Aortic Aneurysm & Peripheral Artery Disease | Dr. Shi Zhenyu (Vascular Surgery) | CMCS Shanghai

About Dr. Shi Zhenyu

Dr. Shi Zhenyu is a vascular surgeon at Zhongshan Hospital, Fudan University — one of China's premier academic medical centres for cardiovascular and vascular disease. He specialises in endovascular repair of complex aortic aneurysms, hybrid open-endovascular procedures, and treatment of peripheral arterial occlusive disease. Dr. Shi has trained extensively in Europe and North America and is a leading figure in the development of hybrid thoracoabdominal aortic surgery in China. His practice emphasises physiological minimalism: achieving durable vascular reconstruction through the smallest possible surgical footprint, enabling rapid patient recovery even in high-risk cases.

Case Overview

A 68-year-old retired university professor with a 20-year history of poorly controlled hypertension, severe COPD (FEV1 1.2 L), and prior open abdominal aortic aneurysm repair presented with a 3-month history of incidentally discovered thoracoabdominal aortic aneurysm and dull back pain. CTA three-dimensional reconstruction confirmed Crawford Type II thoracoabdominal aortic aneurysm — the most complex anatomical subtype — with maximum diameter 7.2 cm (high rupture risk), an infrarenal neck of only 5 mm precluding standard endovascular repair, visceral arteries (coeliac axis, superior mesenteric artery, bilateral renal arteries) arising from or immediately adjacent to the aneurysm sac, and severely calcified and tortuous iliac arteries. Conventional open repair carried an estimated perioperative mortality of 20–30% given the patient's pulmonary reserve; pure endovascular repair was anatomically impossible. Dr. Shi Zhenyu performed a staged hybrid procedure: retroperitoneal visceral debranching (coeliac-SMA bypass with Dacron graft) to create an adequate endovascular landing zone, followed by thoracoabdominal stent-graft deployment with chimney technique for bilateral renal artery preservation. Operative time 320 minutes; blood loss 400 mL. No paraplegia, no endoleak, no renal function deterioration. The patient was extubated within 4 hours, mobilised at 24 hours, and discharged on day 7. At 1-year follow-up, the aneurysm sac had stabilised at 6.0 cm with all visceral bypass grafts and renal stents patent.

Patient Background

• Age / Sex: 68-year-old male
• Occupation: Retired university professor
• Chief Complaint: Incidentally discovered thoracoabdominal aortic aneurysm for 3 months; dull back pain
• Cardiovascular History: Hypertension for 20 years — poorly controlled; prior open abdominal aortic aneurysm repair 20 years earlier (prosthetic graft now aged)
• Pulmonary History: COPD for 10 years; FEV1 1.2 L — severely impaired pulmonary reserve
• Physical Examination: Pulsatile abdominal mass palpable; bilateral dorsalis pedis pulses diminished

Imaging and Pre-operative Assessment

CTA Three-Dimensional Reconstruction

• Aneurysm extent: From the descending thoracic aorta (T10 level) to the infrarenal abdominal aorta — Crawford Type II classification (most complex subtype, involving the majority of the thoracoabdominal aorta)
• Maximum diameter: 7.2 cm — high rupture risk threshold exceeded
• Proximal neck: Only 5 mm of normal aorta above the renal arteries — insufficient for standard endovascular stent-graft fixation; pure EVAR/TEVAR anatomically impossible
• Visceral artery involvement: Coeliac axis, superior mesenteric artery (SMA), and bilateral renal arteries all originating from or immediately adjacent to the aneurysm sac — standard stent coverage would result in visceral and renal ischaemia
• Iliac access: Bilateral common iliac arteries severely calcified and tortuous — large-sheath endovascular access technically challenging

Pre-operative Diagnosis

• Primary: Crawford Type II thoracoabdominal aortic aneurysm
• Cardiovascular: Hypertension Grade 3 — very high risk
• Pulmonary: COPD with severely impaired pulmonary function

Clinical Decision Making and MDT Discussion

This case represented what vascular surgeons describe as the Everest of aortic surgery. Three treatment strategies were evaluated at multidisciplinary team discussion:

• Option A — Conventional open repair: Thoracoabdominal incision with prosthetic graft replacement. Massive physiological insult; aortic cross-clamping required with spinal cord ischaemia risk exceeding 10%; estimated perioperative mortality 20–30% given the patient's pulmonary reserve. Rejected.
• Option B — Pure endovascular repair (EVAR/TEVAR): Minimally invasive but anatomically impossible — insufficient proximal landing zone; stent-graft deployment would inevitably cover visceral and renal artery origins, causing catastrophic ischaemia. Not feasible.
• Option C — Hybrid procedure (Dr. Shi Zhenyu's recommendation): Open visceral debranching via small retroperitoneal incision to reroute visceral blood flow and create an adequate endovascular landing zone, followed by minimally invasive stent-graft deployment to exclude the aneurysm sac. This approach avoids thoracotomy and laparotomy, eliminates the need for prolonged aortic cross-clamping, and dramatically reduces spinal cord ischaemia and cardiopulmonary complication risk.

