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Development of Endovascular Surgery in China

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    SUMMARY

    Development of Endovascular Surgery in China

    Zhonggao Wang*

    Before seeing any angiographic machines and devices, the author spent several years and had a review written on "Selective visceral arterial selective angiogragphy" in 1977 in which the Seldinger technique was introduced and how to prepare the angiographic guidewires and catheters, how to perform the selective arterial catheterization to different arteries and what was the proper dosage of control media that should be used in various arteries were described in detail [1]. Even now that review should still have its reference value. In addition, how to use the mentioned method to identify the bleed point(s) in the gastrointestinal (GI) tract for those with GI bleeding caused by unknown reason was also described. [2] Then at an occasional chance when I worked at the PUMC Hospital, in Beijing (Peking) in 1983, during the cavography carried out for a female 18-year-old patient with intractable ascites (her height was 152 cm, the abdominal girth was 92 cm), Dr. Yang Ning, a radiologist, and I found out that the patient had a web in the inferior vena cava (IVC), and it was penetrated casually by a heavy stiff angiographic catheter with exertion, afterwards, a continuous leak of ascites occurred at the femoral puncture point for a few days requiring local compression with bandage to reduce the leaking. At less than 10 days, however, to our surprise, suddenly not only no more leaks could be seen at the puncture point, but also the ascites disappeared completely [3, 4]. Since then, a new concept of applying special but simple device to treat complicated lesion, such as the mention above, was emerged.

    In 1984, with YAG laser fiber, Dr. Li Zhunheng, a specialist of Laser, and I carried out animal studies and treated patients with arterial occlusive disorders and web-type Budd-Chiari syndrome (BCS) at the Beijing An Zhen Hospital [5-7]. Though YAG laser fiber was once employed in clinic, after the occurrence of the incidence that a laser fibroptic fiber was broken during the web penetration process, the Laser method was abandoned. In 1992, on the basis of animal studies, we first made and applied our indigenous stent to treat patients with BCS caused by the IVC web successfully [8, 9].

    Having finished abundant animal studies, in 1995, we successfully used the silk-covering stent-graft to treat traumatic femoral arteiovenous fistula first in China, and the stent-graft was also made by ourselves [10]. In 1996, we treated a patient with descending aortic aneurysm and two cases with aortic dissection via semi-open method, which is called "hybrid method" nowadays. We combined the stent with the prosthesis, used invagination and loop method to replace the suture method, and thus simplified the anastomtic technique, shorten the operative time and reduced the operative bleeding [11]. In the same year, we successfully treated a case with a left traumatic internal carotid to internal jugular venous fistula caused by a tremendous cerebral stealing which resulted in hemiplagia and the fistula deeply located close to the cranial base, surgical means was failed to reach the fistula and the fistula was successfully sealed by the endograft [10]. In 1998, we were still the first in China to successfully treat infra-renal abdominal aortic aneurysm with indigenous stenting graft after animal studies [12] and assigned an agreement with Chinese Drug Administration for clinical trial of endografts.

    The author was the first one in China to use the imported Talent Endograft for treating the infra-renal AAA in 1988 [13] and the same for aortic dissection in early 1999 [14].

    My friend Prof. Muller-Wiefel and H Raithel of Germany were the ones who helped Jing ZP in Shanghai to complete the first group of endo-luminal treatment for patients with infrarenal AAA in China in 1998 using imported device (Vanguard) [15].

    Afterwards, using a semi-open technique (hybrid method) or extra-anatomic method to successfully to complete a total arch replacement [16], Dr. Guo Wei of PLA's 301 Hospital became the first in China to complete endo-lumnal treatment for thoracoabdominal aneurysm [17].

    At the same time, we confirmed by animal studies that if using endografting technique, at least some lesions of aneurysms occurring in the thoracoabdominal and even aortic arch parts could be treated with the same minimally invasive method [18, 19].

