肝硬化门静脉高压患者TIPS术后门静脉分支远端血栓形成相关因素及其对预后的影响

摘要 目的：探究肝硬化门静脉高压患者经颈静脉肝内门体静脉分流术（TIPS）后门静脉分支远端血栓形成影响因素及其对预后的影响。方法：选取南方医科大学南方医院2021年1月~2023年1月行TIPS的300例肝硬化门静脉高压患者,根据术后6个月内门静脉分支远端血栓形成发生与否分为血栓组与非血栓组。对比两组临床资料,多因素Logistic回归分析TIPS术后门静脉分支远端血栓形成的相关因素。对比两组术后6个月预后情况。结果：术后门静脉分支远端血栓形成发生率10.67%（32/300）。血栓组年龄、术前3 d内血浆D-二聚体（D-D）、总胆固醇（TC）、低密度脂蛋白（LDL）水平、门静脉主干直径、门脉左支直径、Child-Pugh分级A级比例、门静脉流速与非血栓组对比差异均有统计学意义（P＜0.05）;多因素Logistic回归分析显示,高龄、LDL水平升高、门脉左支直径增大是TIPS术后门静脉分支远端血栓形成的危险因素,Child-Pugh分级为A级为保护因素（P＜0.05）。血栓组TIPS术后6个月TIPS支架通畅率、肝性脑病、肝功能损伤及死亡发生率与非血栓组对比无统计学意义（P＞0.05）。结论：肝硬化门静脉高压TIPS术后门静脉分支远端血栓形成与年龄、术前LDL、Child-Pugh分级、门脉左支直径相关,但对患者术后6个月TIPS支架通畅率、肝性脑病、肝功能损伤及死亡发生率没有影响。     

Surgical Strategy for Hepatocellular Carcinoma Patients with Portal/Hepatic Vein Tumor Thrombosis

Background

Portal/hepatic vein tumor thrombosis (PVTT/HVTT) in hepatocellular carcinoma (HCC) is a sign of advanced stage disease and is associated with poor prognosis. This study investigated the surgical outcomes of patients with HCC and PVTT/HVTT to determine the most appropriate surgical treatment strategy for these patients.

Materials and Methods

The study population included 77 HCC patients from January 2004 to June 2009 who underwent hepatectomy in our department and were diagnosed with PVTT/HVTT based on pathological examination. The patients were divided into two groups: in group 1, PVTT/HVTT was located in the hepatic resection area and removed with the tumor en bloc (38 cases); in group 2, PVTT/HVTT was beyond the resection line and removed by suction or thrombectomy (39 cases). Concerning the factor of surgical margins, the patients were further divided into four subgroups: group 1A: patients in group 1 with surgical margins ≤1 cm (28 cases); group 1B: patients in group 1 with surgical margins >1 cm (9 cases); group 2A: patients in group 2 with surgical margins ≤1 cm (28 cases); and group 2B: patients in group 2 with surgical margins >1 cm (9 cases).

Results

Most of the characteristics of groups 1 and 2 were similar. Patients in group 2 had significantly higher median blood loss (p=0.002) and higher blood transfusion rate (p=0.002) during the operation, which were not considered prognostic factors (p=0.323 and 0.571, respectively). The median overall survival (OS) duration in group 1 was significantly longer than that in group 2 (14.3 vs. 10.4 months, p=0.047). The median OS durations in groups 1A, 1B, 2A, and 2B were 14.3, 42.7, 7.5, and 18.0 months, respectively, which were significantly different(p=0.018).

Conclusions

When PVTT/HVTT is located in the hepatic resection area and removed with the tumor en bloc, the median OS duration is longer. Based on this finding, widening the surgical margins when technically possible may increase OS.     