Dr. Shi Zhenyu's MDT statement: For a Crawford Type II case of this complexity, pure open surgery is reckless and pure endovascular repair is impossible. Hybrid surgery combines the anatomical reconstruction capability of the open surgeon with the precision of the interventionalist. It is the optimal compromise for high-risk thoracoabdominal aneurysm — not a fallback, but a deliberate strategy.

Surgical Procedure

Approach: Visceral debranching (retroperitoneal) + thoracoabdominal endovascular stent-graft repair with chimney technique
Anaesthesia: General anaesthesia + epidural anaesthesia (post-operative analgesia)
Operative time: 320 minutes
Estimated blood loss: 400 mL

Phase 1 — Open Visceral Debranching

Dr. Shi selected a left retroperitoneal approach — rather than transabdominal — to minimise bowel handling, reduce ileus risk, and facilitate rapid post-operative recovery. The coeliac axis and superior mesenteric artery were exposed through this approach.

An 8 mm Dacron prosthetic graft was anastomosed in a jump-graft configuration: the proximal end to the coeliac axis and the distal end to the SMA, rerouting visceral blood flow away from the aneurysm sac. This debranching manoeuvre transformed the anatomical situation: the visceral arteries — previously arising from the aneurysm — were now supplied by the bypass graft, allowing the stent-graft to safely cover their native origins without causing ischaemia. Critically, this created a substantially longer proximal landing zone of healthy aorta above the now-redundant visceral origins.

Dr. Shi's operative note: The retroperitoneal approach is not simply a smaller incision — it is a fundamentally different physiological insult. By avoiding the peritoneal cavity entirely, we eliminate post-operative ileus, reduce fluid shifts, and preserve the patient's pulmonary function. This is why a patient with FEV1 of 1.2 L can be extubated in 4 hours and walking the next day.

Phase 2 — Endovascular Stent-Graft Repair

Bilateral femoral arteries were surgically exposed and accessed with large-bore sheaths and super-stiff guidewires. Under digital subtraction angiography (DSA) guidance, a modular thoracoabdominal stent-graft system was advanced to the target zone.

Precise deployment was performed using intraoperative angiographic landmarks, positioning the stent-graft proximal body in the now-adequate landing zone above the renal arteries — a zone that existed only because of the Phase 1 debranching. The aneurysm sac from T10 to the infrarenal aorta was excluded from the circulation.

Chimney technique for renal artery preservation: To ensure uninterrupted bilateral renal perfusion, parallel renal artery stents (chimney grafts) were deployed within each renal artery simultaneously with main stent-graft release — running in parallel with the main body to maintain renal inflow despite stent-graft coverage of the native renal ostia.

Completion angiography confirmed complete aneurysm sac exclusion with no endoleak, and patent flow in the coeliac-SMA bypass graft, bilateral renal chimney stents, and iliac limbs.

Post-operative Management and Recovery

ICU Course

• Extubation: Endotracheal tube removed within 4 hours of procedure completion
• Spinal cord protection: Mean arterial pressure maintained above 90 mmHg throughout; lumbar cerebrospinal fluid drain placed pre-operatively and maintained for 48 hours post-operatively to reduce spinal cord ischaemia risk — no neurological deficit detected
• Renal protection: Iso-osmolar contrast agent used intraoperatively; aggressive post-operative hydration; serum creatinine remained within normal range

ERAS Protocol

• Hour 6: Oral fluids commenced
• Day 1: Independent ambulation (facilitated by absence of peritoneal entry and ileus)
• Day 2: Regular diet resumed
• Day 7: Discharged home (conventional open repair typically requires 2–3 weeks hospitalisation)

