Invasive weeds often possess strong resistance to biotic stresses, which causes huge ecological problems. Both plant growth regulators (PGRs) and arbuscular mycorrhizal (AM) fungi contribute to plant growth and resistance. However, their combined interactions in invasive plants' defense remain poorly understood. To address this knowledge gap, the invasive weed Alternanthera philoxeroides was treated with gibberellins (GA) and paclobutrazol (PAC), inoculated with Clariodeoglous etunicatum to test its response to pathogenic fungi. We found that these two PGRs suppressed AM fungi colonization. Both GA and AM fungi significantly promoted aboveground plant growth, while the two PGRs and AM fungi reduced pathogen infection. Metabolite analysis revealed that AM fungi inoculation significantly elevated vanillic acid, gentisic acid, and pomiferin content. Moreover, flavone, organic acid, and amino acids were positively related with plant growth, while jasmonic acid and amino acids were correlated with plant resistance. Our findings provide direct evidence that, through PGRs and metabolites, AM fungi could be "chemical armed" and contribute to plant growth and resistance to pathogens. These findings offer new insights into how PGRs and AM fungi modulate metabolites to enhance invasive plants' resistance, which might contribute to understanding the mechanism of plant invasion and weed management in agro-ecosystem.

This study analyzed the dynamic variation in leaf ecological stoichiometry of lettuce during the whole growth period under the two different fertility levels, and explored the potential application of ecological stoichiometry theory for precise fertilization management of lettuce under the evaluated experimental condition. Taking the two critical leaf ages of 10.39 and 24.25 as dividing points, the growth process of lettuce can be divided into three stages: the initial slow growth stage—S1, mid-rapid growth stage—S2, and subsequent slow growth stage—S3. With plant growth, the contents of carbon (C) and nitrogen (N) in leaves kept increasing, while phosphorus (P) content showed a trend of rising first and then decreasing. The leaf C:N ratio declined steadily, and the C:P and N:P ratios decreased first and then increased. Most stoichiometric indicators exhibited significant differences among different growth stages (p < 0.05). Compared with the medium fertility level treatment, the aboveground biomass of lettuce under the higher fertility level treatment slightly increased, but the contents of C, N, and P in leaves all decreased, and no significant differences in various ecological stoichiometric indicators were observed between the two fertility level treatments (p > 0.05). The dynamic variation patterns of leaf C, N, and P contents and their stoichiometric ratios of the tested lettuce under the designed experimental conditions were consistent with the Homeostasis Theory and Allometric Growth Theory of ecological stoichiometry. Based on the above results, this study established ecological stoichiometric reference criteria suitable for dynamic nutrient regulation of lettuce. Collectively, the present findings not only established targeted ecological stoichiometric reference criteria for dynamic nutrient regulation of the lettuce cultivar used in the study under the tested fertility conditions, but also this research idea may be extended to nutrient regulation of other lettuce cultivars or other crop species.

Cotton cultivation faces sustainability challenges due to excessive fertilization practices. Hence, how to rationally optimize cotton fertilization management, and to achieve the reduction of fertilizer input and the increase of benefits in cotton production, is a key problem that this paper intends to solve. In the first year, we established a control using a local recommended fertilization treatment (450 kg ha-1 of urea and 375 kg ha− 1 of monoammonium phosphate) and implemented six nitrogen-phosphorus reduction experiments to investigate the ecological stoichiometric characteristics and interactions between cotton leaves and root soil during flowering and boll-setting stage. After determining the theoretical optimal fertilization treatment based on ecological stoichiometry theory, we validated the optimization effects using machine learning combined with DSSAT simulations. In the second year, we further tested the theoretical optimal fertilization treatment in the field. Cotton leaf N: P ratios were below 13, and root soil N: P ratios were below 2.35, indicating nitrogen limitation in both. The DSSAT + XGBoost algorithm effectively modeled growth responses to various fertilization treatments. The treatment reducing nitrogen to 90

