledge supplement. Professor Jing Zaiping, Director of Vascular Surgery Department of Changhai Hospital, Second Military Medical University, suggested that lifestyle diseases have become a major risk factor for increased morbidity, disability and mortality of many diseases. If we consider tuberculosis based on malnutrition as a representative of “poverty disease”, then vascular disease based on atherosclerosis can be regarded as a typical example of “affluenza disease”. As we eat more and move less over time, our vascular system is silently damaged by the nutrients that cannot be consumed. For this reason, we invited Prof. Jing Zaiping to write an article on the minimally invasive treatment of vascular diseases. Jing Zaiping, Department of Vascular Surgery, Shanghai Changhai Hospital Minimally invasive endoluminal isolation for abdominal aortic aneurysm The word “aneurysm” is derived from the Greek word meaning “widened”. According to the current standard, if the diameter of a local artery exceeds 50% of the original normal artery in that area, it is called “aneurysm”. Aneurysms can occur in a number of vessels in the body, but they are most common in the abdominal aorta. Abdominal aortic aneurysms are at the same risk of rupture as aortic coarctation, and the larger the diameter of the aneurysm, the higher the risk of rupture. The greatest scientist of the 20th century, Albert Einstein, the greatest president of France, Charles de Gaulle, and our famous geologist, Professor Li Siguang, all passed away due to ruptured aortic aneurysms. Imagine if the aortic aneurysm had been effectively treated and these celebrities had lived longer, what would the world have been like? What would history have been like? Unfortunately, history is history and there are no “what ifs”. Abdominal aortic aneurysms tend to occur in older patients, which is different from aortic coarctation aneurysms, mainly due to the different pathogenesis of the two. One of the main causes of abdominal aortic aneurysms is atherosclerosis of the arteries! This process can be said to be a “miracle” – the longer the life course and the older the age, the higher the proportion of atherosclerosis and the higher the proportion of abdominal aortic aneurysms. In addition to the “sequelae” of many “rich diseases” such as hyperglycemia, hyperlipidemia, hypertension and the “side effects” of modern lifestyle and rhythm, and to a certain extent, accelerated and aggravated this process. This process is somewhat accelerated and aggravated. Currently, we advocate active intervention for patients with abdominal aortic aneurysms larger than 137.5 px in diameter. The traditional treatment is also mostly open surgery, replacing the diseased vessel with an artificial one, which still has the inherent deficiencies of open surgery such as surgical trauma and anesthesia risks. Nowadays, minimally invasive endoluminal isolation has become the treatment of choice for most patients with abdominal aortic aneurysms. Again, under simple local or lumbar anesthesia, a small incision is made at the root of the patient’s thigh, and a specially designed endoluminal graft is delivered to the abdominal aortic aneurysm using the same catheter and guidewire. The graft is accurately positioned, opened, and propped inside the aneurysm. Due to the separating effect of the endoluminal graft, the blood flow on the inside of the graft (inside the abdominal aorta) no longer touches the outer aneurysm wall, thus “isolating” the aneurysm wall from the abdominal aortic blood flow. Once the aneurysm wall is no longer in contact with the blood flow, it is no longer subject to the external impact of the blood flow and the risk of aneurysm rupture is completely eliminated. There are two main types of endoluminal grafts used in endoluminal isolation: bifurcated endoluminal grafts and open-end endoluminal grafts. The former is named because the distal end of the intraluminal graft enters the right and left iliac arteries respectively, resembling a bifurcation, and is mainly used for abdominal aortic aneurysms below the opening of the renal artery (also known as “subrenal abdominal aortic aneurysms”). This type of abdominal aortic aneurysm is the main type commonly used for endoluminal isolation. With the rapid development of endovascular techniques, open-window endoluminal grafts have been created. This type of endoluminal graft is a “window” modification (i.e., a hole) in the graft trunk that allows the endoluminal graft to isolate the aneurysm while maintaining flow through the “window” to the branch artery. Therefore, windowed endoluminal grafts are mainly used for aneurysms of the visceral branches of the abdominal aorta (also known as “perirenal abdominal aortic aneurysms”), which often emanate from important branch arteries such as the celiac trunk artery, renal artery, and superior mesenteric artery, and which, if treated with general endoluminal isolation, may result in If treated with general endoluminal isolation, intestinal ischemia and intestinal necrosis or renal ischemia and renal failure may occur as a result of “excessive” isolation. The use of open-window endoluminal grafts can completely circumvent these problems while isolating the aneurysm. Endoluminal minimally invasive treatment of severe degenerative aortic stenosis We know that blood circulation is one of the most important physiological functions of the body and is necessary for the survival of the body. Due to the normal operation of blood circulation, all functions of blood can be realized, thus ensuring the relative stability of the internal environment of the body and the normal metabolism of all tissues and organs in the body. In the process of blood circulation, the heart is the “starting point”, the “pump” and the “engine”! The heart contracts normally so that arterial blood can be transported to all parts of the body, providing oxygen and nutrients for