Percutek Therapeutics
Developer of Minimally Invasive Cardiovascular Treatment Devices
Today's sharing is byProfessor Zheng Cao's Team from Huanggang Central HospitalTwo Highly Challenging TEVAR Surgery Cases Completed. These two patients with Stanford Type B aortic dissection presented complex conditions: retrograde dissection involving the root of the left subclavian artery (LSA), resulting in a significantly insufficient proximal anchoring zone; the LSA originated from the posterior wall of the aortic arch, with a large, crater-like ostium; additionally, there was a large proximal entry tear, severe compression of the true lumen, a large false lumen, and significant tortuosity with a winding course of the descending aorta.
In response to these challenges, Professor Zheng Cao's team innovatively adopted the Percutek Therapeutics Thoracic Aortic Stent Graft System, which allows for effortless fenestration using only a V-18 guidewire, efficiently completing the in-situ reconstruction of the LSA. This solution precisely overcame technical difficulties such as controlling the angle of the in-situ fenestration and establishing access through tortuous vessels, ensuring complete closure of the lesion while effectively reconstructing LSA blood supply. Postoperatively, the patient recovered well with significant lesion closure, fully demonstrating the technical advantages of this procedure and the team’s exceptional skills.
Gender:Male
Age:54 years old
Chief Complaint:Intermittent chest pain for more than half a year, worsened in the past 3 days.
History of Present Illness:Intermittent migratory retrosternal pain without obvious cause appeared half a year ago, mainly characterized by distending pain, lasting from several minutes to more than ten minutes, accompanied by palpitations and chest tightness. Three days ago, severe chest pain occurred, which was relieved after rest, and the patient came to our hospital for further diagnosis and treatment.
Past Medical History:Previous smoking history, with a history of hypertension, Grade 3 hypertension (very high risk), without regular medication treatment.
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Preoperative Three-dimensional Reconstruction
Preoperative CTA Cross-Section
Condition of the Aortic Arch
Stanford Type B Aortic Dissection, with the proximal end already involving the root of the LSA, and a significantly insufficient proximal anchoring zone. The distance between the LCCA and LSA is only 8.7mm, requiring extension of the proximal anchoring zone and reconstruction of the LSA.
The lesion range of aortic dissection is large, with a small true lumen and a large false lumen. High demands are placed on the sealing, compliance, and adhesion of thoracic aortic stent grafts, as well as the stability, trackability, and flexibility of the delivery system.
LSA originates from the posterior wall of the aortic arch, forming an acute angle with the aortic arch. Its ostium is large and presents a "volcano mouth" shape, which poses challenges for in-situ fenestration angle control during surgery. Additionally, common covered stents on the market are more difficult to fenestrate.
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 endoleaks and occlusion, and the mid- to long-term outcomes are suboptimal.
Endovascular Repair of Thoracic Aortic Stent Grafts with In Vitro Fenestration: Excellent sealing of lesions, preserving original hemodynamic characteristics, but the procedure is complex. Preoperative modification of the stent according to measurement results is required, which is time-consuming; precise alignment and ultra-selective fenestration during the operation are necessary, posing higher risks.
Endovascular Repair of Thoracic Aortic Stent Graft + In-situ Fenestration: The effect of lesion sealing is good, and there is no need to modify the stent before surgery. However, the in-situ fenestration of traditional aortic stent grafts has higher requirements for interventional instruments, requiring special membrane-piercing instruments such as in-situ fenestration needles, lasers, and biopsy needles.
The Hua Mai thoracic aortic stent graft can be fenestrated in situ using the soft tip of a CTO guidewire. Considering the mid- to long-term treatment outcomes and the simplicity of intraoperative manipulation, after comprehensive evaluation, Professor Zheng Cao's team chose Hua Mai • Tian Yi.®Endovascular repair of the thoracic aorta with a covered stent graft and reconstruction of the left subclavian artery using the in-situ fenestration technique.
01. The patient was placed in the supine position under general anesthesia. After routine disinfection and draping, the right femoral artery was punctured using the Seldinger technique. An 8F sheath was inserted, with two pre-installed suturing devices, later replaced by a 14F sheath. The left brachial artery was punctured, and an 8F sheath and steerable sheath were inserted; a pigtail catheter was positioned in the ascending aorta as backup. A gold marker pigtail catheter was advanced through the right femoral artery, and angiography was performed segment by segment to confirm its placement within the true lumen. A dissection extending from distal to the LSA to the left common iliac artery was observed, with the primary tear located at the root of the LSA.
Abdominal Aortic Angiography
Aortic Arch Angiography
Ascending Aorta Angiography
02. A Percutek Therapeutics PTBS3632180 thoracic aortic stent graft was implanted in the right femoral artery, with its proximal end located at the posterior edge of the LCCA, covering the LSA. After precise positioning, the blood pressure was controlled during deployment.