Follow-up Results

• 1-month CTA: Stent-graft configuration excellent; no endoleak; coeliac-SMA bypass graft patent; aneurysm sac diameter reduced to 6.5 cm (progressive thrombosis)
• 6-month assessment: Patient asymptomatic; weight increased by 3 kg; pulmonary function unchanged from pre-operative baseline; walking normally without limitation
• 1-year CTA: Aneurysm sac stable at 6.0 cm; all visceral bypass grafts and renal chimney stents patent; no secondary intervention required

Expert Commentary — Dr. Shi Zhenyu

1. The Logic of Hybrid Surgery

For Crawford Type II thoracoabdominal aneurysm — the most anatomically demanding subtype — neither pure open nor pure endovascular repair is optimal in the high-risk patient. Hybrid surgery is not a compromise born of limitation. It is a deliberate strategy that deploys each technique where it excels: open surgery for anatomical reconstruction and landing zone creation; endovascular repair for aneurysm exclusion without aortic cross-clamping. The result is durable oncological-grade vascular reconstruction with the physiological footprint of a minimally invasive procedure.

2. Minimally Invasive Means Minimal Physiological Disruption

During my training in Europe and North America, I came to understand that minimally invasive surgery is not defined by incision length — it is defined by the degree of physiological disruption. The retroperitoneal approach eliminates peritoneal entry, prevents post-operative ileus, preserves diaphragmatic function, and reduces fluid requirements. For a patient with FEV1 of 1.2 L, these are not marginal gains — they are the difference between extubation at 4 hours and prolonged ventilator dependence. The approach is chosen for the patient's physiology, not for the surgeon's convenience.

3. Visceral Debranching: The Technical Foundation

The coeliac-SMA bypass is the technical centrepiece of the hybrid procedure. The anastomosis must be tension-free and angulation-free. We routinely use a jump-graft configuration rather than separate bypasses to each vessel — reducing the number of anastomoses and the risk of individual anastomotic stenosis. Intraoperative Doppler confirmation of bypass graft flow before proceeding to the endovascular phase is non-negotiable. If the bypass is not functioning, the endovascular phase cannot proceed safely.

4. The Future: Fully Endovascular Solutions

Hybrid surgery still requires a surgical incision. The next frontier is fully endovascular management of complex thoracoabdominal aneurysms using fenestrated EVAR (FEVAR) and branched EVAR (BEVAR) — custom-manufactured stent-grafts with pre-formed fenestrations or branches aligned to each visceral artery. These technologies are established in Europe and North America and are entering clinical practice in China. When they become widely available, the hybrid approach will evolve. Until then, for high-risk patients in China, hybrid surgery remains the safest and most cost-effective strategy for Crawford Type II disease.

How CMCS Shanghai Coordinated This Case

China Medical Concierge Shanghai (CMCS) supported this patient's care pathway from initial overseas inquiry through 1-year vascular surveillance. Our coordination included:

• Pre-arrival review of CTA imaging and prior operative records from the original abdominal aortic aneurysm repair; specialist referral to Dr. Shi Zhenyu's vascular surgery team at Zhongshan Hospital, Fudan University
• Arrangement of CTA three-dimensional reconstruction and cardiopulmonary risk assessment (pulmonary function testing, echocardiography, coronary evaluation) for complete pre-operative stratification
• Bilingual interpretation during the MDT discussion, including detailed explanation of the three treatment options, hybrid procedure rationale, chimney technique, spinal cord protection strategy, and realistic recovery timeline
• Coordination of pre-operative lumbar cerebrospinal fluid drain placement and anaesthesia planning with the neurological monitoring team
• Surgical admission logistics: hospital registration, hybrid operating suite scheduling (requiring simultaneous surgical and interventional radiology capability), and accommodation support for accompanying family
• On-site medical interpretation throughout the ICU stay and ward recovery, including ERAS protocol guidance, CSF drain management, and early mobilisation support
• Post-discharge coordination of 1-month and 6-month CTA surveillance scheduling, antihypertensive optimisation liaison, and communication with the patient's home cardiologist
• 1-year vascular surveillance coordination: CTA reporting, bypass graft patency assessment, and long-term follow-up planning with Dr. Shi's team

For international patients facing complex aortic disease — particularly those with prior aortic surgery, severe comorbidities, or anatomically challenging aneurysms that have been deemed inoperable or too high-risk elsewhere — the combination of hybrid surgical expertise and advanced endovascular capability at Shanghai's leading vascular centres represents a genuine pathway to treatment that may not be available in their home country. CMCS exists to connect patients with that expertise: ensuring every anatomical option is evaluated, every risk is explained in their language, and every step from pre-operative planning to long-term surveillance is coordinated with precision and care.

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.