Aortic Aneurysm | Prof. Dong Zhihui (Vascular Surgery) | CMCS Shanghai

About Prof. Dong Zhihui

Prof. Dong Zhihui is a senior vascular surgeon at Zhongshan Hospital, Fudan University. He specializes in endovascular repair of aortic aneurysms and peripheral arterial disease. His clinical focus includes EVAR, TEVAR, and complex aortic reconstruction procedures.

Case Overview

A 68-year-old male with a 15-year history of poorly controlled hypertension and severe COPD presented with two months of intermittent chest and back pain, worsening over one week. CT angiography revealed a Crawford Type II thoracoabdominal aortic aneurysm — the most extensive and highest-risk subtype — with a maximum diameter of 7.2 cm and involvement of all four visceral vessels. Prof. Dong Zhihui's team at Zhongshan Hospital performed a one-stage hybrid repair combining open visceral revascularization with endovascular stent grafting. The patient was extubated on day 1, transferred out of ICU on day 3, and discharged on day 10 with no neurological deficits and intact renal function.

Patient Background

• Age / Sex: 68-year-old male
• Chief Complaint: Intermittent chest and back pain for 2 months; worsening with abdominal distension for 1 week
• Medical History: Hypertension for 15 years (irregular medication); COPD for 10 years; 40 pack-year smoking history
• Physical Exam: BP 160/90 mmHg, HR 88 bpm; abdominal distension; systolic bruit audible periumbilically; bilateral dorsalis pedis pulses diminished

Pre-operative Workup

Laboratory Results

• Creatinine: 110 μmol/L (mild renal impairment)
• D-dimer: Significantly elevated

Imaging (CT Angiography)

• Disease Extent: Aortic involvement from the lower thoracic aorta (T8 level) to bilateral common iliac arteries — Crawford Type II thoracoabdominal aortic aneurysm (the most extensive classification)
• Maximum Diameter: 7.2 cm (high rupture risk)
• Visceral Involvement: Celiac axis, superior mesenteric artery (SMA), and bilateral renal arteries all involved; ostial neck length <5 mm or conically dilated — unfavorable for standard branched endografts
• Iliac Access: Severely tortuous and calcified bilateral iliac arteries — unsuitable for standard EVAR delivery systems

Cardiopulmonary Assessment

• FEV1: 55% of predicted (severe COPD — open thoracotomy not tolerable)
• Echocardiography: Diastolic dysfunction; EF 60%

Diagnosis & Surgical Strategy

Diagnosis: Complex thoracoabdominal aortic aneurysm (Crawford Type II); Grade 3 hypertension; COPD.

Procedure: One-stage hybrid repair — open visceral vessel reconstruction combined with endovascular thoracic stent grafting (TEVAR) with chimney technique.

Rationale: Open surgical repair was excluded due to the patient's severely compromised pulmonary function. Fully fenestrated endovascular repair (FEVAR) was not feasible given the unfavorable visceral ostial anatomy and the lead time required for custom device fabrication. The hybrid approach — performed in a dedicated hybrid operating suite — addressed visceral perfusion through open reconstruction while using endovascular techniques to exclude the aneurysm sac, minimizing aortic cross-clamp time and thoracic trauma.

Surgical Plan

• Step 1 (Open): Transabdominal exposure of the celiac axis, SMA, and bilateral renal arteries; chimney stent grafts pre-positioned in SMA and left renal artery
• Step 2 (Endovascular): Thoracic stent graft deployment via iliac access; chimney grafts maintained visceral perfusion alongside the main thoracic endograft

Operative Procedure

• Anesthesia: General anesthesia with double-lumen endotracheal intubation (lung protection); supine position
• Setting: Hybrid operating suite with intraoperative DSA (digital subtraction angiography)
• Spinal Protection: Lumbar cerebrospinal fluid (CSF) drain placed; intraoperative NIRS (near-infrared spectroscopy) monitoring of spinal cord oxygenation
• Open Phase: Laparotomy via paramedian incision; celiac axis, SMA, left and right renal arteries dissected and mobilized; chimney covered stents pre-deployed in SMA and left renal artery given <5 mm ostial necks
• Endovascular Phase: Super-stiff guidewire advanced to ascending aorta via left common iliac artery; thoracic stent graft (Valiant Captivia or equivalent) deployed with proximal landing zone at T8; chimney stents aligned and deployed under fluoroscopic guidance
• Completion Angiography: SMA and bilateral renal arteries patent (TIMI III flow); no Type I or III endoleak; spinal cord NIRS stable throughout
• Closure: No active bleeding; abdomen closed in layers; drains placed