Implantation of Percutek Thoracic Stent
Confirm position with contrast after three releases
Rapid Release Main Stent and Proximal Bare Stent
Contrast imaging shows the stent in good shape and accurately positioned.
03. After introducing the Ver single-bend catheter and support catheter into the left brachial artery, the V-18 guidewire was exchanged. The adjustable bend sheath and Ver catheter were adjusted under multi-angle fluoroscopy to correctly face the stent graft at the aortic arch. The V-18 guidewire was then used in conjunction with the catheter to successfully puncture the membrane.
LSA Angiography
Multi-angle adjustable sheath and catheter tip vertical stent graft
Guidewire successfully breaks through the membrane
Multi-angle fluoroscopy confirms successful membrane rupture
04. Sequentially use 2*20mm, 4*60mm, 6*40mm, 8*60mm, and 10*40mm PTA balloon catheters to expand the fenestration.
2*20mm Balloon Dilation Window
4*60mm Balloon Dilation Window
6*40mm Balloon Expandable Window
8*60mm Balloon Dilation Window
05. A 9*58mm balloon-expandable vascular covered stent was implanted in the proximal LSA, followed by post-dilation of the subclavian stent using a 12*40mm balloon.
Placement of Branch Stent
Release Branch Stent
Angiography confirmed branch stent morphology
Balloon-Expandable Branch Stent
06. Contrast imaging showed that the main stent and the left subclavian artery branch stent were in good position. No opacification of the false lumen of the dissection was observed, with no significant endoleak or other abnormalities. Blood flow in the thoracic aorta, abdominal aorta, and supra-aortic branches remained unobstructed.
Postoperative Thoracic Aortography
Postoperative Abdominal Aortic Angiography
07. Withdraw all guidewires, catheters, and sheaths. Apply pressure dressing to each puncture site. Procedure completed.
Comparison of Follow-up Examination Before Discharge with Preoperative Status
Preoperative/Postoperative 3D Reconstruction Comparison
Preoperative/Postoperative CTA Axial Comparison
Postoperative review showed good recovery, with smooth blood flow in all branches, no signs of cerebral infarction or cerebral ischemia, complete exclusion of aortic dissection, no endoleak, and good position and morphology of all stents.
Gender:Male
Age:43 years old
Chief Complaint:Black stool for 2 days accompanied by chest tightness.
History of Present Illness:Black stool appeared 2 days ago without obvious cause, accompanied by mild chest tightness, lasting from a few minutes to more than ten minutes. CTA examination at another hospital suggested aortic dissection, and the patient was transferred to our department for emergency treatment.
Past Medical History:History of diabetes, hypertension, and hyperlipidemia for many years, well-controlled with oral medications.
Preoperative Three-dimensional Reconstruction
Preoperative CTA Cross-Section
Condition of the aortic arch lesion
Stanford Type B Aortic Dissection: The proximal retrograde tear has extended to the root of the LSA, with a significantly insufficient proximal anchoring zone. The distance between the LCCA and LSA is only 13mm, requiring proximal extension of the anchoring zone and reconstruction of the LSA.
LSA originates from the posterior wall of the aortic arch, with a large opening that presents challenges for in-situ fenestration angle control during surgery. Additionally, common covered stents on the market are more difficult to fenestrate.
The lesion range of aortic dissection is extensive, with a small true lumen and a large false lumen. Additionally, the descending aorta has a tortuous course, making high demands on the trackability and flexibility of the stent delivery system during endovascular exclusion procedures. The stent itself must also possess excellent sealing, conformability, apposition, and minimal elastic recoil.
Severe thrombosis at the root of the LSA should be handled with gentle care.
01. The patient was placed in the supine position, with routine disinfection and draping. After general anesthesia, the Seldinger technique was used to puncture the right femoral artery and left brachial artery respectively, and an 8F sheath was inserted. Two suturing devices were pre-embedded in the right femoral artery, which was then replaced with a 14F sheath. A steerable sheath and a pigtail catheter were inserted into the left brachial artery for standby use in the ascending aorta. A gold marker pigtail catheter was advanced through the right femoral artery, and angiography was performed segment by segment to confirm its location in the true lumen. A dissection formed distal to the LSA, with the proximal tear located distal to the LSA. A Ver single-curve catheter was introduced via the left femoral artery, and segmental angiography confirmed its location in the false lumen.
Descending Aorta Angiography
Thoracic Aorta False Lumen Contrast
Ascending Aortography
LSA Angiography
02. The Percutek Therapeutics PTBS3228180 thoracic aortic stent was introduced via the right femoral artery, positioned at the posterior edge of the LCCA, covering the LSA. After precise positioning, the stent was deployed under controlled blood pressure.