    Since March 1999, the indigenous large-caliber stent-graft and its delivery system had been manufactured using for minimally invasive technique to treat the most disaster disorder occurring in the aortic dissections, and it has been proved the aortic dissections could be well treated with minimally invasive technique [20]. Until now, we have treated more than 132 cases [21] even including a successful treatment of a total aortic dissection by using only a single piece of endograft deployed in the ascending aorta, in fact, the lesions of that case included 3 tears, diffuse aortic dissection, real lumen stenosis and cardiac ischemia [22]. And an arch aneurysm was also well treated with endograft after an extra-anatomic bypass [23].

    The deceleration injury of descending aortic lesions was previously treated only by surgery, and in 2001, it was well treated by us endo-luminally [24, 25]. Recently, a branched graft that included a subclavian branch at the top of aortic endograft was invented by Dr. Li Chao of the Beijing University and which is especially proper for DeBakey III aortic dissection with its proximal part adjacent to the left subclavian artery [26].

    With the rapid development of new technology, the treatment has been remarkably simplified and the companies are able to almost immediately provide devices for different lesions and also provide with special personnel's cooperation in a very helpful way, which makes the treatment much easier than before. Now most of the patients treated by us come from the minor hospitals of remote cities usually only equipped with simple and basal facilities, but not from the major hospitals. The surgeons serving at the major hospitals usually directly go rapidly to the related hospitals through the modern traveling facilities and let the patients have the fastest treatment to be carried out as early as possible. However, the situation to move the patients to the major hospitals has been changing. Some surgeons are requested to treat 2 even 4 patients each week in the remote cities recently, it represents a trend of lated development of such treatment, and now has been mostly organized by the companies that manufacture such endografts.

    Most recently, Dr. Shen LZ developed another hybrid technique during a revised elephant trunk surgery in which the distal proximal prosthesis is connected with an endograft, it served as the original elephant trunk, but could be expanded automatically to seal the distal dissecting lesions in the arch-descending aorta. Its advantage is to avoid the second stage surgery and endo-luminal deployment [27].

    So far, the number of patients with aortic dissection treated by endografting at 10 major hospitals where the surgeons learned the technique from the author has been around 800. If concerning the entire nation, the number would be more than 1000 and around 100 hospitals are doing such procedures now. The endo-luminal treatment including the hybrid or semi-interventional method for treating aortic dissection seems like rapidly grow-up spring bamboo shoots after a heavy and timely rain, and it is very likely to have a specially bright future in comparison with the treatment for patients with the infra-renal abdominal aortic aneurysm abdominal aortic aneurysm (AAA) what was required is not a challenge to the vascular surgeons at all, time will finally tell it. However, the surgical procedures for handling aortic dissections with long segmental involvement of the aorta are a really big challenge to the surgeons because of the possibly disaster complication, such as paraplegia.

    It is predicted that the distinctive difference now existed between China and the Western World in term of the related treatment of AAA and aortic dissection would be disappeared in the future. The endo-luminal treatment of greater vessel disorders has a much better prospect than those occurring in the other part of the body.

    REFERENCES

    1. Wang ZG, Zhu Y. Selective abdominal visceral arteriography. Foreign Medicine (Surgical Part). 1978, 5: 147-152

    2. Wang ZG, Zhu Y. The application of the Selective abdominal visceral arteriography in the patients with gastrointestinal bleeding. Foreign Medicine (Surgical Part). Foreign Medicine. 1979, 3: 115-117

    3. Wang ZG, Li ZJ, Wu QH, et al. Membranous obstruction of the inferior vena cava (Report of 15 cases) Proc. CAMS and PUMC. 1987, 2: 76 - 82

    4. Wang ZG, Jones RS. Budd-Chiari syndrome. Current Problems in Surgery. 1996, 33: 81-220

    7. Li ZH, Wang ZG, Zhang C, et al. Animal studies for Laser angioplasty. Bulletin of Heart and Vessel. 1985, 4: 49-526.

    8. Li ZH, Wang ZG. Experimental studies on Laser angiography. Beijing Med. 1986, 8: 244

    9. Li ZH, Wang ZG. The application of Laser in cardiovascular disorders. Chin J Surg. 1986, 24: 573

    10. Zhang XM, Wang XJ, Wang ZG, et al. Study of expandable stent in the inferior vena cava. Chin J Radiology. 1997, 31: 35-40