all tissues and organs. The aortic valve, as the “gate” of arterial blood flowing out of the heart, opens and closes normally to ensure the “correct route” of arterial blood, playing the role of the “throat” in the circulation. It plays the role of the “throat” in the circulation. Once the aortic valve is diseased, it may adversely affect the normal blood circulation. Severe degenerative aortic stenosis is one such lesion and is a serious life-threatening condition. As the aortic valve has been severely degenerated, the valve calcification causes a significant narrowing of the blood outflow pipe, the blood in the heart can hardly be pumped out smoothly, and the normal blood circulation of the body is almost limited to a halt. Patients at this time are often combined with varying degrees of heart failure and are directly threatened with death. The only traditional treatment is to open the heart and perform valve replacement. Due to the traumatic nature of the procedure and the effects of anesthesia and extracorporeal circulation, 30% of patients do not receive surgical treatment because they are unable to tolerate the procedure. Now, the advent of minimally invasive sphere-expandable aortic valve endovenous replacement has truly become the last resort for these critically ill patients. Patients do not need an open chest, general anesthesia, cardiac arrest, or cardiopulmonary diversion. An 8 mm diameter catheter is introduced through the femoral artery at the root of the thigh, and under X-ray guidance, it reaches the diseased aortic valve, the balloon inflates, the stent opens smoothly and snaps securely into the annulus, and the “replacement” prosthetic valve immediately begins to work. The “replacement” prosthetic valve immediately began to work, and the “pumping” of the heart was restarted, and the blood circulation of the body was restored. Since the Department of Vascular Surgery of Changhai Hospital took the lead in carrying out “transcatheter aortic valve ball expansion endovenous minimally invasive replacement” in China, several patients with severe degenerative aortic stenosis have been given a new lease of life in the Department of Vascular Surgery of Changhai Hospital. Endoluminal minimally invasive treatment of arterial obstructive diseases The main trunk of the ascending aorta, aortic arch, descending aorta and abdominal aorta are not easily obstructed because of their large lumen and fast blood flow, while other vessels with smaller diameter are different. Influenced by various internal and external factors, such as atherosclerosis, hypertension, hyperlipidemia, hyperglycemia, smoking, inflammation, trauma, external pressure, etc., these vascular lumens can become narrowed or even blocked, directly causing the occurrence of ischemia in the distal (downstream) tissues or organs, thus exhibiting their different ischemic symptoms. Arterial obstructive lesions can be divided into three parts: head and neck, abdominal visceral branch area, and lower extremity area. The head and neck lesions mainly occur in the carotid artery, vertebral artery, and subclavian artery, and the symptoms of ischemia are dizziness, headache, darkness, syncope, and weakness of upper limbs. Obstructive lesions of the arteries in the abdominal visceral branches are mostly caused by the celiac trunk, superior mesenteric artery and renal artery. The first two are mainly responsible for the blood supply of the digestive system, so the symptoms of ischemia are mainly abdominal pain, nausea, vomiting, and C and other “indigestion” manifestations. In addition to assisting the kidneys to perform the task of “drainage and decontamination”, the renal artery also has the function of blood pressure regulation. Therefore, when the renal artery becomes narrowed or obstructed, hypertension and renal insufficiency (renal failure) may occur. The typical manifestations of arterial obstructive lesions in the lower extremities are intermittent claudication, resting pain and gangrene, also known as the “ischemic trilogy”! Intermittent claudication is an early symptom, which means that after walking for a certain distance, the patient will experience pain in the lower extremity, and after a short rest, the pain will disappear, but after walking again for a certain distance, the symptoms will appear again, which often indicates that the arteries supplying blood to the lower extremity have become significantly narrowed. This often indicates that the arteries supplying blood to the lower extremities have become significantly narrowed. When the “resting pain” stage is reached, the pain in the lower extremities will be unbearable even if the patient does not do anything – resting – and this indicates that the narrowing of the blood vessels has reached the edge of “disaster”. What is “disaster” is the final stage of “gangrene”, when the blood vessels of the lower limbs have basically lost their blood supply, and once the limbs are deprived of blood supply, oxygen and nutrients, necrosis begins, starting from the tip of the most distal toe, then the foot, then the lower leg. The plane of necrosis gradually rises until the whole lower extremity, and finally, the limb will not escape the fate of amputation. At present, in the treatment of arterial obstructive diseases, minimally invasive endovascular treatment techniques, represented by balloon-stent technology, have largely replaced the traditional open surgery based on artificial vascular bypass. The overall treatment trend of endovascular treatment is “from near to far” and “from large to small”, driven by the continuous progress of endovascular equipment and technology, the treatment scope of arterial obstructive disease is continuously expanding from proximal to distal extremities, from large to small and medium-sized vessels. The scope of treatment for arterial obstructive disease is expanding from proximal to distal limbs and from