Implantation of Percutek Therapeutics Thoracic Stent
Confirmation after release
03. The V-18 guidewire was exchanged through the left brachial artery, and the steerable sheath and Ver catheter were adjusted so that the tip was positioned directly at the stent graft in the aortic arch. The V-18 guidewire was used with the catheter to successfully puncture the membrane. Multi-angle fluoroscopy confirmed successful puncture, followed by sequential dilation of the fenestration using 2*20mm, 4*60mm, and 8*60mm PTA balloons. The stent graft was accessed using the balloon-with-sheath technique.
Adjust the deflectable sheath, Ver catheter head faces the covered stent.
2*20mm Balloon Dilation Window
4*60mm Balloon Dilation Window
8*60mm Balloon Dilation Window
04. Through the balloon-sheath technique via the aortic fenestration site, a 10*58mm balloon-expandable covered stent was inserted proximally into the LSA through the left brachial artery and deployed using balloon dilation.
Balloon with sheath enters the fenestration window
Balloon-Expandable Branch Stent
05. Postoperative angiography showed smooth blood flow in the branches above the aortic arch, with the main stent and branch stents in good position. No contrast enhancement was observed in the thoracic aortic dissection, no significant endoleak, and blood flow in the abdominal aorta and its branches remained unobstructed.
Postoperative Angiography
06. Withdraw all guidewires, catheters, and sheaths. Apply pressure dressing to each puncture site. Procedure completed.
Comparison of Follow-up Examination Before Discharge with Preoperative Status
Preoperative/Postoperative 3D Reconstruction Comparison
Preoperative/Postoperative CTA Axial Contrast
Postoperative review showed good recovery, with smooth blood flow in all branches, no signs of cerebral infarction or cerebral ischemia, complete isolation of the entry tear and false lumen of the aortic arch dissection, no endoleak, and good stent position and morphology.
Summary of Case Experience
The two cases shared here involve patients with Stanford Type B aortic dissection, where the proximal retrograde tear has already extended to the root of the left subclavian artery (LSA), leaving an insufficient proximal anchoring zone. Additionally, the proximal entry tear of the dissection is large, the true lumen is small, and the false lumen is large. The primary challenge of the surgery lies in effectively sealing the lesion while ensuring the long-term prognosis of the patients. The tortuous course of the descending aorta poses extremely high requirements for the stability, deliverability, and flexibility of the stent delivery system. Moreover, the covered stent must exhibit excellent sealing ability, conformability, apposition, and minimal elastic recoil.
In response to these challenges, Professor Zheng Cao's team implemented precise measures by selecting the Percutek Therapeutics Thoracic Aortic Stent Graft System for treatment. During the procedure, the stent graft fenestration was effortlessly completed using only a V-18 guidewire. The fenestration site was easily penetrable and expandable, and the balloon dilation process was simple, safe, and reliable, achieving an efficient and secure supra-aortic reconstruction of the LSA. Postoperatively, the stent showed excellent morphology with significant lesion sealing, no endoleaks occurred, and the patient had a favorable prognosis. The supra-aortic reconstruction results fully met the preoperative planning expectations, demonstrating the team’s exceptional technical expertise and extensive clinical experience.
Expert Introduction
Professor Zheng Cao
Director of the Department of Cardiac and Vascular Surgery at Huanggang Central Hospital, and Director of the Huanggang Interventional Radiology Quality Control Center. Specializes in minimally invasive treatments for peripheral vascular diseases and cardiac and major vascular diseases. Current positions: Member of the Hubei Medical Association's Interventional Medicine Branch, Member of the Hubei Anti-Cancer Association's Tumor Intervention Professional Committee, Executive Director of the Hubei Cerebrovascular Disease Prevention and Treatment Association, Member of the Neurointervention Committee, First Youth Committee Member of the Hubei Hepatobiliary Diseases Association, and Standing Committee Member of the Huanggang Oncology Medical Association.
Department Introduction
Huanggang Central Hospital Cardiovascular Surgery
The Department of Cardiac and Vascular Surgery at Huanggang Central Hospital is a key clinical specialty in Hubei Province, a council unit of the China Hemorrhagic Center Alliance, a council unit of the Tiantan Neurointerventional Alliance, and the quality control center for radiological intervention in Huanggang City. It is a distinctive department in southeastern Hubei that leads the region and is advanced within the province, specializing in minimally invasive treatments for peripheral vascular diseases and cardiac macrovascular diseases. The department consists of specialized wards, hybrid operating rooms, and outpatient services, equipped with state-of-the-art facilities such as China's first Siemens nexaris Angio-CT hybrid operating room, GE and Philips large flat-panel angiography machines, thrombectomy systems, and varicose vein radiofrequency ablation systems, among other related interventional diagnostic and treatment equipment.
The Department of Cardiovascular Surgery currently has 9 specialized doctors and 19 nursing and technical staff. The medical staff have gone to Beijing Anzhen Hospital, Xuanwu Hospital, the First Affiliated Hospital of Sun Yat-sen University, Wuhan Union Hospital, and other institutions for further study and training. More than 1,200 surgeries are performed annually, including almost all interventional diagnosis and treatment procedures available in China.
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