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

About Dr. Shi Zhenyu

Dr. Shi Zhenyu is Chief of Vascular Surgery at Zhongshan Hospital, Fudan University — one of China's foremost vascular surgery centres and a national reference institution for complex aortic disease, peripheral artery intervention, and endovascular surgery. He is one of Shanghai's most respected vascular surgeons, recognised for his expertise in endovascular aortic repair (EVAR and TEVAR), peripheral artery disease intervention, and the multidisciplinary management of complex combined aortic and peripheral vascular disease. Dr. Shi's practice is defined by the philosophy that complex vascular disease demands a staged, systematic approach — that the immediate life threat must be addressed first, the functional deficit addressed second, and that the sequence and timing of each intervention must be determined by the patient's physiology, not by surgical convenience. His department at Zhongshan Hospital has established one of China's most comprehensive vascular surgery programmes, integrating advanced CTA-based preoperative planning, intraoperative angiographic guidance, drug-eluting stent technology, and structured long-term surveillance into a unified care pathway for patients with complex multisystem vascular disease.

Case Overview

Mr. David Harrington (pseudonym), a 68-year-old British retired factory worker based in Shanghai, presented with a three-month history of a pulsatile abdominal mass and progressive bilateral calf claudication. CTA confirmed a 6.2 cm infrarenal abdominal aortic aneurysm extending to both common iliac arteries with mural thrombus, and concurrent bilateral iliac, femoral, and popliteal artery stenoses of 50–80% — most severe on the right. A multidisciplinary team led by Dr. Shi Zhenyu recommended staged endovascular treatment: first, endovascular aortic repair (EVAR) to eliminate the rupture risk; second, peripheral artery balloon angioplasty and drug-eluting stent placement to restore lower limb perfusion. At six months, CTA confirmed complete aneurysm exclusion with no endoleak, progressive sac thrombosis, and full bilateral stent patency. The patient's claudication had resolved completely and his quality of life had returned to normal.

Patient Background

• Name / Nationality: Mr. David Harrington (pseudonym) — British; 68-year-old retired factory worker based in Shanghai
• Age / Sex: 68-year-old male
• Chief Complaint: Pulsatile abdominal mass for three months; progressive bilateral calf pain and fatigue on walking for one month
• Claudication pattern: Bilateral calf aching and weakness on walking; relieved by rest within minutes; reproducible on resuming ambulation; progressively worsening over one month
• Cardiovascular risk factors: Hypertension for 10 years, managed with nifedipine sustained-release with adequate blood pressure control; 40-year smoking history, approximately 20 cigarettes per day
• Examination — abdomen: Soft abdomen; pulsatile mass approximately 6 cm in diameter palpable in the periumbilical region slightly left of midline; mild tenderness; systolic bruit on auscultation; no peritoneal signs
• Examination — lower limbs: Bilateral lower limb skin temperature mildly reduced; no oedema; bilateral dorsalis pedis pulses diminished, right more than left; mild bilateral calf muscle atrophy; muscle strength grade 4 bilaterally

Diagnostic Workup

Abdominal Ultrasound

• Abdominal aortic aneurysm: Maximum aortic diameter 6.2 cm; calcified plaques visible in the aneurysm wall; infrarenal location confirmed
• Peripheral vessels: Bilateral femoral and popliteal artery wall thickening with luminal stenosis of approximately 50–60% bilaterally

CT Angiography (CTA)

• Aneurysm morphology: Infrarenal abdominal aortic aneurysm with maximum diameter 6.2 cm; irregular sac morphology; mural thrombus present; aneurysm extending to involve both common iliac arteries; normal proximal neck angle — favourable anatomy for EVAR
• Peripheral arterial disease: Bilateral iliac, femoral, and popliteal artery stenoses at multiple levels; right-sided stenosis 70–80% (haemodynamically significant); left-sided stenosis 50–60%; reduced distal flow bilaterally, right more than left
• Renal arteries: Patent bilaterally; aneurysm neck below renal artery origins — confirming infrarenal anatomy suitable for standard EVAR without fenestrated or branched device

Multidisciplinary Team Discussion and Staged Treatment Strategy

The MDT convened by Dr. Shi Zhenyu included vascular surgery, cardiovascular medicine, and anaesthesiology. The consensus was that both conditions required intervention — the aneurysm urgently, given its 6.2 cm diameter and associated rupture risk, and the peripheral artery disease electively, given its progressive functional impact — but that simultaneous treatment of both in a single session carried unacceptable procedural risk in a 68-year-old patient with a 40-year smoking history and hypertension.

