Percutek Therapeutics
Developer of Minimally Invasive Cardiovascular Treatment Devices
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Today's sharing is byProfessor Lang Dehai's Team from Ningbo Second HospitalTEVAR Surgery for In-situ Reconstruction of the Aortic Arch Branches Using Only a 0.035" Soft-tip Guide Wire. The patient had Standford Type B aortic dissection, with retrograde dissection involving the root of the left subclavian artery (LSA), resulting in an insufficient proximal anchoring zone that needed to be extended proximally, and LSA reconstruction was required. Due to the short distance between the left common carotid artery (LCCA) and LSA, choosing the best surgical plan became crucial for treatment. This not only required effective closure of the lesion but also efficient reconstruction of the LSA while ensuring the patient's long-term prognosis.
Professor Lang Dehai's team, with rich clinical experience, successfully sealed the thoracic aortic lesion using the Percutek Therapeutics thoracic aortic stent graft. Meanwhile, the team innovatively employed a 0.035" mucus wire soft head to efficiently complete the reconstruction of the LSA through in-situ fenestration technology. The patient recovered well after the surgery, fully demonstrating the superiority of this surgical plan and the team's exceptional skills.
Gender:Male
Age:57 years old
Chief Complaint:Chest and back distension pain for 8 hours.
Physical Examination:Clear consciousness, soft spirit, pulse 88 beats/min, respiration 15 breaths/min, blood pressure 160/89 mmHg, soft abdomen, no tenderness or rebound tenderness, palpable pulsations of bilateral femoral arteries, popliteal arteries, posterior tibial arteries, and dorsalis pedis arteries.
Past Medical History:Generally in good health.
Diagnosis:Aortic Dissection (Standford Type B), Celiac Artery Dissection Aneurysm, Hypertension.
Detailed Explanation of Aortic CTA:Stanford Type B Aortic Dissection, intimal tear located in the descending thoracic aorta with a diameter of 7mm, false lumen anterior to the true lumen; minimal effusion around the aortic wall with evidence of intramural hematoma, thrombus, and ulcerative projections; proximal hematoma has extended to the root of the LSA, the distance between LSA and LCCA is only 8.5mm, left vertebral artery dominance; good blood flow visualization in the three branches above the aortic arch; the celiac trunk, superior mesenteric artery, and right renal artery originate from the false lumen, while the left renal artery originates from the true lumen.
Preoperative Three-dimensional Reconstruction
Preoperative CTA Cross-Section
Aortic Lesion Condition
Stanford Type B Aortic Dissection, with a large tear located in the descending aorta, a small true lumen, and a large false lumen. This condition requires high stability, passability, and flexibility of the delivery system.
The intramural hematoma of the aortic wall has involved the root of the LSA, with a significant lack of proximal anchoring zone. Moreover, the distance between the LCCA and the LSA is less than 10mm, necessitating the extension of the proximal anchoring zone and the reconstruction of the LSA.
LSA forms an acute angle with the aortic arch, and its ostium is large, presenting a "volcano mouth" shape, which poses challenges for in-situ fenestration angle control during surgery. Additionally, common covered stents on the market are relatively difficult to fenestrate.
There is a hematoma lesion at the root of the LSA, and gentle manipulation should be noted.
Surgical Plan Strategy
Thoracic Endovascular Aortic Repair with Direct Coverage of the Left Subclavian Artery: The procedure is simple and effective, but covering the left subclavian artery may lead to clinical manifestations of posterior circulation ischemia and upper limb ischemia in patients.
Endovascular Repair of Thoracic Aortic Stent Graft + Left Subclavian Artery Chimney Technique: The surgical procedure is relatively simple, but the left subclavian artery is tortuous and narrow, with a higher risk of endoleak and occlusion, and the mid- to long-term outcomes are suboptimal.