Rational Classification of Portal Vein Thrombosis and Its Clinical Significance

Portal vein thrombosis (PVT) is commonly classified into acute (symptom duration <60 days and absence of portal carvernoma and portal hypertension) and chronic types. However, the rationality of this classification has received little attention. In this study, 60 patients (40 men and 20 women) with PVT were examined using contrast-enhanced computed tomography (CT). The percentage of vein occlusion, including portal vein (PV) and superior mesenteric vein (SMV), was measured on CT image. Of 60 patients, 17 (28.3%) met the criterion of acute PVT. Symptoms occurred more frequently in patients with superior mesenteric vein thrombosis (SMVT) compared to those without SMVT (p<0.001). However, there was no significant difference in PV occlusion between patients with and without symptoms. The frequency of cavernous transformation was significantly higher in patients with complete PVT than those with partial PVT (p<0.001). Complications of portal hypertension were significantly associated with cirrhosis (p<0.001) rather than with the severity of PVT and presence of cavernoma. These results suggest that the severity of PVT is only associated with the formation of portal cavernoma but unrelated to the onset of symptoms and the development of portal hypertension. We classified PVT into complete and partial types, and each was subclassified into with and without portal cavernoma. In conclusion, neither symptom duration nor cavernous transformation can clearly distinguish between acute and chronic PVT. The new classification system can determine the pathological alterations of PVT, patency of portal vein and outcome of treatment in a longitudinal study.     

Prevention of Postoperative Deep Vein Thrombosis in Patients with Malignant Disease

We have used the ¹²⁵I-fibrinogen test to asses the value of an improved method of peroperative intermittent calf compression as a prophylactic measure against postoperative thrombosis. In a group of 99 patients over the age of 40 undergoing operations lasting more than 30 minutes the technique reduced the incidence of postoperative thrombosis by over 75%. In patients suffering from malignant disease, who are generally considered to be in the very high risk category, the reduction achieved was almost 90%.     

Impact of Regional Vein Thrombosis in Patients with Klebsiella pneumoniae Liver Abscess

Klebsiella liver abscess (KLA) is an emerging infection in Asia caused by hypermucoviscous strains of Klebsiella pneumoniae. It is associated with thrombophlebitis of portal and hepatic veins. The natural history and role of anticoagulation for this regional thrombophlebitis is unclear. In a retrospective study of 169 subjects with KLA over 7 years, thrombophlebitis was identified in 53/169 (31.4%). Only 1 received therapeutic anticoagulation. Despite this 30/49 (73.2%) of those with follow up scan available showed improvement or recanalization (mean duration between scans 44 days). Abscess resolution was associated with improvement in thrombophlebitis.     

脾切除及贲门周围血管离断术对肝硬化门静脉高压患者肝脏血流动力学的影响及其术后门静脉血栓形成的因素分析

目的:探讨脾切除及贲门周围血管离断术对肝硬化门静脉高压患者肝脏血流动力学的影响,并分析患者术后门静脉血栓形成的危险因素。方法:选择2016年1月-2017年12月在我院进行脾切除及贲门周围血管离断术的96例肝硬化门静脉高压患者,于术前、术后1d、3d、7d采用彩色多普勒超声对患者的肝脏血流动力学指标进行动态监测。统计术后7d内患者门静脉血栓的发生率,并将患者分为血栓组(n=28)和无血栓组(n=68),对两组患者的一般资料、手术指标、彩色多普勒超声监测指标等进行单因素分析,并采用Logistic多因素回归分析门静脉血栓形成的危险因素。结果:患者在术前、术后1d、3d、7d时的门静脉内径、最大流速、血流量呈逐渐降低的趋势,肝动脉内径、最大流速、血流量呈逐渐升高的趋势,且各时间点间两两比较差异有统计学意义(P0.05)。术后7d内有28例患者出现门静脉血栓,发生率为29.17%。血栓组和无血栓组患者在性别、年龄、体质量指数、手术时间、术前门静脉流速比较差异无统计学意义(P0.05);血栓组患者Child-Pugh分级为B级比例、术中出血量、脾质量、腹水量、术前门静脉内径均高于无血栓组,术后门静脉内径、术后门静脉流速均低于无血栓组(P0.05)。经Logistic多因素回归分析显示,患者术后门静脉内径、术后门静脉流速是门静脉血栓形成的危险因素(P0.05)。结论:行脾切除及贲门周围血管离断术的肝硬化门静脉高压患者术后进行肝脏血流动力学监测,有助于患者术后的疗效判断,且术后门静脉内径、术后门静脉流速是门静脉血栓形成的危险因素。     

Spectral CT Imaging in Patients with Budd-Chiari Syndrome: Investigation of Image Quality

