Physician-modified endografts for urgent and emergent aortic pathology

Symptomatic or ruptured thoracoabdominal aortic aneurysms (TAAA) carry a high morbidity and mortality. Modern fenestrated and/or branched endovascular devices (B/FEVAR) have improved the immediate peri-operative mortality of TAAA and have increased the number of people that can undergo repair - in those who might otherwise be prohibitively high risk for surgery. Most modern B/FEVAR are custom made devices that require 6-12 weeks to assemble and ship to the site of implantation. Thus, patients who require more urgent repair due to symptomatic or ruptured aneurysms may not have access to this potentially life saving technology. Physician-modified endografts (PMEGs), or traditional endografts that have been back-table modified to have fenestrations or branches, have partially fixed this problem as they can be constructed in less than an hour and can provide similar results to modern custom made devices. Here we review the existing data behind the use of PMEGs in urgent and emergent aortic pathology and summarize a case describing one methodology for PMEG construction that has been standardized at our institution.