Endovascular Repair of Thoracic Aortic Stent Grafts with In Vitro Fenestration: Effective sealing of lesions, preservation of original hemodynamic characteristics, but complex operation. Preoperative modification of the stent is required based on measurement results, which is time-consuming; precise alignment and super-selective window positioning are required during the procedure, posing higher risks.
Endovascular Repair of Thoracic Aortic Stent Graft + In-situ Fenestration: The lesion can be effectively sealed without the need for preoperative stent modification. However, traditional in-situ fenestration of aortic stent grafts requires advanced interventional instruments, such as in-situ fenestration needles, lasers, and biopsy needles for special membrane-piercing procedures.
The Hua Mai thoracic aortic stent graft can perform in-situ fenestration using a 0.035" soft-tip mudskipper guidewire. Considering the mid-to-long-term treatment outcomes and the simplicity of intraoperative manipulation, after comprehensive evaluation, Professor Lang Dehai's team chose Hua Mai • Tianyi.®Endovascular repair of the thoracic aorta with a covered stent graft and reconstruction of the left subclavian artery using in-situ fenestration technology.
Treatment Plan
Proposed total intravenous anesthesia for thoracic aortic dissection endovascular repair with stent graft + in-situ fenestration of the left subclavian artery (using a 0.035" system malleable guidewire with soft tip for membrane puncture).
01. Under general anesthesia, a suture device was pre-embedded through puncture of the right femoral artery, with an 11F short sheath pre-placed. A gold marker catheter was introduced, and angiography of the abdominal aorta showed clear imaging of the true lumen of the left renal artery, while the false lumen of other visceral vessels was also visible.
Abdominal Aortic Angiography
02. Puncture along the left brachial artery and introduce a marker catheter into the ascending aorta for angiography. The left vertebral artery dominance is obvious, and the distance between LSA and LCCA is less than 10mm.
Anteroposterior Angiography of Thoracic Aorta
Thoracic Aorta LAO Angiography
03. Controlled hypotension to around 90/55 mmHg, introduced a super-stiff guidewire and the Percutek Therapeutics thoracic main stent PTBS3430180 via the right femoral artery approach. During the operation, 1-2 segments were slowly released along the posterior edge of the LCCA. After confirming accurate positioning with another angiography, the main stent was further released. Angiography showed that the covered stent did not cover the LCCA but covered the LSA.
Release of Thoracic Stent
Contrast imaging showed accurate positioning and good morphology of the covered stent.
04. A 5F Ver catheter was introduced along the left brachial artery, with its tip positioned vertically against the main stent graft. A 0.035" long mudskipper guidewire was then introduced to assist the catheter in successfully puncturing the membrane and entering the aorta.
The soft tip of the loach guidewire successfully broke through the membrane.
05. A 0.035" long mudy guide wire was further advanced into the descending aortic segment, and a snare was introduced via the right femoral artery to capture the mudy guide wire, establishing the guidewire path. The perforation site was then sequentially dilated using 4*40mm, 6*40mm, and 8*40mm Amanda balloons. During the procedure, a distinct compression notch was observed.
Establish a guidewire path from the left brachial artery to the right femoral artery
4*40mm Balloon Dilation Window Opening
6*40mm Balloon Dilation Window
8*40mm Balloon Dilatation Window
06. An 8F long sheath was introduced along the right femoral artery, and an 8*50mm Viabahn covered stent was placed at the fenestration site. The distal end avoided the left vertebral artery, and the proximal end extended 1cm beyond the covered stent before complete deployment.
Right Femoral Artery Introduction of Viabahn
Viabahn exceeds the covered stent by 1 cm
Release Branch Stent
Balloon-expandable branch stent
07.The final full aortography showed that the LSA fenestrated stent was well reconstructed, the proximal main stent was positioned and visualized well, and the visualization of the right renal artery, celiac artery, and superior mesenteric artery of the abdominal aorta significantly improved compared to before stent implantation.
Postoperative Thoracic Aortography
Postoperative Abdominal Aortic Angiography
08.Withdraw all guidewires, catheters, and sheaths, tighten the pre-placed sutures, and apply pressure dressing to each puncture site. Procedure completed. No related adverse complications post-operation.
