Physician-modified stent graft with inner branches for treating ruptured thoracoabdominal aortic aneurysm

Thoracoabdominal aortic aneurysm (TAAA) repair remains challenging in patients with high surgical risk. We report a case of TAAA in an 84-year-old woman with type Ib endoleak after thoracic endovascular aortic repair with coeliac artery coverage due to impending ruptured TAAA. A stent graft was assembled to create 3 fenestrations and sew 3 inner grafts for the superior mesenteric artery (SMA) and bilateral renal arteries. This stent graft system was inserted into the thoraco-abdominal aorta and partially unsheathed until the first inner branch endograft fully expanded. The wire was used to catheterize the stent graft, inner branch, and SMA from the left upper limb, and a bridge stent was deployed from the inner branch to the SMA. A similar procedure was performed for bilateral renal arteries. The stent graft system was fully unsheathed. Postoperative computed tomography angiography revealed no endoleak and good flow of the visceral artery. The use of the physician-modified inner branched endograft system described is feasible and can make TAAA endovascular repair simpler and safer.