⚠️ Teaching Case Note: This case has been de-identified and reconstructed for educational purposes. Clinical details reflect real surgical decision-making and outcomes. Patient identity is fully protected.
6.8 cm Aortic Aneurysm, 8 mm Neck, Three Comorbidities — Repaired Without Opening the Chest
He was 72 years old, with 20 years of poorly controlled hypertension, COPD, a history of coronary stenting, and kidneys already working at half capacity. A routine health check found his aorta had expanded to 6.8 cm — from the lower thoracic segment down into the upper abdomen. He had back pain. His family was told that open surgery carried a mortality risk above 20%. They declined.
Dr. Weiguo Fu's team at Zhongshan Hospital, Fudan University, offered a different answer: a fully minimally invasive hybrid repair — a neck bypass, thoracic stent graft, and chimney stents for the visceral vessels — performed in a single hybrid operating room session, 180 minutes, 150 mL blood loss, no chest incision, discharge on day five.
At one year, the aneurysm had shrunk to 5.2 cm. No endoleak. The patient was walking normally.
The Anatomy: Every Standard Criterion Violated
The CTA with three-dimensional reconstruction defined the problem in full. The aneurysm extended from the lower thoracic aorta to the upper abdominal aorta — Crawford Type II in distribution — with a maximum diameter of 6.8 cm. Three anatomical features made conventional endovascular repair (EVAR) technically prohibited by standard criteria.
First, the proximal neck measured only 8 mm above the renal arteries. Standard EVAR requires a minimum of 15 mm for adequate stent fixation; below that threshold, Type I endoleak — pressurized flow between the stent and the aortic wall — becomes the dominant failure mode. The neck was also conical, with an angulation exceeding 60 degrees, compounding the sealing challenge.
Second, the celiac axis and superior mesenteric artery (SMA) origins were compressed by the aneurysm sac and showed ulcerated plaque — meaning any stent graft covering the visceral segment would risk ischemia to the gut and liver unless those vessels were explicitly reconstructed.
Third, both common iliac arteries were severely tortuous with calcified plaque, making delivery of large-bore sheaths — required for thoracic stent grafts — technically demanding and high-risk for access-site complications.
Laboratory findings added further constraint: creatinine at 135 μmol/L (eGFR 45 mL/min), placing the patient at high risk for contrast-induced nephropathy; elevated BNP indicating limited cardiac reserve. ASA Class III.
The MDT Decision: Hybrid Repair Over Custom Fenestration
The multidisciplinary team considered three options. Open thoracoabdominal repair was declined by the patient and family, and the team concurred — the combination of COPD, cardiac history, and renal impairment placed perioperative mortality above 20% for a Crawford II open repair, with additional risks of paraplegia and respiratory failure. Custom fenestrated stent grafts — devices manufactured with pre-cut holes aligned to the visceral vessels — were technically appropriate but required a 4–6 week fabrication lead time and carried costs that were prohibitive. The patient was symptomatic.
Dr. Fu's team selected a hybrid approach combining three components: a left common carotid to left subclavian artery bypass through a small cervical incision, to extend the proximal landing zone to Zone 2 and allow coverage of the left subclavian origin without causing left arm or vertebral ischemia; thoracic endovascular aortic repair (TEVAR) with a large-diameter thoracic stent graft to exclude the thoracic component; and chimney stent grafting of the celiac axis and SMA — parallel bare-metal stents deployed alongside the main aortic graft to maintain visceral perfusion without fenestration.
Contrast volume was capped at 80 mL with aggressive peri-procedural hydration to protect renal function.
The Operation: Three Procedures, One Session, One Hybrid OR
Stage one — cervical bypass. Through a small incision along the anterior border of the left sternocleidomastoid muscle, the left common carotid and left subclavian arteries were exposed. An 8 mm PTFE bypass graft was anastomosed between them. This step secured cerebral and left upper limb perfusion, allowing the thoracic stent graft to cover the left subclavian origin without ischemic consequence — extending the proximal landing zone from Zone 3 to Zone 2 and providing the 15+ mm of healthy aortic wall needed for secure proximal fixation.
Access preparation. Bilateral groin incisions exposed the common femoral arteries. Pre-close suture technique (Perclose ProGlide) was deployed at both access sites — sutures placed before sheath insertion, allowing percutaneous closure of large-bore arteriotomies at the end of the case and eliminating the need for open femoral repair.
Stage two — endovascular repair under DSA guidance. A pigtail catheter was advanced to the aortic arch for roadmap angiography, precisely marking the renal arteries, celiac axis, and SMA origins in three-dimensional space.
TEVAR stent deployment. A large-diameter thoracic stent graft (Valiant Captivia) was delivered via the right femoral artery. Rapid ventricular pacing reduced cardiac output transiently during deployment, minimizing stent migration from pulsatile flow. The graft was released to cover the left subclavian origin — now safe given the cervical bypass — and extend distally to the visceral segment.