Alien plants often form dominant communities in invaded habitats where there would be strong intraspecific competition among the invader populations. But roles of arbuscular mycorrhizal fungi (AMF) in invasive plants’ intraspecific competition, especially in different invasion time has been rarely reported. In this study, greenhouse experiments were conducted to assess the differential effects of AMF on the growth and competitiveness between early invader (EI) and late invader (LI) of an invasive plant Sphagneticola trilobata. The results showed that the mycorrhizal colonization rate of EI was significantly higher than that of LI. AMF significantly promoted the aboveground growth, but showing no significant impacts on the root growth in EI. In contrast, AMF significantly inhibited aboveground growth, but enhanced root growth in LI. Furthermore, AMF inoculation also significantly enhanced the aboveground relative interaction intensity (RII) of EI and the belowground RII of LI, but inhibited the LI’s aboveground RII and the EI’s belowground RII. AMF also significantly enhanced neighborhood interaction intensity (NInt) of LI on EI, but decreased NInt of EI on LI. This study highlights the completely different roles of AMF on intraspecific competitors, which is LI had facilitation effect on EI, while EI suppressed the growth of LI with the interaction with AMF. These findings contribute to a deeper understanding of the community dynamics underlying the sequence of invasive colonization and provide a theoretical basis for developing control and management strategies for invasive plants in future.

Accurate predictions of irrigation’s impact on crop yield are crucial for effective decision-making. However, current research predominantly focuses on the relationship between irrigation events and soil moisture, often neglecting the physiological state of the crops themselves. This study introduces a novel intelligent irrigation approach based on distributional reinforcement learning, ensuring that the algorithm simultaneously considers weather, soil, and crop conditions to make optimal irrigation decisions for long-term benefits. To achieve this, we collected climate data from 1980 to 2024 and conducted a two-year cotton planting experiment in 2023 and 2024. We used soil and plant state indicators from 5 experimental groups with varying irrigation treatments to calibrate and validate the DSSAT model. Subsequently, we innovatively integrated a distributional reinforcement learning method—an effective machine learning technique for continuous control problems. Our algorithm focuses on 17 indicators, including crop leaf area, stem leaf count, and soil evapotranspiration, among others. Through a well-designed network structure and cumulative rewards, our approach effectively captures the relationships between irrigation events and these states. Additionally, we validated the robustness and generalizability of the model using three years of extreme weather data and two consecutive years of cross-site observations. This method surpasses previous irrigation strategies managed by standard reinforcement learning techniques (e.g., DQN). Empirical results indicate that our approach significantly outperforms traditional agronomic decision-making, enhancing cotton yield by 13.6% and improving water use efficiency per kilogram of crop by 6.7%. In 2024, our method was validated in actual field experiments, achieving the highest yield among all approaches, with a 12.9% increase compared to traditional practices. Our research provides a robust framework for intelligent cotton irrigation in the region and offers promising new directions for implementing smart agricultural decision systems across diverse areas.

This study presents a hybrid modeling framework synergizing process-based crop modeling with evolutionary optimization to reconcile yield sustainability with nitrogen management in arid cotton systems. Building upon the DSSAT-CROPGRO model’s demonstrated superiority over pure machine learning approaches in simulating nitrogen–crop interactions (calibrated with multi-year phenological datasets), we develop a genetic algorithm-embedded decision system that simultaneously optimizes nitrogen use efficiency (NUE) and economic returns. Field validations across contrasting growing seasons demonstrate the framework’s capacity to reduce nitrogen inputs by 15–20% while increasing profitability by 8–12% compared to conventional practices, without compromising yield stability. The tight coupling of mechanistic understanding with multi-objective optimization advances precision agriculture through two key innovations: (1) dynamic adaptation of fertilization strategies to both biophysical processes and economic constraints and (2) closed-loop integration of crop physiology simulations with evolutionary computation. This paradigm-shifting methodology establishes a new template for developing environmentally intelligent decision-support systems in water-limited agroecosystems.

Endovascular Aortic Aneurysm Repair (EVAR) can effectively prevent the continuous growth and rupture of Abdominal Aortic Aneurysms (AAA). It is widely used in the treatment of abdominal aortic aneurysm. Endoleak is a serious complication after EVAR operation. How to predict the occurrence of endoleak is an urgent problem to be solved. In this study, local multi-dimensional anatomical features of 381 AAA patients were calculated. Combined with morphological features and different machine learning (ML) methods, the occurrence of endoleak was predicted. The results showed that the model using Gaus Naive Bayes classfier had the best comprehensive prediction performance for the occurrence of endoleak, with AUC of0.735 and accuracy of 0.771. The use of ML combined with multi-modal local anatomical features can preliminarily predict the occurrence of endoleak events before surgery, avoid excessive follow-up, and improve long-term management of patients in clinical practice.

Downregulated RhoA/ROCK1/YAP/F-actin axis leads to decreased AoSMC stiffness and promotes AD formation.