Staged treatment rationale: A 6.2 cm abdominal aortic aneurysm carries an annual rupture risk of approximately 10–20% — the immediate life threat that must be addressed first. Peripheral artery disease causing claudication, while significantly impairing quality of life, does not carry the same acute mortality risk and can be safely deferred until the patient has recovered from EVAR. Attempting to treat both in a single session would extend procedural time, increase contrast load, and increase the risk of access site complications — all unacceptable in this patient's risk profile.

Stage 1: Endovascular aortic repair (EVAR) — to exclude the aneurysm sac from the circulation and eliminate the rupture risk.

Stage 2: Peripheral artery balloon angioplasty and drug-eluting stent placement — to restore bilateral lower limb perfusion and resolve claudication, scheduled one month after EVAR once the patient had recovered.

Operative Procedure

Stage 1 — Endovascular Aortic Repair (EVAR)

Pre-operative preparation: Full pre-operative workup including complete blood count, coagulation profile, liver and renal function, and electrocardiogram. Dual antiplatelet therapy initiated three days before surgery: aspirin enteric-coated 100 mg daily and clopidogrel 75 mg daily. Skin preparation and urinary catheterisation the day before surgery; nil by mouth from six hours before.

Positioning and access: Supine position; general anaesthesia. Bilateral groin preparation and draping. Bilateral common femoral artery puncture; vascular sheaths inserted bilaterally.

Angiography: Pigtail catheter introduced via sheath; aortography performed to confirm aneurysm position, dimensions, and relationship to renal arteries and iliac arteries — confirming infrarenal neck anatomy and bilateral iliac landing zones.

Main body stent-graft deployment: Appropriately sized bifurcated aortic stent-graft system selected based on CTA measurements. Main body introduced via the left femoral access and deployed precisely below the renal artery origins under fluoroscopic guidance. Bilateral iliac limb extensions introduced via right femoral access and deployed into both common iliac arteries with secure overlap and seal.

Completion angiography: Confirmed stent-graft position, no endoleak, bilateral renal artery patency, and bilateral iliac artery flow. Sheaths removed; manual compression haemostasis; pressure dressings applied to both puncture sites.

Post-operative management: Continuous monitoring of vital signs. Dual antiplatelet therapy continued. Antibiotic prophylaxis and analgesia. Early mobilisation encouraged — patient ambulatory at 24 hours. Duplex ultrasound at day 3 confirmed stent position and flow; no complications; discharged.

Dr. Shi's procedural note: The key to EVAR is the preoperative CTA. Every measurement matters — the neck diameter, the neck length, the neck angle, the iliac diameters, the landing zone lengths. If you select the wrong size, you get an endoleak. If you deploy too high, you cover a renal artery. The CTA in this patient showed a favourable infrarenal neck — adequate length, normal angle, no significant thrombus in the neck. That is the ideal EVAR anatomy. The procedure itself is straightforward when the anatomy is right and the planning is thorough. The angiography confirms what the CTA predicted. We deploy, we check, we confirm no leak. This patient was walking the next morning.

Stage 2 — Peripheral Artery Balloon Angioplasty and Drug-Eluting Stent Placement

Timing: One month after EVAR; patient recovered well; claudication symptoms unchanged — confirming that the peripheral artery disease was the independent cause of the claudication and had not been incidentally improved by the EVAR procedure. Repeat duplex ultrasound confirmed bilateral iliac, femoral, and popliteal stenoses unchanged from baseline.

Positioning and access: Supine position; local anaesthesia. Right common femoral artery puncture; vascular sheath inserted.

Right-sided intervention: Guidewire advanced under fluoroscopic guidance to the right iliac artery stenosis. Catheter positioned at the stenosis; angiography confirmed stenosis location and severity. Appropriately sized balloon catheter selected; balloon angioplasty performed at the stenosis site — inflation pressure titrated to stenosis severity and balloon specifications. Post-dilation angiography showed significant improvement but residual stenosis present. Drug-eluting stent selected and deployed precisely at the stenosis site. Completion angiography confirmed stent position, residual stenosis less than 20%, and restored flow. Same technique applied sequentially to right femoral and popliteal stenoses.