To assess the image quality of monochromatic imaging from spectral CT in patients with Budd-Chiari syndrome (BCS), fifty patients with BCS underwent spectral CT to generate conventional 140 kVp polychromatic images (group A) and monochromatic images, with energy levels from 40 to 80, 40 + 70, and 50 + 70 keV fusion images (group B) during the portal venous phase (PVP) and the hepatic venous phase (HVP). Two-sample t tests compared vessel-to-liver contrast-to-noise ratio (CNR) and signal-to-noise ratio (SNR) for the portal vein (PV), hepatic vein (HV), inferior vena cava. Readers’ subjective evaluations of the image quality were recorded. The highest SNR values in group B were distributed at 50 keV; the highest CNR values in group B were distributed at 40 keV. The higher CNR values and SNR values were obtained though PVP of PV (SNR 18.39 ± 6.13 vs. 10.56 ± 3.31, CNR 7.81 ± 3.40 vs. 3.58 ± 1.31) and HVP of HV (3.89 ± 2.08 vs. 1.27 ± 1.55) in the group B; the lower image noise for group B was at 70 keV and 50 + 70 keV (15.54 ± 8.39 vs. 18.40 ± 4.97, P = 0.0004 and 18.97 ± 7.61 vs. 18.40 ± 4.97, P = 0.0691); the results show that the 50 + 70 keV fusion image quality was better than that in group A. Monochromatic energy levels of 40–70, 40 + 70, and 50 + 70 keV fusion image can increase vascular contrast and that will be helpful for the diagnosis of BCS, we select the 50 + 70 keV fusion image to acquire the best BCS images.     

Inflammation Activation Contributes to Adipokine Imbalance in Patients with Acute Coronary Syndrome

Inflammation can be activated as a defensive response by the attack of acute coronary syndrome (ACS) for ischemic tissue injury. The aim of the present study was to investigate the impact of ACS-activated inflammation on adipokine imbalance and the effects of statins on the crosstalk between inflammation and adipokine imbalance during ACS. In this study, 586 subjects were categorized into: (1) control group; (2) SA (stable angina) group; and (3) ACS group. Circulating levels of hs-CRP, adiponectin and resistin were measured by ELISA. Furthermore, forty C57BL/6 mice were randomized into: sham, AMI, low-statin (atorvastatin, 2 mg/kg/day) and high-statin (atorvastatin, 20 mg/kg/day) group. After 3 weeks, AMI models were established by surgical coronary artery ligation. Circulating levels and adipose expressions of adiponectin and resistin were assessed in animals. Besides, we investigate the effects of atorvastatin on ox-LDL-induced adipokine imbalance in vitro. As a result, we found that ACS patients had higher hs-CRP and resistin levels and lower adiponectin levels. Our correlation analysis demonstrated hs-CRP concentrations were positively correlated with resistin but negatively with adiponectin levels in humans. Our animal findings indicated higher circulating hs-CRP and resistin levels and lower adiponectin levels in AMI mice. Atorvastatin pre-treatment dose-dependently decreased hs-CRP and resistin levels but increased adiponectin levels in mice. The consistent findings were observed about the adipose expressions of resistin and adiponectin in mice. In study in vitro, ox-LDL increased cellular resistin expressions and otherwise for adiponectin expressions, which dose-dependently reversed by the addition of atorvastatin. Therefore, our study indicates that the ACS attack activates inflammation leading to adipokine imbalance that can be ameliorated by anti-inflammation of atorvastatin.     

纤溶酶治疗下肢深静脉血栓184例疗效观察

目的观察纤溶酶对下肢深静脉血栓的临床疗效.方法随机将234例下肢深静脉血栓的病人分为治疗组和对照组,对照组用低分子右旋糖酐加丹参,静滴;治疗组采用纤溶酶.治疗前后及过程中进行血液流变学检测及多普勒超声检查.结果治疗组总有效率为95.7%,对照组的总有效率为92%,经多普勒超声检查,治疗组有效率为91.3%,疗效明显优于对照组的76%,有显著性差异.结论下肢静脉血栓是临床较常见疾病,纤溶酶对与控制深静脉血栓,改善病人血管栓塞状况效果明确,安全可靠.     