Operative Data

• Operative Time: 240 minutes
• Estimated Blood Loss: ~300 mL
• Contrast Volume: 80 mL (iso-osmolar agent; renal protection protocol)
• Aortic Cross-clamp Time: None — controlled hypotension (SBP <90 mmHg) used briefly to reduce endoleak risk during deployment

Post-operative Course & Recovery

ICU Monitoring Priorities

• Neurological: Lower limb motor function assessed hourly (paraplegia surveillance)
• Renal: Hourly urine output; creatinine trend monitored
• Visceral: Abdominal signs monitored for bowel ischemia
• Hemodynamic: MAP maintained >80 mmHg to ensure spinal cord perfusion; CSF pressure controlled via lumbar drain

Recovery Timeline

• Day 1: Extubated; alert and oriented; bilateral lower limb movement intact
• Day 3: Transferred to general ward; liquid diet commenced; creatinine peaked at 130 μmol/L then trended down
• Day 10: CTA confirmed stent graft in correct position, all visceral vessels patent, complete aneurysm sac thrombosis; discharged
• Complications: None — no paraplegia, no renal failure, no bowel ischemia, no endoleak

Follow-up & Long-term Management

• Surveillance: CTA at 1, 3, 6, and 12 months post-discharge; annual imaging thereafter
• Medications: Lifelong dual antiplatelet therapy (aspirin + clopidogrel); strict blood pressure control (ACEI/ARB); statin therapy for lipid management

Expert Commentary — Prof. Dong Zhihui

1. Minimally Invasive Solutions for Anatomically Complex Disease

Crawford Type II thoracoabdominal aortic aneurysm has historically carried surgical mortality rates exceeding 15–20% with open repair. By combining open visceral vessel preparation with endovascular exclusion of the aneurysm sac, we avoided thoracotomy and aortic cross-clamping entirely — the two greatest contributors to mortality and paraplegia in this disease. The chimney technique, while technically demanding, provided a practical and timely solution for a patient whose anatomy precluded custom fenestrated devices. This reflects the direction of complex aortic surgery: individualized, minimally invasive, and anatomy-driven.

2. Multi-organ Protection as a Surgical Discipline

In complex aortic repair, the operation does not end when the stent is deployed. Spinal cord protection through CSF drainage and NIRS monitoring, renal protection through contrast minimization and intraoperative hydration, and visceral protection through precise stent alignment are each independent disciplines that must be executed simultaneously. In this case, creatinine peaked at only 130 μmol/L despite pre-existing renal impairment — a result of deliberate, protocol-driven organ protection rather than chance.

3. Individualized Strategy Over Algorithmic Thinking

Not every complex aortic aneurysm should be treated with the same device or the same approach. For this patient — elderly, high pulmonary risk, unfavorable iliac access, short visceral ostia — a rigid adherence to standard FEVAR protocols would have either delayed treatment dangerously or produced a suboptimal result. The ability to adapt — selecting chimney grafts, modifying access strategy, and integrating open and endovascular techniques in a single stage — is what defines experienced aortic surgery at this level.

How CMCS Shanghai Coordinated This Case

China Medical Concierge Shanghai (CMCS) supported this patient's care pathway from initial overseas inquiry through discharge and follow-up planning. Our coordination included:

• Pre-arrival CTA image review and specialist referral to Prof. Dong Zhihui's vascular surgery team at Zhongshan Hospital
• Arrangement of cardiopulmonary assessment, laboratory workup, and 3D CTA reconstruction
• Bilingual interpretation during MDT planning discussions and pre-operative consent
• Surgical admission logistics, including hospital registration and accommodation coordination for accompanying family
• On-site medical interpretation throughout the ICU and ward stay
• Post-discharge follow-up coordination, including CTA scheduling at 1 and 3 months and remote check-in with the surgical team

For international patients facing a life-threatening aortic diagnosis, the combination of urgency, complexity, and unfamiliar medical systems creates an overwhelming burden. CMCS exists to remove that barrier — ensuring patients reach the right specialist, at the right institution, with every clinical and logistical detail managed.

This case report is de-identified and published for educational purposes. All clinical details have been anonymized in accordance with patient privacy standards. CMCS Shanghai is a medical concierge service and does not provide direct medical care.