BackgroundThoracic aortic dissection (TAD) is one of the most fatal cardiovascular diseases. One of its important pathological characteristics is the local inflammatory response. Many studies have found that Macrophage polarization plays an extremely critical role in the inflammatory progression and tissue remodeling of TAD. Costunolide (CTD) has an improving effect on oxidative stress and inflammation in the body. However, whether it can promote the integrity of extracellular matrix in Aortic dissection and its mechanism are still unclear.MethodsThe male C57BL/6J mice were used to construct an animal model of TAD with β-aminopropionitrile (BAPN) (100 mg/kg/day, lasting for 28 days), and then CTD (10 mg/kg or 100 mg/kg) was injected intraperitoneally for 28 days to check the survival rate, TAD incidence, aortic morphology and other indicators of the mice. Using hematoxylin-eosin (HE), Masson, Elastin van Gieson (EVG) staining, immunofluorescence (IF), and immunohistochemical staining, the study aimed to determine the therapeutic effects of CTD on an animal model with BAPN-induced TAD. To enhance the examination of the regulatory mechanism of CTD, we conducted transcriptome sequencing on arterial tissues of mice in both the BAPN group and the BAPN + CTD100 group. Next, ANG II were used to construct TAD model in vascular smooth muscle cells (VMSCs). The effects of CTD on the proliferation, migration, invasion, and apoptosis of ANG II-induced cells are to be detected. The expression of MMP2, MMP9, P65, and p-P65 in each group will be examined using Western blot. Finally, the overexpression of IκB kinaseβ (IKKβ) will be established in VMSCs cells to further explore the protective function of CTD.ResultsThe result showed that CTD significantly inhibited BAPN induced mortality and TAD incidence in the animal model, improved aortic vascular morphology, promoted the integrity of extracellular matrix in TAD, reduced tissue inflammation, reduced the accumulation of M1 macrophage, promoted M2 macrophage polarization, and reduced the expression of NF-κB pathway related proteins. Mechanistically, CTD significantly weakened the proliferation, migration, invasion, and apoptosis. p-P65 protein expression of TAD cells were induced by ANG II and IKK-β.ConclusionCTD has the potential to alleviate inflammation, VSMC apoptosis, MMP2/9 levels, and enhance extracellular matrix integrity in TAD by inhibiting the NF-κB signaling pathway.

Traditional medical imaging and biomechanical studies have challenges in analyzing the long-term evolution process of abdominal aortic aneurysm (AAA). The homogenized constrained mixture theory (HCMT) allows for quantitative analysis of the changes in the multidimensional morphology and composition of AAA. However, the accuracy of HCMT still requires further clinical verification. This study aims to establish a patient-specific AAA growth model based on HCMT, simulate the long-term growth and remodeling (G&R) process of AAA, and validate the feasibility and accuracy of the method using two additional AAA cases with five follow-up datasets. The media and adventitia layers of AAA were modeled as mixtures composed of elastin, collagen fibers, and smooth muscle cells (SMCs). The strain energy function was used to describe the continuous deposition and degradation effect of the mixture during the AAA evolution. Multiple sets of growth parameters were applied to finite element simulations, and the simulation results were compared with the follow-up data for gradually selecting the optimal growth parameters. Two additional AAA patients with different growth rates were used for validating this method, the optimal growth parameters were obtained using the first two follow-up imaging data, and the growth model was applied to simulate the subsequent four time points. The differences between the simulated diameters and the follow-up diameters of AAA were compared to validate the accuracy of the mechanistic model. The growth parameters, especially the stress-mediated substance deposition gain factor, are highly related to the AAA G&R process. When setting the optimal growth parameters to simulate AAA growth, the proportion of simulation results within the distance of less than 0.5 mm from the baseline models is above 80%. For the validating cases, the mean difference rates between the simulated diameter and the real-world diameter are within 2.5%, which basically meets the clinical demand for quantitatively predicting the AAA growth in maximum diameters. This study simulated the growth process of AAA, and validated the accuracy of this mechanistic model. This method was proved to be used to predict the G&R process of AAA caused by dynamic changes in the mixtures of the AAA vessel wall during long-term, assisting accurately and quantitatively predicting the multidimensional morphological development and mixtures evolution process of AAA in the clinic.