Reexamination before discharge compared with preoperative
Preoperative/Postoperative 3D Reconstruction Comparison
Preoperative/Postoperative CTA Axial Comparison
One week after the surgery, a follow-up aortic CTA showed good remodeling of the thoracic aorta and normal morphology of the fenestrated stent. The distal visceral zone showed good contrast.
Summary and Insights
This case sharing involves a patient with Type B aortic dissection, where the false lumen partially affects the root of the LSA. The proximal anchoring zone is significantly insufficient, necessitating the expansion of the proximal anchoring zone and reconstruction of the LSA. Additionally, the patient requested minimal skin incisions on the upper limbs prior to the surgery.
Professor Lang Dehai's team prioritized the use of Percutek Therapeutics' thoracic aortic stent in this case. The left brachial artery was only punctured, and a 0.035" long mackerel guidewire was introduced along with a Ver catheter to easily complete the fenestration operation. A traction guidewire was used to introduce the LSA fenestrated stent via the femoral artery approach, completing the reconstruction of the LSA and avoiding the conventional fenestration procedure involving left brachial artery incision.Percutek Therapeutics' Thoracic Aortic Stent Graft Demonstrates Precise Proximal Positioning Capability. The Fenestration Area Features a Coating Design That Combines Easy Penetrability and Expandability. With the 0.035" Soft-Tip Mudskipper Guidewire, Membrane Puncture Can Be Completed Rapidly. The Balloon Dilation Process Is Simple, Safe, and Reliable. Post-Implantation, the Stent Exhibits an Ideal Shape, with Significant Lesion Sealing and No Endoleaks. The Treatment Outcome Is Definitive, and the Patient’s Prognosis Is Favorable.
Expert Introduction
Professor Lang Dehai
Academic Positions:Currently serving as a member of the Vascular Surgery Branch of the Chinese Medical Doctor Association, a member of the first National Committee of the Vascular Surgery Specialty Committee of the National Cardiovascular Disease Expert Committee, the Deputy Chairman of the Vascular Surgery Branch of the Zhejiang Medical Association, the Vice President of the Vascular Surgery Branch of the Zhejiang Medical Doctor Association, the Chairman of the Peripheral Vascular Specialty Committee of the Zhejiang Integrated Traditional and Western Medicine Association, and the Chairman of the Vascular Surgery Branch of the Ningbo Medical Association.
Expert Profile:Currently serving as the Director of the Vascular Surgery Department and Chief Physician at Ningbo Second Hospital, as well as a mentor for master's degree candidates. Over the years, he has been engaged in clinical work in vascular surgery and has developed significant expertise in the minimally invasive endovascular treatment of thoracic aortic dissection aneurysms and abdominal aortic aneurysms. He was one of the earlier practitioners in the province to perform surgeries and interventional treatments for lower limb arteriosclerosis obliterans, with success rates and long-term patency rates leading within the province. Additionally, he started performing carotid artery stenting and endarterectomy to prevent cerebral infarction caused by carotid artery stenosis relatively early on. He has extensive clinical experience in the surgical and interventional treatment of renal artery stenosis, subclavian artery stenosis, arterial aneurysms in the limbs, visceral artery aneurysms, varicose veins in the lower limbs causing swelling and ulcers, and deep vein thrombosis in the lower limbs.
Hu Songjie, Chief Physician
Academic Positions:Youth Committee Member of the China Diabetic Foot Alliance, Committee Member of the Vascular Surgery Branch of the Zhejiang Province Physician Association, Committee Member of the Vascular Surgery Branch of the Zhejiang Integrated Traditional Chinese and Western Medicine Association, Deputy Chairman of the Youth Committee of the Vascular Surgery Branch of the Zhejiang Medical Association, Committee Member and Secretary of the Vascular Surgery Branch of the Ningbo Medical Association.