    11. Wang ZG, Wu JD, Wang SH, et al. Treating of Budd-Chiari syndreom with balloon dilatation and stenting. Chin Med J. 1995, 75: 35-39

    12. Chen XM, Wang ZG, Wang SH, et al. Endografting treatment of traumatic arteriovenous fistula. Chin J General Clinic. 1999, 8: 406-407

    13. Wang ZG. Surgicla treatment of supre-renal abdominal aneurysms. Chin J General Clinic. 2000, 9: 158-162

    14. Chen XM, Wang ZG, Yu J. Endoluminal treatment for infra-renal abdominal aneurysm. Chin J General Clinic. 1998, 8: 128-129

    15. Wang ZG. Complicated infra-renal abdominal aortic aneurysm treating with talent stent-graft system: a case report. In Ed.

    16. Wang ZG. Vascular Surgery (Proceedings of Third Congress of the Asian Vascular Society) (1st Edition). Beijing: International Academic Publishers. 1998, 534-539

    17. Wang ZG, Chen XM, Yu J. Endograft treatment for aortic dissection. Chin J General Clinic. 1999, 8: 403-405

    18. Jing ZP, Muller-Wiefel H, Raithel D, et al. Endografting for treating abdominal aortic aneurysms. Chin J Surg 1988, 36: 212-214

    19. Massimo C, Wang ZG, Gruz CEA, et al. Endolummal replacement of the entire aorta for acute type A aortic dissection in a patient with Marfan syndrome. J Thorac Cardiovasc Surg 2000, 120: 818-820

    20. Guo W, Zhang GH, Liang FZ, et al. Combining intervention with surgery to treat complicated thorocoabdominal aneurysm. Chin J Surg. 1999, 37: 704

    21. Shu C, Wang ZG, Lv XS. Experimental studies on endoluminal treatment for thoracoabdominal aneurysms. Chin J General Clinic 2000, 9: 135-138

    22. Zhang FX, Jin YJ, Liu FQ, Wang ZG. Design and observation of the covering endograft for arch aneurysms. Chin Med J. 2002, 82: 496-497

    23. Wang ZG, Cheng XM, Wang SH, et al. Minimally invasive treatment for aortic dissections. Chin J Thoracic Cardiovascular Surg. 2000, 6: 36-37

    24. Wang ZG, Gu YQ, Zhang XM, et al. Aortic dissection treated with endografting. Chin Clinical Journal. 2004, 4: 9-11

    25. Wang ZG. Deployment of endograft in the ascending aorta to reverses Type A aortic dissection. Asian J Surg. 2003, 26: 116-118

    26. Wang ZG. Arch aneurysm treated by endografting after an extra-anatomic bypass. International Angiology. 2005 (in process)

    27. Wang ZG, Li M, Gu YQ, et al. Treatment of aortic deceleration injury: Report of 12 cases. Abdominal Surg. 2004, 17: 81-83

    28. Wang ZG. Development of endovascular surgery in China: A personal view. Program & Abstract Book of the 5th International Congress on Vascular & Endovascular Surgery. Beijing, 2004, 39

    29. Li Chao, Li Yuliang, Wang Zhonggao, et al. Endovascular branched aortic stent-graft repair for aortic arch dissection. Program & Abstracts of 5th International Congress on Vascular and Endovascular Surgery. Beijing, 2004, 56

    30. Shen LZ, Liu ZG, Chang Q, et al. Aortic dissection treated with Aortic arch replacement and Elephant trunk method. Chin J Surg. 2004, 42

    (Edited by Jin Liu, Ji Huang, Lian Hu and Yanling Xiao)

    * Zhonggao Wang, male, MD, professor, president of Chinese Vascular Society and Distinguished Fellow of American Vascular Society, past president of Asian Vascular Society, past vice president of International Union of Angiology; Address: Xuan Wu Hospital and Vascular Institute, Capital University of Medical Science, Beijing, Postcode: 100053; Tel: 010-63047006; E-mail: zhonggaowang@yahoo.com

 
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