间歇性充气加压疗法对下肢深静脉血栓患者血液流变学的影响

目的:观察间歇性充气加压疗法(intermittent pneumatic compression,IPC)对下肢深静脉血栓形成(deep vein thrombosis of lower limbs,DVT)患者的治疗效果,并从血液流变学方面探讨间歇性充气加压的作用机理.方法:2003年3月-2010年9月我科收治的243例下肢深静脉血栓患者,将其中42例IPC治疗病例定为B组实验组,145例单纯药物治疗病例中选取60例定为A组对照组.观察两组患者血液流变学指标和小腿肿胀消退情况的对比.结果:两组患者全血粘度、红细胞聚集指数、红细胞电泳时间、红细胞变形性,在治疗第1天较入院时无差异,组间无差异(P＞0.05),第3天较入院时有差异(P＜0.05),组间第3天有差异(P＜0.05),两组患者下肢肿胀度均明显消退,但B组肿胀消退速度明显快于对照组(P＜0.05).结论:间歇性充气加压治疗仪可有效改变血液流变学状态,改善血液高凝状态,有效缓解肢体肿胀症状,缩短住院时间.且不增加治疗难度,使用简单,治疗依从性好.     

间歇性充气加压疗法对下肢深静脉血栓患者血液流变学的影响

目的：观察间歇性充气加压疗法（intermittent pneumatic compression,IPC）对下肢深静脉血栓形成（deep vein thrombosis oflower limbs,DVT）患者的治疗效果,并从血液流变学方面探讨间歇性充气加压的作用机理。方法：2003年3月-2010年9月我科收治的243例下肢深静脉血栓患者,将其中42例IPC治疗病例定为B组实验组,145例单纯药物治疗病例中选取60例定为A组对照组。观察两组患者血液流变学指标和小腿肿胀消退情况的对比。结果：两组患者全血粘度、红细胞聚集指数、红细胞电泳时间、红细胞变形性,在治疗第1天较入院时无差异,组间无差异（P〉0.05）,第3天较入院时有差异（P〈0.05）,组间第3天有差异（P〈0.05）,两组患者下肢肿胀度均明显消退,但B组肿胀消退速度明显快于对照组（P〈0.05）。结论：间歇性充气加压治疗仪可有效改变血液流变学状态,改善血液高凝状态,有效缓解肢体肿胀症状,缩短住院时间。且不增加治疗难度,使用简单,治疗依从性好。     

Combined Hepatic Vein, Umbilicoportal Vein, and Superior Mesenteric Artery Catheterization in Portal Hypertension: Estimation of the Portal Fraction of Total Hepatic Blood Flow in Cirrhotic Patients

Hemodynamic data were obtained in 13 cirrhotic patients with severe portal hypertension, undergoing combined hepatic vein, umbilicoportal vein, and superior mesenteric artery catheterization. The relative clearance of indocyanine green, the portohepatic gradient (difference between the free portal venous pressure and the free hepatic venous pressure), and the estimated hepatic blood flow were measured. The portal fraction (PF) of total hepatic blood flow was calculated in all patients using indicator dilution curves obtained from the portal bifurcation, a right hepatic vein, and when possible a left hepatic vein (six cases) after injection of ⁵¹Cr-labeled red blood cells (⁵¹Cr RBC) into the superior mesenteric artery. Flows were overestimated because of loss of indicator through spontaneous portosystemic shunts; however, the ratio between hepatic and portal indicator dilution curves can be used to calculate the portal fraction of total hepatic blood flow since no extrahepatic shunts existed after the bifurcation of the portal vein (as shown on portography). In 10 patients, 15 series of curves were calculable and the PF varied between 30.1 and 100% (mean ± SE: 71.1 ± 6.2%). In the three other patients, only delayed activity from recirculation was detected from portal and hepatic vein samples and PF was 0%; in these three cases, portography and arteriography revealed spontaneous portacaval shunting with reverse and/or stagnant circulation in the portal vein. In the 13 patients, no correlation existed between PF and the relative clearance of indocyanine green or the portohepatic gradient, parameters generally used as indices of severity in cirrhosis. In 10 patients, no correlation was found between PF and the estimated hepatic blood flow.     