large to small and medium vessels. Minimally invasive endoluminal isolation for aortic coarctation aneurysms The human vascular wall is composed of an inner, middle and outer lining, similar to a sandwich or triple splint structure, forming a strong “dam” that safely restrains the smooth flow of the “river” (blood flow). The lining of the blood vessel is directly impacted by the blood flow at all times. In some special cases where the vessel wall is diseased, the endothelium is torn open and the turbulent blood flow gushes “out”; the outer layer of the endothelium is the relatively weak middle membrane layer, and further out is the outer membrane layer, so if the blood flow gushes directly out of the outer membrane, the aorta ruptures! If the outer membrane temporarily resists the attack of blood flow and the “dam” does not break immediately, the blood flow still rages inside the “dam”, forming a sandwich between the inner and outer membranes, and the sandwich expands under the action of continuous blood flow to form a sandwich aneurysm. Once ruptured, all the blood in the body can be quickly drained in just a few minutes and the patient has no chance of survival! Why does an aortic coarctation aneurysm occur? There are both endogenous and exogenous causes. Endogenous causes are abnormalities of the aortic vessel wall itself, such as congenital genetic diseases (e.g., “Marfan syndrome”), atherosclerosis, various infections, and damage to the vessel wall caused by trauma, etc. External causes are non-vascular wall factors, the most common of which is the effect of intravascular blood flow – hypertension! -hypertension! As mentioned earlier, blood vessels and blood flow are like the relationship between a dam and a river. The higher the blood pressure, the higher the water level, the more likely the dam will go wrong and the greater the chance of small cracks in the vessel wall resulting in the formation of a coarctation aneurysm, especially if the vessel itself is diseased. With the changes in modern lifestyle and pace of life, the low age and youthfulness of hypertension patients is becoming more and more obvious. The relative lack of awareness of regular medical checkups and the long-standing misconception that hypertension only occurs in older age groups have led to a low detection rate of hypertension (especially in younger age groups); even if it is detected, some patients fail to adhere to treatment and formal therapy, making the effective control rate of hypertension also low. All of the above have contributed to a certain extent to the current trend of low incidence and critical condition of aortic coarctation aneurysm. Aortic coarctation aneurysm poses a great threat to the patient, his family and society. How can effective treatment be provided? Traditional treatment requires opening the chest cavity under cardiac arrest (extracorporeal circulation), which is more traumatic and risky in terms of anesthesia, and therefore a last resort for both the patient and the physician. Now, with minimally invasive endovascular isolation, patients can be successfully treated without excessive surgical and anesthetic risks and without the “pain of the skin”. What is endovascular isolation? Under simple local or lumbar anesthesia, a small incision of about 3 cm is made at the base of the patient’s thigh (or a smaller incision in the upper extremity or neck), and a special endoluminal graft is delivered to the aortic endoluminal fissure and released; the endoluminal graft covers the endoluminal fissure and “isolates” the vessel wall from the blood flow in the aorta. Once the endothelial fissure is sealed, the interstitial layer can be thrombosed (i.e., in a relatively stable state) and the patient with a coarctation aneurysm will no longer experience rupture hemorrhage and sudden death. This also shows that “minimally invasive” and “effective” are the two main features of endoluminal isolation. Aortic coarctation aneurysms are divided into descending aortic coarctation aneurysms, aortic arch coarctation aneurysms and ascending aortic coarctation aneurysms depending on the site of occurrence. The pathologic characteristics of different coarctation aneurysms are different, and the specific endoluminal isolation procedures are also different. The descending aortic coarctation aneurysm is the most common and is currently treated by minimally invasive endoluminal isolation with a straight endoluminal graft, which is relatively simple to perform; the aortic arch coarctation aneurysm is treated by minimally invasive endoluminal isolation with a branch endoluminal graft because it involves a branch artery; the ascending aortic coarctation is treated by minimally invasive endoluminal isolation with a short tube endoluminal graft because of the short distance. Branched endoluminal grafts represent the highest level of minimally invasive endoluminal treatment for aortic coarctation aneurysms. This type of graft involves an additional branch stent or stents extending from the main body of the graft, which at the time of release is located in the aorta, while the branch stents extend precisely into the branch arteries of the aorta. The advantage of using them is that they can adequately isolate the clogged aneurysm involving the branch artery, and at the same time protect the blood supply to the branch artery from ischemic symptoms. The difficulty of using it is also understandable, as all these main and branch stents must be precisely “in their own way”, and they must be entered exclusively through minimally invasive endoluminal means. Therefore, it is the highest level of technology and the most difficult to operate. At present, the Department of Vascular Surgery of Changhai Hospital has successfully treated many patients with complex aortic arch coarctation aneurysms by applying this technique. (This article is from May 30, 2012 News Morning Post by Wen S. Xie)