Chimney stent placement. Via the left femoral artery and left brachial artery access, two bare-metal stents were advanced in parallel to the main aortic graft — one into the celiac axis, one into the SMA. These chimney stents were positioned to protrude 10–15 mm above the main graft's proximal edge, creating parallel channels that preserved visceral perfusion despite the main graft covering the visceral aortic segment.
Kissing balloon technique. Simultaneous balloon dilation of both chimney stents and the main aortic graft at their interface compressed the gutter spaces between parallel stents — the primary mechanism of Type III endoleak in chimney configurations. Completion angiography confirmed complete aneurysm exclusion, no endoleak, and unobstructed flow in the celiac axis, SMA, and both renal arteries.
Operative data: Total time 180 minutes. Estimated blood loss 150 mL. Contrast volume 80 mL. No transfusion.
Recovery: ICU for 24 Hours, Home on Day Five
Immediate post-procedural angiography confirmed complete aneurysm sac exclusion with no Type I or Type III endoleak. All target vessels — celiac axis, SMA, bilateral renal arteries — were patent without stenosis.
The patient was monitored in the ICU for 24 hours with continuous renal function surveillance. Creatinine stabilized at 140 μmol/L — a marginal rise from baseline, within the expected range given contrast exposure, and without progression to acute kidney injury. Lower limb perfusion was intact bilaterally. No neurological deficit. No signs of bowel ischemia.
Anticoagulation was transitioned from low-molecular-weight heparin to dual antiplatelet therapy (aspirin + clopidogrel) for long-term chimney stent patency. Systolic blood pressure was maintained strictly below 120 mmHg to reduce mechanical stress on the stent-graft interface. The patient was discharged on postoperative day five.
Follow-Up: Aneurysm Shrinking, Visceral Vessels Patent, No Endoleak
At one month: CTA showed complete thrombosis of the aneurysm sac, well-positioned stent grafts, patent chimney stents, and normal visceral organ perfusion. No endoleak of any type.
At one year: the aneurysm sac had regressed from 6.8 cm to 5.2 cm — a 23% reduction in maximum diameter, confirming durable aneurysm exclusion and sac depressurization. The chimney stents remained fully patent. The patient reported normal walking tolerance and light daily activity — a functional outcome that open thoracoabdominal repair, even if survived, rarely achieves at one year in a 72-year-old with COPD and cardiac disease.
Expert Commentary — Dr. Weiguo Fu
"The anatomical criteria for standard EVAR exist for a reason — they define the conditions under which the device performs as designed. An 8 mm neck, a conical geometry, visceral artery involvement: each of these individually would exclude most patients from conventional endovascular repair. Together, they define a case that most centers would refer for open surgery or decline to treat.
The chimney technique does not eliminate the anatomical constraints — it works around them. By placing parallel stents into the visceral vessels before the main graft is deployed, we reconstruct the visceral circulation in real time, without waiting weeks for a custom device. The kissing balloon step is not optional — it is the mechanism by which we close the gutter between the chimney stent and the main graft wall. If that step is imprecise, the gutter remains, and the gutter is the endoleak.
The cervical bypass is the step that makes the proximal landing zone adequate. Without it, covering the left subclavian origin risks vertebral and left arm ischemia. With it, Zone 2 becomes available — and Zone 2 gives us the neck length we need. It is a small incision. It takes 45 minutes. It is the difference between a case that is anatomically feasible and one that is not.
This patient was 72 years old with four significant comorbidities. He walked out of the hospital on day five. At one year, his aneurysm is smaller than it was at presentation. That is what minimally invasive vascular surgery is for — not to replace open surgery where open surgery is appropriate, but to treat the patients who cannot survive open surgery and would otherwise have no option."
About Dr. Weiguo Fu
Dr. Weiguo Fu is Chief of Vascular Surgery at Zhongshan Hospital, Fudan University, and one of China's foremost experts in endovascular aortic repair. He has pioneered minimally invasive techniques for aortic aneurysm and peripheral arterial disease, and leads one of China's highest-volume centers for complex endovascular procedures. Dr. Fu is widely recognized for his expertise in hybrid aortic repair, chimney and fenestrated EVAR, and the treatment of complex vascular conditions in high-risk and elderly patients.
How CMCS Supported This Patient
China Medical Concierge – Shanghai (CMCS) coordinated the full care pathway: specialist matching and priority access to Dr. Fu's team at Zhongshan Hospital, multidisciplinary team coordination across vascular surgery, interventional radiology, cardiology, and nephrology, Mandarin-English interpretation for all consultations — including the detailed informed consent process for a high-risk hybrid endovascular procedure in a patient with multiple comorbidities — family communication support throughout the admission, and long-term follow-up coordination including CTA surveillance scheduling, antiplatelet therapy monitoring, and blood pressure management planning.
For international patients and expatriates in Shanghai facing complex aortic disease — where the combination of anatomical complexity, surgical risk stratification, and long-term endoleak surveillance determines both survival and quality of life — CMCS provides end-to-end support from initial imaging review to annual follow-up and beyond.
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