On the Operating Table, Supply Chain Issues Can Be Life or Death

For months, heart surgeons have been warning that the country faces a shortage of aortic grafts, an imported product needed to treat life-threatening vascular disease.                                      

Looking down at the open chest cavity, Li Guangnan was frustrated.

A heart surgeon at a major hospital in a second-tier city, he had opened the patient’s chest to repair a type A aortic dissection — a kind of tear in the aorta, the body’s largest and most important blood vessel. Aortic graft surgery is a challenging procedure with life-or-death stakes.

Li had just discovered a complication: He was all out of grafts in the patient’s size.

He knew he was running low on artificial grafts. He’d been asking his supplier for a shipment for years, but the company kept telling him they were running low due to pandemic controls. Li gave a pseudonym because of the sensitivity of the issue.

Li had no choice: He got to work modifying a mismatched graft to fit. “Using an improper artificial graft is not easy,” Li said. “Doing a surgery with the wrong one raises risks of blood leakage and other complications; but if I didn’t do the surgery, the patient was very likely to die.”

In the next few hours, Li scrupulously repaired the aorta, and the patient eventually passed out of danger.

Some hospitals faced a worse situation. On April 28, a cardiovascular surgeon from Ningxia published a post on the Twitter-like platform Weibo: “Due to impassable logistics in Shanghai, the artificial grafts and cardiac stents that we need are running out. Just now, a type A aortic dissection patient could not receive surgery in our hospital.” A person who claimed to be working in another hospital replied, saying that they faced the same situation. The original poster did not reply to Sixth Tone’s interview request, and not long after Sixth Tone contacted him, he deleted his post.

Five cardiovascular surgeons across China told Sixth Tone that the country has been suffering a shortage of artificial grafts since early in the pandemic, aggravated by the two-month lockdown of Shanghai.

Chronic heartache

Surgeons told Sixth Tone that Dacron-made artificial grafts, mainly used for treating aortic diseases, have been in short supply since 2020.

It’s a small, highly specialized industry. Just two companies, the German-owned Maquet and Japan’s Terumo, make most of the world’s supply. Maquet’s factories, in France, account for about 80% of the grafts used in China.

Pandemic-era disruptions and lockdown shipping disruptions have made the life-saving product scarce. The Chinese finance magazine Caijing quoted an anonymous source described as a former Maquet employee saying that the company had entered the pandemic with limited production capacity, owing to a longer-than expected transition from US to French production sites.

Li said there’s not much hope for a domestic substitute. Factory workers require years of training. “Artificial grafts must simulate natural blood vessels,” he said. “In addition to texture and elasticity, blood plasma must not leak, and upstream materials science must be tested.”

Li, and other surgeons interviewed by Sixth Tone, speak regularly with manufacturers and make occasional visits to factories to understand the products.

“The materials used in artificial grafts are very complicated,” Li said. “For instance, the coating material for artificial prostheses is highly confidential. And the training of the workers is also very rigorous and time-consuming.”

A medicine-focused investor, surnamed Chen, told Sixth Tone that grafts require highly advanced materials science, and China lags global peers in materials science.

In 2022, due to pandemic controls at the Port of Shanghai, many goods imported from other countries were stuck in the city, creating shortages that spilled across China. “The shortage of artificial grafts has only worsened,” Li said.

Neither Maquet nor Terumo replied to interview requests from Sixth Tone.

Yu Qian, a pseudonym, is an associate chief surgeon at a hospital in Guangdong province. In the past two years, he’s seen two major shortages: one due to the decrease in capacity at factories overseas; and this year, a shipping shortage due to the lockdown in Shanghai. “Imported medical products usually arrive in Shanghai’s port first before being distributed to other Chinese cities. If Shanghai’s port is blocked, the entire country is affected,” he explained.

Life or death

From the surface, a plain, white, Dacron-made graft does not catch the eye. But replacing a patient’s broken blood vessel with it can save a patient’s life. Without these artificial grafts, patients can die from treatable conditions, especially a serious one like a type A aortic dissection.

According to Li, type A aortic dissections usually appear and become life-threatening in a flash. “This is a disease that forces you to race against time,” he said. “Patients with this disease die very quickly, and the death rate increases by 1% every hour after its initial occurrence. Fifty percent of type A aortic dissection patients die within two days if they cannot get proper treatment in time.”

But the graft flips the odds.“Once patients have artificial grafts,” Li says, “about 90% of them will survive.”

On the social media platform Xiaohongshu, some family members of type A aortic dissection patients have described delays likely caused by shortages of grafts. Some of them were shocked by the fast progress of this disease, while some witnessed how this small graft could miraculously give the patient a second life. But many describe a common experience — the first hospital where the patients arrived saying they could not do the surgery, before transferring patients to another hospital that could.

A man said that his father was sent to a county-level hospital first, and was diagnosed with type A aortic dissection, but the hospital could not perform the surgery because they did not have the appropriate artificial graft. As a result, his father had to be transferred to the prefecture-level hospital. Another woman said that delays of this surgery caused her sister-in-law to die before entering the operating room. Several other people commented, “For patients with this disease, just having a chance to do the surgery already represents good luck.”

There’s a variety of reasons a patient might have to be transferred, so not all these cases would have been caused by a lack of grafts. Doctors are frequently reluctant to discuss the shortage, so patients often do not know the reason.