Background The prognostic implication of initial focal contrast enhancement (FCE), including focal intimal disruption (FID) and intramural blood pool (IBP), in acute type B intramural hematoma (IMH) remain unclear. Objectives The purpose of this study was to compare the prognostic implications in IMH with or without FCE. Methods A total of 574 patients were enrolled. FID was defined as an intimal disruption with contrast-filled out-pouching from the aorta lumen with a communicating orifice of >3 mm, and IBP was defined as a localized contrast medium-filled pool inside the IMH. Results A total of 207 (36.1%) patients with initial FCE, including 132 (63.8%) FIDs and 75 (36.2%) IBPs, were identified. Patients with FCE accompanying IMH were more likely to have hypertension (P = 0.001), pleural effusion (P = 0.006), fewer aortic segments involved (P < 0.001), more adverse aortic events (AAEs) (P < 0.001), and fewer freedom from intervention (P = 0.002). Pleural effusion (HR: 1.79; 95% CI: 1.25-2.55; P = 0.001) and FCE (HR: 1.51; 95% CI: 1.12-2.02; P = 0.006) were identified to be the independent risk factors of AAEs. In the subgroup analysis, IMH with initial FID were more likely to progress than those with initial IBP (P < 0.001). FIDs located at the proximal descending aorta (HR: 2.95; 95% CI: 1.65-5.29; P < 0.001) were associated with AAEs. Conclusions Patients with FCE accompanying IMH were more likely to progress, especially in those initial FID localized at the proximal descending aorta. (Nature course and predictors of progression of intramural hematoma: A retrospective, multicenter study; ChiCTR2300073829).

Objective: Midaortic syndrome is a rare clinical condition that has been mainly studied in juveniles through case reports and series. This study aims to report the anatomic characteristics and long-term outcomes of 41 adult patients with midaortic syndrome who received open surgical treatment or endovascular treatment over a 14-year period. Methods: A consecutive cohort of 41 adult patients diagnosed with midaortic syndrome at our center between January 2008 and November 2021 were enrolled in the study. Patients' baseline and anatomic characteristics were collected and analyzed. Primary follow-up outcomes included death and reintervention. Other follow-up outcomes included hypertension and complications. Results: The study enrolled 41 adult patients with midaortic syndrome with a mean age of 37.5 +/- 13.4 years. Twenty-five patients received open surgical treatment, and 16 patients received endovascular treatment. Isolated infrarenal lesions were more likely to be found in the endovascular treatment group (P = .005), whereas patients with multiple (P = .002) or intravisceral involvement (P = .001) were more likely to be found in the open surgical treatment group. The open surgical treatment group was more likely to have a lower postoperative peak systolic pressure gradient (P = .020). The 5- and 10-year reintervention-free survivals were 87.7% and 71.7% in the open surgical treatment group and 92.3% and 79.1% in the endovascular treatment group, respectively. Conclusions: Both open surgical treatment and endovascular treatment showed satisfactory long-term efficacy outcomes for adult patients with midaortic syndrome. Given the patients' relatively young age and long life expectancy, strict and regular lifelong follow-up is necessary. (JTCVS Open 2024;19:1-8)

A) Computed tomography angiography confirmed penetrating aortic ulcer in the aortic arch.(B) Digital subtraction angiography confirmed the diagnosis.(C ) Design of the novel double inner-branched device.(D) Deployment of the stent-graft in the ascending aorta.(E) Confirmation of two inner branches with balloons.(F) Deployment of bridged covered stents in the innominate artery and left common carotid artery.(G) Deployment of the distal stent-graft.(H ) Final angiography showed procedural success.(I ) Computed tomography angiography was followed up for 6 months.PAU, penetrating aortic ulcer;