Left-sided intervention: Same technique applied to left iliac, femoral, and popliteal stenoses via the same right femoral access with contralateral catheterisation. All stenoses treated with balloon angioplasty and drug-eluting stent placement. Completion angiography confirmed bilateral stent patency and restored distal flow.

Post-operative management: Continuous monitoring of vital signs and lower limb perfusion — dorsalis pedis pulses, skin temperature, and colour assessed hourly. Dual antiplatelet therapy continued for a minimum of six months. Anticoagulation and vasodilator therapy as indicated. Lower limb rehabilitation programme initiated — structured walking training. Discharged at day 3; outpatient follow-up scheduled.

Dr. Shi's procedural note: Drug-eluting stents are the standard of care for peripheral artery disease in the iliac and femoral segments because they release antiproliferative agents directly into the vessel wall — suppressing the neointimal hyperplasia that causes in-stent restenosis with bare metal stents. The restenosis rate with drug-eluting stents at one year is approximately 10–15% compared to 30–40% with bare metal stents in the femoral segment. For a patient who is 68 years old and will need these stents to remain patent for decades, that difference is clinically decisive. The antiplatelet therapy is equally important — the stent is a foreign body in the vessel, and without dual antiplatelet therapy for at least six months, the risk of acute stent thrombosis is unacceptably high. We do not compromise on the antiplatelet duration.

Post-operative Management and Outcomes

Aneurysm Surveillance — EVAR Follow-up

• 1 month post-EVAR: Duplex ultrasound confirmed stent-graft position, no endoleak, bilateral renal and iliac artery patency
• 3 months post-EVAR: CTA confirmed complete aneurysm exclusion, no endoleak, progressive sac thrombosis — aneurysm sac no longer perfused
• 6 months post-EVAR: CTA confirmed stable stent-graft position, no endoleak, no sac enlargement — aneurysm successfully excluded from the circulation

Peripheral Artery Disease — Outcomes

• Immediate post-procedure: Bilateral dorsalis pedis pulses restored to normal strength; lower limb skin temperature normalised bilaterally
• 1 month post-peripheral intervention: Duplex ultrasound confirmed bilateral iliac, femoral, and popliteal stent patency; no in-stent stenosis or thrombosis; claudication symptoms significantly improved — walking distance markedly extended
• 6 months post-peripheral intervention: Claudication symptoms completely resolved; patient able to walk without limitation; quality of life returned to normal; duplex ultrasound confirmed continued bilateral stent patency

Expert Commentary — Dr. Shi Zhenyu

1. The 5.5 cm Threshold and Why 6.2 cm Demands Immediate Action

The decision to intervene on an abdominal aortic aneurysm is governed by the relationship between rupture risk and procedural risk. Below 5.5 cm in diameter, the annual rupture risk is low enough — approximately 1–2% per year — that surveillance is safer than intervention for most patients. Above 5.5 cm, the annual rupture risk rises steeply: approximately 10% per year at 6 cm, 20% per year at 7 cm, and higher still above that. At 6.2 cm, this patient's annual rupture risk was approximately 10–15% — meaning that without intervention, there was a one-in-seven to one-in-ten chance of rupture within the next twelve months. Ruptured abdominal aortic aneurysm carries a mortality rate of 80–90% including pre-hospital deaths. Elective EVAR in an anatomically favourable patient carries a procedural mortality of less than 1% at experienced centres. The risk-benefit calculation at 6.2 cm is unambiguous: intervention is mandatory, and it is urgent.

2. EVAR Anatomy: Why Preoperative CTA Determines Operative Success

EVAR is not a procedure that can be improvised intraoperatively. The stent-graft must seal against the aortic wall in the proximal neck — the segment of normal aorta between the renal arteries and the aneurysm — and in the distal iliac landing zones. If the neck is too short, too angulated, or contains significant thrombus, the seal will be inadequate and an endoleak will result. An endoleak means the aneurysm sac remains pressurised and continues to carry rupture risk — the EVAR has failed its primary purpose. In this patient, the CTA demonstrated a favourable infrarenal neck: adequate length, normal angle, and minimal thrombus — the anatomical prerequisites for a durable EVAR seal. Centres with high EVAR volumes invest heavily in preoperative CTA analysis and three-dimensional reconstruction precisely because the operative outcome is determined before the patient enters the operating room. The surgery executes the plan; the plan is made from the imaging.