高凝状态对非小细胞肺癌患者深静脉血栓形成的影响

目的:探讨高凝状态对非小细胞肺癌患者深静脉血栓形成的影响,为临床治疗提供依据。方法:选择2010年5月至2013年6月在我院接受治疗的非小细胞肺癌患者195例,记录患者姓名、年龄、性别、病理类型、手术、临床分期、放化疗、伴随疾病、身体状况评分(eastern cooperative oncology group,ECOG评分)及是否发生血栓等指标。调查入选患者的高凝状态指标,包括血小板(platelet,PLT)、纤维蛋白原(fibrinogen,Fib)、血浆凝血酶原时间(plasma prothrombin time,PT)、凝血酶时间(thrombin time,TT)、活化部分凝血活酶时间(activated coagulation time of whole blood,APTT)和D-二聚体(D-dimer)。结果:195例非小细胞肺癌患者中,PLT高于正常上限的有42例(21.5%),FIB升高的有78例(40%),TT延长的有12例(6.2%),PT缩短的有45例(23.1%),D-D升高的有60例(30.8%),APTT缩短的有15例(7.7%)。两项指标异常的有62例(31.8%),FIB和D-D升高的有32例(16.4%);三项指标异常的有27例(13.8%),PLT、FIB及D-D升高的有15例(7.7%);四项指标异常的有5例(2.6%),PLT、FIB及D-D升高,而PT缩短的有5例(2.6%)。所有患者各凝血指标中位值PLT为219×109/L,FIB为3.6 g/L,TT为13.4 s,PT为10.8 s,D-D为0.341 mg/L,APTT为29.7 s。结论:高凝状态对非小细胞肺癌患者深静脉血栓形成具有重要的促进作用,应受到临床的重视。     

选择性入肝血流阻断应用于肝癌合并门脉高压手术中的疗效观察

目的：探究选择性入肝血流阻断（SPVE 法）在肝癌合并门脉高压手术中的临床应用效果。方法：选择我院2009 年10 月 ~2014 年10 月期间确诊为肝癌合并门脉高压的患者80 例,按照随机数字数表法分为观察组和对照组各40 例,观察组行SPVE 法进行血流阻断,对照组行全入肝血流阻断法（Pringle 法）进行血流阻断。对比两组手术时间、阻断血流时间、手术中出血量、输血 量、手术前后患者肝功能相关指标及术后并发症发生率。结果：两组手术时间和血流阻断时间对比差异无统计学意义（P>0.05）,而 观察组术中出血量及输血量均小于对照组,差异具有统计学意义（P<0.05）;术后观察组血液中谷丙转氨酶（ALT）、谷草转氨酶 （AST）和总胆红素（TB）水平均低于对照组,而血清蛋白（ALB）和血红蛋白（Hb）水平高于对照组,差异均有统计学意义（均P<0. 05）;观察组并发症发生率为22.5%,明显低于对照组的37.5%,差异有统计学意义（P<0.05）。结论：SPVE法应用在肝癌合并门脉 高压手术中,可以显著减少术中的出血量和输血量,有利于术后肝功能的恢复,有效地降低术后并发症的发生。     

Intervention for Diagnosis of Deep Vein Thrombosis in Acute Stroke Patients: A Hospital-Based Study

Background

Immobile stroke patients are at high risk of deep vein thrombosis (DVT). Demographic studies suggest a low incidence of DVT in Asian patients, but that might be underestimated.

Objective

Intervention by in-hospital case management for diagnosis of DVT in patients with acute stroke.

Patients and Methods

Intervention was defined as: recommendation of D-dimer test for patients who are immobile by day 4 after stroke onset and compression ultrasonography if the level of D-dimer is ≥500 ng/ml. Treating physicians were notified by case managers before they failed to do so for qualified patients. Data of patients hospitalized 12 months before and 8 months after the intervention, including basic demographics, Glasgow Coma Scale score, National Institute of Health Stroke Scale (NIHSS) score, laboratory results, and examination reports, was retrieved from electronic medical records for analysis by code searches for acute stroke.

Results

A total of 2523 patients were identified. 1528 were before and 995 after intervention. More patients after intervention had D-dimer test and ultrasound examination than that before intervention (22.1% vs 8.6%, P<0.001 and 15.1% vs 1.2%, P<0.001, respectively). Ultrasound diagnosis of DVT was significantly more after than before intervention (2.0% vs 0.3%, P<0.001). DVT was 55.7 per 1000 in patients with a NIHSS score≧18. Male sex (Odds ratio 0.33, 95% confidence intervals: 0.11–0.98), NIHSS score (Odds ratio 1.05, 95% confidence intervals: 1.00–1.09), and intervention (Odds ratio 5.39, 95% confidence intervals: 1.88–15.44) were independent predictors of ultrasound diagnosis of DVT.

Conclusions

Intervention by in-hospital case management may be an effective strategy for improvement of under-diagnosis of DVT in acute stroke patients.     