Objectives: Aberrant splenic artery aneurysms (ASAAs) located at the splenomesenteric trunk (SMT) and the celiacomesenteric trunk have a close anatomical relationship with the superior mesenteric artery (SMA). The aim of this study was to review our institutional experience of endovascular treatment for ASAAs and evaluate the long-term outcomes. Methods: A retrospective review of patients with ASAAs who underwent endovascular treatment between December 2006 and December 2022 was performed. The demographics of the patients, aneurysm characteristics, treatment strategies, perioperative and long-term outcomes, and complications were analyzed. Results: A total of 29 patients with ASAAs were endovascularly treated at our institution. The SMT variant occurred in the majority of the patients. All ASAAs were characterized by eccentric growth and extremely short inflow arteries. Only 1 patient’s inflow artery of the aneurysm exceeded 1 cm in length. Thirteen patients were treated by coil embolization alone. Four patients received bare stent-assisted coil embolization. A combination of coil embolization and covered stent placement across the orifice of the aberrant splenic artery was performed in the remaining 12 cases. Coil migration into the SMA occurred in 2 patients during the operation. Technical success was achieved in all patients. With a median duration of 63 (34–101) months of follow-up, no intestinal ischemia, aneurysm-related death, aneurysm rupture, or sac enlargement occurred. Three cases of aneurysm sac reperfusion were observed, and 1 patient underwent reintervention with secondary embolization. Asymptomatic occlusion of the covered stent was detected in 1 patient at 2 years. Conclusions: Endovascular treatment is a safe, effective, and durable option for ASAAs. Inflow embolization might be difficult to achieve in ASAAs and poses a high risk of coil migration into the SMA. Long-term observation indicates that reasonable use of the covered stent could achieve reliable inflow artery exclusion in ASAAs without intestinal complications. Clinical impact Aberrant splenic artery aneurysm (ASAA) is an extremely rare entity. This study reported a large sample size of ASAAs treated by endovascular techniques with long-term follow-up. The ASAA was characterized by an extremely short inflow artery and a close anatomical relationship with the superior mesenteric artery (SMA). Endovascular treatment is a safe, effective, and durable option for ASAAs. Inflow embolization might be difficult to achieve in ASAAs and pose a high risk of coil migration into the SMA. Long-term observation indicates that reasonable use of the covered stent could achieve reliable inflow artery exclusion in ASAAs without intestinal complications.

In subtropical monsoon climate regions, traditional plants in constructed wetlands such as farmland ditches underperform in cold months, detracting from both purification capacity and esthetic appeal. To alleviate this weakness, this study introduced Phalaris arundinacea, a species with strong adaptability and cold tolerance, into a plant community dominated by Phragmites australis, constructing an ingenious composite plant community for year-round water quality restoration and enhancement of attractiveness. First, laboratory simulations revealed significant seasonal differences in the removal rates of ammonia nitrogen (NH3-N), total nitrogen (TN), and total phosphorus (TP) by the P. arundinacea community and P. australis community under different pollutant loads. Phragmites australis showed superior NH3-N and TN removal capabilities from May to October, whereas P. arundinacea excelled in the rest of the months throughout the year. For TP removal, P. australis outperformed P. arundinacea from July to October, while P. arundinacea was more effective from January to May. We then verified this in rear farmland ditches, where P. australis were strategically partial substituted with P. arundinacea (Partial Replacement Treatment [PRT]), and compared it with unchanged farmland ditches (Control Treatment). We found that PRT enhanced decontamination efficiency over the year, especially significantly improving the water quality during colder months. Hence, this study advocates a novel strategy for effective annual decontamination and maintenance of wetlands such as farmland ditches, highlighting the importance of seasonally adaptive plant communities for water restoration. This transformative approach dramatically advances the field of wetland management, insisting on the important role of cold-resistant species for year-round ecosystem service optimization.

Background: The homeostasis constrained mixture theory (HCMT) has significantly enhanced researchers’ comprehension of the growth and remodeling process of soft tissue. However, due to the intricate nature of computational models, adequately meeting the efficiency standards for predicting the growth of abdominal aortic aneurysm (AAA) remains challenging.Objective: This study aims to establish the functional relationship between the growth rate of AAA and the associated growth parameters for rapid prediction of the changes in morphological, bio-mechanical parameters, and composition of AAA.Methods: Leveraging the HCMT, we derived a set of optimal solutions for the growth parameters and the rate of change in maximum diameter of the AAA using follow-up data from the initial two time points encompassing 38 cases. The quantitative relationship between the growth rate of AAA and the gain factors controlling substance deposition was analyzed. Two distinct sets of AAAs with multiple follow-up time points and marked differences in growth rates were employed to validate the accuracy of the quantitative relationship.Results: Through an inversion process of the growth parameters of 38 AAA patients, the function relationship between the gain factors and the growth rate was quantified by fitting with an exponential function. For the validation cases, the mean annual difference rates between the simulated diameter and the real-world diameter, derived from the follow-up data, were found to be within 1.5%, essentially meeting the clinical requirements for accurately predicting the maximum diameter growth of AAA.Conclusion: This study provides a quantitative analysis of the relationship between the growth rate and the gain factors, offering the potential to fulfill the accuracy and efficiency needs in predicting changes in AAA diameter. The findings hold promise for assisting in diagnostic and treatment decision-making processes.