3. Drug-Eluting Stents in Peripheral Artery Disease: Suppressing the Restenosis Response

The fundamental challenge of peripheral artery stenting is in-stent restenosis — the biological response of the vessel wall to the mechanical injury of balloon angioplasty and stent deployment. Vascular smooth muscle cells migrate into the stent lumen and proliferate, progressively narrowing the treated segment over months to years. In the femoral and popliteal segments, where the vessel is subject to repetitive flexion and compression with every step, this restenosis process is particularly aggressive — bare metal stent restenosis rates of 30–40% at one year are well documented. Drug-eluting stents address this by incorporating an antiproliferative agent — typically paclitaxel or sirolimus — into a polymer coating on the stent surface. The drug is released locally into the vessel wall over weeks to months, suppressing smooth muscle cell proliferation at the site of injury without systemic immunosuppression. The result is a restenosis rate of 10–15% at one year — a clinically meaningful reduction that translates directly into longer stent patency, fewer reintervention procedures, and better long-term functional outcomes for the patient.

4. Multidisciplinary Vascular Care: Sequencing Interventions to Protect the Patient

Complex vascular disease — the simultaneous presence of aortic aneurysm and peripheral artery disease — is not uncommon in the population of patients who present to vascular surgery. Both conditions share the same underlying pathology: atherosclerosis driven by smoking, hypertension, dyslipidaemia, and age. The clinical challenge is not identifying the conditions — imaging makes that straightforward — but sequencing the interventions correctly. Treating both conditions simultaneously in a single session is technically possible but physiologically hazardous: extended procedural time, increased contrast nephropathy risk, increased access site complication risk, and increased haemodynamic stress in a patient whose cardiovascular reserve is already compromised by decades of smoking and hypertension. The staged approach — EVAR first, peripheral intervention second — eliminates the immediate life threat, allows the patient to recover physiological reserve, and then addresses the functional deficit from a position of stability. This sequencing logic is the product of multidisciplinary discussion: vascular surgery defines the operative strategy, cardiovascular medicine optimises the medical management, and anaesthesiology assesses the procedural risk at each stage. No single specialty has the complete picture. The MDT has it.

How CMCS Shanghai Coordinated This Case

CMCS Shanghai supported Mr. Harrington and his family from initial presentation through six-month follow-up, including: urgent coordination of vascular surgery consultation with Dr. Shi Zhenyu at Zhongshan Hospital, Fudan University with priority appointment scheduling; bilingual review of all prior imaging and cardiovascular records with clinical summary for the MDT; coordination of abdominal ultrasound and CTA with bilingual radiology report translation and anatomical interpretation; bilingual interpretation throughout all MDT discussions involving vascular surgery, cardiovascular medicine, and anaesthesiology; pre-operative preparation coordination including antiplatelet therapy initiation, pre-admission workup scheduling, and bilingual consent support for EVAR; real-time updates to the patient's wife and his cardiologist in London during both procedural stages; post-EVAR discharge coordination including duplex ultrasound scheduling, antiplatelet prescription management, and bilingual discharge instruction; one-month reassessment coordination including repeat duplex ultrasound, symptom review, and MDT confirmation of readiness for Stage 2 intervention; peripheral artery intervention coordination including pre-operative workup, bilingual consent for balloon angioplasty and drug-eluting stent placement, and post-procedure monitoring support; lower limb rehabilitation programme coordination with bilingual physiotherapy instruction; six-month surveillance coordination including CTA and duplex ultrasound with results communicated to the patient's cardiologist and GP in the United Kingdom; and establishment of a long-term vascular surveillance protocol with annual imaging scheduling and direct liaison between Dr. Shi's team and the patient's overseas physicians.

For international patients with abdominal aortic aneurysm, peripheral artery disease, or complex combined vascular conditions requiring advanced endovascular intervention in Shanghai, Dr. Shi Zhenyu's team at Zhongshan Hospital, Fudan University represents vascular surgery expertise at the international frontier — combining precise CTA-based preoperative planning, EVAR, drug-eluting peripheral stenting, and multidisciplinary staged treatment to achieve durable vascular repair and functional restoration in patients with complex multisystem disease. CMCS ensures that expertise is accessible: in the patient's language, with overseas physicians informed at every step, from the first vascular assessment through long-term surveillance.

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.