Development of Endovascular Surgery in China
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 . 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.  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 . 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 . 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 . In 1998, we were still the first in China to successfully treat infra-renal abdominal aortic aneurysm with indigenous stenting graft after animal studies  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  and the same for aortic dissection in early 1999 .
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) .
Afterwards, using a semi-open technique (hybrid method) or extra-anatomic method to successfully to complete a total arch replacement , Dr. Guo Wei of PLA's 301 Hospital became the first in China to complete endo-lumnal treatment for thoracoabdominal aneurysm .
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 . Until now, we have treated more than 132 cases  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 . And an arch aneurysm was also well treated with endograft after an extra-anatomic bypass .
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 .
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 .
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.
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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)
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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: email@example.com