To the Editor: Iliac vein compression syndrome (IVCS) is a well-documented anatomic abnormality characterized by the compression of iliac veins from the adjacent artery and vertebra. Depending on whether deep vein thrombosis was co-existing, IVCS could be classified into thrombotic and nonthrombotic lesions. Endovascular procedures have become the mainstream treatment for nonthrombotic IVCS.[1] In most cases, balloon dilation is insufficient to treat nonthrombotic IVCS because the venous wall is easily recoiled. Stenting for iliac vein lesion is therefore necessary for keeping enlargement of the venous lumen. However, stent implantation may bring side effects such as in-stent thrombosis and restenosis. In-stent restenosis (ISR) caused by intimal hyperplasia remains a major drawback of stenting in arterial diseases. However, the evidence about the occurrence and predictors of ISR in nonthrombotic IVCS is limited. We therefore conducted this research to identify the incidence of ISR and explore the potential predictors of ISR in patients with nonthrombotic IVCS. Patients with nonthrombotic IVCS, who accepted stenting between 2017 and 2020 in our vascular department, were retrospectively analyzed. The study protocol was approved by the Human Research Ethics Committees of Zhongshan hospital, Fudan University (No. B2017-115), and the patient informed consent was waived. Every limb was considered as an independent data in all statistical analysis. Patients underwent stenting under local anesthesia. To precisely evaluate the venous lesion, intravascular ultrasound was performed for each limb. Diameter or area of venous stenosis was calculated using the formula: (1–minimal vessel diameter [area]/reference vessel diameter [area]) × 100%. Patients received a combination of aspirin and rivaroxaban for at least 6 months after stenting, and follow-up was suggested at 3, 6, 12 months and yearly thereafter. During the follow-up, all computed tomography (CT) scans were performed with a 64-slice detector (Optima CT 660, General Electric and Aquilion 64, Tokyo, Japan) for all subjects. Coronal, sagittal, and oblique pictures were reformatted, and the degree and location of ISR were evaluated independently by a radiologist and a vascular surgeon. In this study, ISR was defined as any degree of stenosis. Limbs could be classified into the ISR and non-ISR group based on whether stenosis has occurred. Continuous data were presented as mean ± standard deviation or median (Q1, Q3) according to their distribution, while categorical data were presented as counts (percentages). Comparison between the two groups was performed using the χ2 test, Mann–Whitney U test, Student's t-test, or Fisher's exact test where appropriate. Multivariable logistic regression analysis was performed by including all potential predictors (P < 0.10 in univariable analyses). A P value (two-sided) <0.05 was recognized as statistically significant; and analyses were conducted using SPSS Statistics (version 23, IBM, Armonk, NY, USA). A total of 68 patients with 78 limbs were eligible for further analysis. The age was 63.94 ± 8.02 years and more than half of them were female. The body mass index (BMI) was 24.97 ± 2.94 kg/m2. The most common comorbidities were hypertension and diabetes. Most of the iliac vein compression (56/78, 71.79%) occurred in the left leg and 10 patients had bilateral lesions. According to the Clinical–Etiology–Anatomy–Pathophysiology classification, there were 6 limbs of C3 (edema), 53 limbs of C4 (skin changes such as pigmentation, eczema, and induration), 7 limbs of C5 (healed venous ulcer), and 12 limbs of C6 (active venous ulcer). During the follow-up period, 10 patients with 10 limbs presented with ISR (12.8%). ISR mainly occurred at the middle of stent (8/10), a location which was close to the original compression point; the remaining two ISR occurred at the proximal segment of stent. The median time of ISR was 7.5 months (3.0–13.0 months) after stenting. The comparison of demographic and anatomic characteristics between two groups was displayed in Table 1. Specifically, the ISR group tended to be older and had a higher percentage of female patients but a lower BMI