不同方案治疗直径小于10cm肝细胞癌合并门静脉癌栓患者影响生存率的观察

目的：探讨两种不同方案治疗直径小于10cm肝细胞癌合并门静脉癌栓患者影响生存率。方法：将我院100例直径小于10cm肝细胞癌合并门静脉癌栓患者按照抽签法随机地均分为A、B两组,A组行单纯肝动脉插管化疗栓撒（TACE）治疗,B组肝癌手术切除联合癌栓切除＋TACE术,比较两组患者治疗前后DLIA蛋白与VEGF蛋白阳性表达率、五年生存率以及影响患者生存率的因素。结果：（1）A组治疗前后DLL4蛋白与VEGF蛋白阳性表达率差异无统计学意义（P〉0．05）,B组治疗前后上述蛋白阳性表达率差异具有统计学意义（P〈0．05,P〈0．01）;（2）根据Kaplan—Meir计算方法,B组五年生存率均明显大于A组（P〈0．001）;（3）经Pearson单因素与COX多因素分析,影响患者预后的危险独立因素为肿瘤大小与手术方式。结论：综合治疗方案用于治疗直径小于10cm肝细胞癌合并门静脉癌栓患者之中,疗效显著,患者五年生存率明显提高。     

Conditioning Factors for High Cardiovascular Risk in Patients with Cushing Syndrome

Objective: To characterize the alterations in carbohydrate and lipoprotein metabolism, to evaluate markers of lipoprotein functionality, and to identify the presence of novel atherogenic risk factors in patients with Cushing syndrome (CS) in comparison with sex- and age-matched controls.Methods: In an open, cross-sectional study, 32 nontreated patients with active CS were consecutively recruited from the Endocrinology Service at “José de San Martín” Clinical Hospital, University of Buenos Aires, Argentina, between April 11, 2010 and December 11, 2012. The patients were compared with sex- and age-matched controls.Results: Versus controls, patients with CS presented with excess weight, central obesity, and hypercortisolism. They also exhibited an insulin-resistant state, with high resistin levels (median [interquartile range], 16 [10 to 22] ng/mL versus 6 [5 to 9] ng/mL; P<.0001), a more atherogenic lipoprotein profile, high oxidized low-density lipoprotein levels (oxLDL; mean ± SD, 100 ± 31 U/L versus 75 ± 32 U/L; P<.05) and high sensitive C-reactive protein levels (median [interquartile range], 1.2 [0.6 to 3.1] mg/L versus 0.6 [0.3 to 1.1] mg/L; P<.05), and increased leukocyte count (mean ± SD, 9.5 ± 2.6 × 10³ cells/μL versus 6.5 ± 1.4 × 10³ cells/μL; P<.0001). Multivariate analyses showed that the increase in waist circumference was associated with both the diagnosis of CS and the degree of insulin resistance. Resistin concentration was related to a greater extent to the diagnosis of CS than to homeostasis model assessment–insulin resistance. Triglyceride and oxLDL levels were only significantly associated with the diagnosis of CS.Conclusion: Hypercortisolism is related to the increase observed in triglycerides and oxLDL levels, and, in combination with insulin resistance, acts to increase waist circumference and amplify the inflammatory process, key factors for the development of cardiovascular disease.Abbreviations: apo = apolipoprotein ARE = arylesterase CETP = cholesteryl ester transfer protein CRP = C-reactive protein CS = Cushing syndrome CV = coefficient of variation HDL = high-density lipoprotein HDL-C = high-density-lipoprotein cholesterol HOMA = homeostasis model assessment LDL = low-density lipoprotein LDL-C = low-density-lipoprotein cholesterol Lp-PLA₂ = lipoprotein-associated phospholipase A₂ oxLDL = oxidized LDL PON = paraoxonase TG = triglyceride     

Surprise in the Battle Field of Vein vs. Artery

Formation of arteries and veins is a complex process. It was shown that activation of the notch signaling pathway in the artery results on the activation of arterial markers and the suppression of vein markers. However, factor, which instructs endothelial cells to take on the vein or artery identity, has not been defined. It was assumed that VEGF, the key molecule which stimulates notch signaling pathway in the artery, is not available in the vein. Thus, endothelial cells, lacking notch signaling, acquire vein identity. Recently, Drs. Tsai and their colleague demonstrated that COUP-TFII, an orphan nuclear receptor, is an important factor that regulates vein identity through suppression of the notch signaling.