Li said that when a hospital has no artificial grafts left, it should send patients to another hospital capable of doing the surgery immediately, no matter how far away that alternative might be. “If there is no artificial graft, the inevitable outcome for that patient is death. Sometimes the doctors will tell you that you might die on the way, but you have to take the risk because if you lie there without having an artificial graft, you are bound to die.”

“Finding the artificial graft is the most important thing,” he said.

Wu Jing, who used a pseudonym for privacy reasons, described the cost of a delay. One day last summer, her grandfather had a stomachache and vomited in the morning. Family members took him to Wuhan’s Zhongnan Hospital, where he was diagnosed with a type A aortic dissection. “You need to prepare 300,000 yuan ($42,784) for the graft surgery and be ready for the loss of both the person and the money,” Wu said the doctor told them.

They decided to transfer him to the more specialized Wuhan Union Hospital to seek advice from other doctors. Wuhan Union gave the same diagnosis. The family finally approved of the surgery. But when they were paying the surgery fee, the grandpa died in the emergency room. “All of this happened within 12 hours, too fast, too severe,” Wu said.

In Li’s hospital, around 100 patients receive graft surgeries every year. In Yu Qian’s hospital, the number was closer to 200-300. Sun Lizhong, a top cardiac surgeon based in Shanghai, performs 300 such surgeries annually. According to Sun’s estimate, there are about 25,000 such surgeries in China every year.

Uneven distribution

Although supply chain issues have affected many hospitals, Sun has not encountered them yet. “I perform a lot of surgeries each year and have a steady need for the product, so suppliers always prioritize my hospital.”

Smaller hospitals come lower in the pecking order, Li said. In the face of recent shortages, hospitals in second-tier cities have little say when negotiating with suppliers. “When suppliers allocate artificial grafts across the country, they allocate the products according to the amount of the orders made by the region. Compared with the largest metropolises like Beijing and Shanghai, which have a relatively large demand, smaller cities are at a disadvantage in fighting for allocation quotas.”

Chen told Sixth Tone that big hospitals in first-tier cities are most likely to be able to get key products, because suppliers prioritize them, while hospitals in central China and southwest China would be most affected.

In the past, Li said, the hospital always stored at least two grafts of each type, in different diameters. If they ran out of one type, they could always ask the supplier to ship more.

Ever since the pandemic, hospitals have struggled to keep the different graft types in stock. “When we ran out of a certain type and turned to the suppliers for help, they always said that they didn’t have any left in stock,” Li said.

He told Sixth Tone that the grafts with a diameter larger than 26 mm are in great need, but also shortest supply at his hospital. Therefore, he’s often had to make more stitches and do more sewing work to adjust smaller-size artificial grafts to larger aortas, adding time and risk to the surgery for patients. Li had to deal with this kind of situation every now and then throughout the pandemic.

The situation at smaller hospitals may be even worse. A friend of Li who worked in another smaller hospital once told him, “We only have one graft now. After we use this one up, we won't have any left.” Sun said that two friends who work in public hospitals have asked for loans of grafts.

Call for Made-in-China

At the end of May, Fan Ruixin, a chief surgeon at the Guangdong Provincial People’s Hospital, which performs the largest number of cardiac surgeries in south China, sighed over the phone and expressed frustration over the issue. “Our hospital has already reported the shortage of artificial grafts to the health commission, but it seems useless. It’s not a problem that can be solved easily.”

Shanghai’s lockdown ended at the start of June. Sixth Tone’s sources refused to discuss current supplies in detail, but as sporadic lockdowns have continued across the country it’s clear that supply chains are still in chaos. Asked if his hospital had received new shipments of grafts, one doctor said only “We only just got out of lockdown.”

It wasn’t just artificial grafts. Many other imported medical materials have also faced shortages during the lockdown. On June 4, Li said that the surgical gloves they used before were imported from other countries, but “the suppliers tell us that all the goods are stuck in Shanghai now,” so they could only wear domestically produced gloves. He and some of his colleagues developed rashes on their hands. He thought it was due to the difference in material and craft. On Sept. 16, Li told Sixth Tone that they still had not received imported gloves.

On Sept. 19, a Hangzhou doctor surnamed Wu told Sixth Tone that there was a shortage of some types of better quality imported heart stents, another important cardiac product, at his hospital during Shanghai’s lockdown, but the shortage has been relieved since the end of the lockdown.

Gloves and heart stents are products that doctors can find substitutes for, but aortic grafts, and many other products, have no usable and accessible alternative. Yu said that the Flo-Thru Intraluminal Shunt, which plays a vital role in the treatment of coronary artery disease and has no domestic substitutes, was also trapped in Shanghai during the lockdown. “We’ve had to change surgery method due to the lack of the Flo-Thru Intraluminal Shunt,” Yu said.

On the night of June 5, Yu Qian said, “The situation seems to have been getting a little better recently.” At that time, Shanghai finally began to lighten its lockdown restrictions. One day before, Li told Sixth Tone, “Nevertheless, the problem of China’s heavy reliance on foreign products hasn’t changed. As long as you don’t have the capacity of production, you have to rely on imported products.”

Editor: David Cohen.

(Header image: Yuichiro Chino/VCG, reedited by Sixth Tone)