than non-ISR group. In contrast, anatomic parameters did not significantly differ between the two groups. But there was a trend toward a lower minimal vessel area (MVA) (43.16 ± 16.68 mm2vs. 55.72 ± 19.70 mm2, t = –1.915, P = 0.059) and a higher percent area stenosis (66.35 ± 12.55% vs. 59.93 ± 10.92%, t = 1.703, P = 0.093) in the ISR group compared with non-ISR group, although these differences did not reach statistical significance. In the multivariable logistic regression analysis, area stenosis was not included for avoiding the colinearity. Table 1 - Baseline and anatomic characteristics of the ISR and non-ISR group after stenting in iliac vein compression syndrome patients. Items ISR (n = 10) Non-ISR (n = 68) U/t/χ 2 P values Age (years) 68.00 ± 7.48 63.24 ± 7.95 −1.972∗ 0.058 Female 8 (80.0) 34 (50.0) 3.157† 0.076 BMI (kg/m2) 23.50 ± 2.71 25.18 ± 2.93 −1.764∗ 0.078 Left side 9 (90.0) 47 (69.12) 0.988† 0.320 CEAP classification|| −0.263∗ 0.813 C3 1 (10.0) 5 (7.4) C4 6 (60.0) 47 (69.1) C5 1 (10.0) 6 (8.8) C6 2 (20.0) 10 (14.7) MVD (mm) 3.19 ± 1.55 3.66 ± 1.45 1.054∗ 0.292 RVD (mm) 10.67 ± 2.62 10.22 ± 2.17 0.596‡ 0.553 Percent diameter stenosis (%) 67.88 ± 18.42 63.26 ± 13.39 1.196∗ 0.232 MVA(mm2) 43.16 ± 16.68 55.72 ± 19.70 1.915‡ 0.059 RVA (mm2) 139.29 ± 60.01 142.86 ± 44.18 0.228‡ 0.820 Percent area stenosis (%) 66.35 ± 12.55 59.93 ± 10.92 1.703‡ 0.093 Stent type 0.682§ Luminexx 2 (20.0) 18 (26.5) Wallstent 7 (70.0) 47 (69.1) Other 1 (10.0) 3 (4.4) Stent number 0.506§ 1 9 (90.0) 64 (94.1) 2 1 (10.0) 4 (5.9) Stent size 0.632∗ 0.527 12 mm 2 (20.0) 10 (14.7) 14 mm 3 (20.0) 33 (48.5) 16 mm 3 (30.0) 20 (29.4) 18 mm 2 (20.0) 5 (7.4) Stent length 0.688∗ 0.491 4 cm 0 (0) 1 (1.5) 6 cm 2 (20.0) 11 (16.2) 7 cm 0 (0) 1 (1.5) 8 cm 0 (0) 9 (13.2) 9 cm 5 (50.0) 31 (45.6) 10 cm 1 (10.0) 6 (8.8) 12 cm 2 (20.0) 9 (13.2) Stent entering into IVC 4 (40.0) 29 (42.6) 0.025† 0.854 Post-stenting MVD (mm) 10.27 ± 1.74 10.09 ± 2.28 0.235‡ 0.815 Post-stenting RVD (mm) 11.36 ± 1.57 12.32 ± 1.63 −0.982‡ 0.235 Residual diameter stenosis (%) 9.50 ± 9.26 17.74 ± 16.97 −1.498‡ 0.138 Post-stenting MVA (mm2) 131.84 ± 48.52 131.05 ± 43.63 0.053‡ 0.958 Post-stenting RVA (mm2) 149.28 ± 53.41 159.77 ± 51.81 −0.596‡ 0.553 Luminal diameter increased (mm) 7.08 ± 2.57 6.43 ± 2.20 0.851‡ 0.397 Luminal area increased (mm2) 88.68 ± 43.07 75.33 ± 36.50 1.056‡ 0.294 Residual area stenosis (%) 11.29 ± 10.91 16.55 ± 16.61 −0.968‡ 0.336 Red blood cells (×1012/L) 4.29 ± 0.66 4.38 ± 0.51 −0.830∗ 0.407 Hemoglobin (g/L) 125.40 ± 15.05 133.34 ± 14.12 −1.647‡ 0.104 Platelets (×109/L) 221.80 ± 61.47 196.35 ± 47.82 1.514‡ 0.134 White blood cells (×109/L) 5.33 ± 1.23 5.90 ± 1.60 −1.082‡ 0.283 Fibrinogen (mg/dL) 276.60 ± 48.48 268.19 ± 63.77 −0.710‡ 0.478 Data are presented as n (%) or mean ± standard deviation.∗U values.†χ2 values.‡t values.§Fisher's exact test was applied.||The Clinical–Etiology–Anatomy–Pathophysiology (CEAP) classification, C3 means edema, C4 means skin changes, such as pigmentation, eczema, and induration, C5 means healed venous ulcer, C6 means active venous ulcer. BMI: Body mass index; CEAP: Clinical–Etiology–Anatomy–Pathophysiology; ISR: In-stent restenosis; IVC: Inferior vena cava; MVA: Minimal vessel area; MVD: Minimal vessel diameter; RVA: Reference vessel area; RVD: Reference vessel diameter; –: Not avaliable. The receiver operating characteristic (ROC) curve was then conducted for MVA in ISR and identified an optimal cutoff value of 48 mm2. The multivariable logistic regression model confirmed that after adjusting for age, sex, and BMI, MVA ≤48 mm2 remained an independent predictor of ISR (adjusted OR = 7.464, 95% CI: 1.282–43.476, P = 0.025). This study provided the data associated with the incidence and risk factor of ISR after stenting in nonthrombotic IVCS patients. According to our results, 12.8% of diseased limbs presented ISR at a median time of 7.5 months after stenting. Multiple regression analyses suggested that MVA was an independent predictor of ISR after stenting in nonthrombotic IVCS. Diseased limbs with an MVA≤48 mm2 might need a more rigorous follow-up after stenting. With consideration of that ISR was more widely used in published reports and intimal hyperplasia might be inappropriate for research when no histopathological report was available for these patients, hence, ISR rather than intimal hyperplasia was adopted in this study.