Expert Profile:With nearly 20 years of experience in vascular surgery, proficient in the conventional diagnosis and treatment of various vascular diseases as well as minimally invasive interventional techniques. Skilled in the diagnosis and treatment of lower extremity arterial occlusive disease, deep vein thrombosis, varicose veins, carotid artery stenosis, visceral artery diseases, thoracoabdominal aortic aneurysms, and aortic dissection, with extensive clinical experience in the surgical treatment of carotid artery stenosis. Completes over 1,000 surgical procedures annually and sees nearly 1,800 outpatient cases each year. Participates in four provincial and municipal research projects and has published more than 10 papers domestically and internationally. Responsible for teaching undergraduate students at Ningbo University School of Medicine.
Dr. Xu Chunbo, Attending Physician
Expert Profile:Attending Physician, Master's Degree, Specializes in the Diagnosis and Treatment of Peripheral Vascular Diseases, Including Lower Limb Arteriosclerosis Obliterans, Carotid Artery Stenosis, Thoracic and Abdominal Aortic Aneurysms, Varicose Veins of the Lower Limbs, and Deep Vein Thrombosis of the Lower Limbs. Completed Advanced Training at Zhongshan Hospital Affiliated with Fudan University, and Published One Article as the First Author in a Chinese Core Journal.
Dr. Yu Zuanbiao, Attending Physician
Academic Positions：Currently serving as the Deputy Chairman and Secretary of the Youth Committee of the Peripheral Vascular Disease Specialty Committee of the Zhejiang Province Association of Integrated Traditional Chinese and Western Medicine.
Expert Profile:Currently a key talent in health technology in Ningbo City, leading and participating in 6 provincial and municipal research projects, publishing 20 papers as the first author, including 6 SCI-indexed articles, and obtaining 10 national patents. Completed advanced training in vascular surgery at the General Hospital of the People’s Liberation Army (301 Hospital). Specializes in the diagnosis and treatment of peripheral vascular diseases such as varicose veins of the lower extremities, deep vein thrombosis, iliac vein compression syndrome, atherosclerotic occlusion of the lower extremities, thoracic and abdominal aortic aneurysms, and arterial dissections. Experienced in minimally invasive interventional and open surgical treatments for conditions like atherosclerotic occlusion of the lower extremities and deep vein thrombosis of the lower extremities, as well as hybrid surgical techniques. Proficient in minimally invasive interventional treatment of aortic diseases and has strong clinical experience in the management of acute and critical cases of vascular diseases.
Department Introduction
Vascular Surgery Department, Ningbo Second Hospital
The Department of Vascular Surgery at Ningbo Second Hospital was established in the early 2000s and became an independent department in 2011, making it the earliest specialized vascular surgery department in the Ningbo region. In recent years, with strong support from the hospital and under the leadership of Director Dehai Lang, the department has grown significantly, with its technical capabilities improving rapidly.
The department currently has 70 beds, 22 specialists, including 3 chief physicians, and 21 with a master's degree or higher. It has become one of the largest vascular surgery specialty departments in the province.
In 2024 alone, the department completed over 4,000 surgical procedures, including more than 1,500 interventional surgeries. These comprised over 200 cases of thoracic aortic dissection and thoracoabdominal aortoiliac aneurysms, over 400 cases of lower extremity arterial occlusive disease, and over 100 cases of carotid artery stenosis treated with endarterectomy and stent placement. Additionally, the department provided various consultation and technical support for vascular surgery diseases to hospitals across the city.
The vascular surgery department was the first in the city to routinely perform carotid endarterectomy, with nearly 90 surgeries performed annually. At the same time, it routinely carries out fenestrated surgeries for aortic dissection and thoracoabdominal aortic aneurysms, including extracorporeal pre-fenestration and in-situ fenestration of the left common carotid artery, left subclavian artery, and renal arteries, as well as double fenestrations, all achieving good results and holding a leading position domestically in China and at the forefront within the city.
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