[2-4] In other researches,[2,4] the incidence of ISR varied from 27% to 77%, owing to different patients, detection methods and time to report. Neglen et al[2] showed that transfemoral venogram identified a cumulative incidence of 77%, 61%, and 15% at 42 months for ISR with any degree, ISR with diameter reduction >20%, and ISR with diameter reduction >50%, respectively. A recent study demonstrated that the incidence of ISR was 27% on post-surgery day 1 and increased to 74% at 3 months.[4] The incidence and severity of ISR reported by these studies were higher than our research. This might be related to the patients, who were included in those study, were different. This research only enrolled nonthrombotic IVCS, while both thrombotic and nonthrombotic IVCS were included in previous studies. Based on CT scan, the incidence of ISR in nonthrombotic IVCS was 12.8% at a median time of 7.5 months after stenting in this research. Obviously, this incidence is much higher than the Neglen et al's[5] report. This discrepancy could be mostly attributed to the different definitions of ISR. Neglen et al[5] reported a relatively low incidence of ISR based on severe stenosis (>50%), while we recorded ISR based on any degree stenosis in this research. Besides, the CT scan that was used in our study to identify ISR might be more sensitive than ultrasonic examination. Univariable analysis demonstrated five potential predictors (age, sex, BMI, MVA, and percent area stenosis) for ISR after stenting, but multivariable regression model recognized MVA as the only independent predictor of ISR. Taken together, all these data indicated a role of MVA in predicting the occurrence of ISR. This might be explained by that a smaller MVA indicated a more advanced stage of disease, thus leading to a higher risk of ISR after stenting. Besides, considering the post-stenting MVA was similar between the two groups, the vessel enlargement was much greater in the ISR group, leading to a stronger outward force by the stent, which would result in overreactive intimal hyperplasia. But further research was still needed to confirm the two assumptions mentioned above. Several limitations needed to be noticed about our study. Firstly, the retrospective nature of this research and the small sample size limited its generalizability, although the majority of included patients were from a prospectively registered cohort. Secondly, since only nonthrombotic IVCS was enrolled in this research, the findings of our study are limited to this subgroup of IVCS. Lastly, the follow-up period was relatively short, the long-term follow up research is needed to observe the association between ISR and the late outcomes of patients. In conclusion, ISR is not a rare condition after stenting in nonthrombotic IVCS patients. MVA is an independent predictor of ISR after stenting, and diseased limbs with an MVA ≤48 mm2 should be recommended with a restrictive follow-up. Conflicts of interest None.

A 55-year-old woman presented with sudden onset of chest tightness and upper back pain.Computed 1 tomography angiography (CTA) revealed intramural hematoma (IMH) involving aortic arch and extending into 2 abdominal aorta (Panel A and B).3 Currently, there is no consensus regarding the best treatment choice of persistent symptomatic aortic arch 4 IMH. 1-3Because of persistent upper back pain following 3-week conservative management, treatment strategies 5 including open surgery versus endovascular repair were discussed with the patient and family.They decided to 6 proceed with endovascular procedure and a written consent was obtained.7 This novel ZIPPER TM endograft system (Hangzhou Endonom Medtech Co., Ltd.China) consists of a main-8 body stentgraft, one outer/inner convertible innominate artery (IA) branch stentgraft and two inner branches for 9 left common carotid artery (LCCA) and left subclavian artery (LSA) (Panel C).10 Key procedure steps: a 22F steerable delivery system was inserted through right femoral artery over a 0.035"