Early Experience of Physician-Modified Endografts for Total Aortic Arch Repair

Medical and surgical comorbidities may present prohibitive risk for open surgical reconstruction of aortic arch pathology. Also, complex anatomy may preclude use of company-manufactured devices available in repair of aneurysmal aortic arch pathology. We sought to describe early experience with physician-modified endografts for management of aortic arch pathology.

This was an institutional review board (IRB)-approved retrospective review of prospectively collected data among patients undergoing total endovascular aortic arch repair with a physician-modified endograft (PMEG) in conjunction with cardiothoracic surgery which was performed at a single institution between December 2020 and August 2024. Primary outcomes were technical success, stroke, and target vessel instability. Secondary outcomes included 30-day mortality, spinal cord ischemia, and reinterventions.

Nine patients underwent total endovascular repair of the aortic arch with proximal seal in zone 0, with 67% presenting needing urgent or emergent repairs. Repairs were completed using 3 retrograde branches in 3 patients (33%), 3 inner branches in one patient (11%), back-table fenestrations in 3 patients (33%), and laser in situ fenestration in one patient (11%), and the remaining repair was completed with a combination of back-table fenestration and laser in situ fenestration (11%). Technical success was achieved in 8 patients (89%), while access vessel rupture prevented repair in the final patient. With a mean follow-up of 150 days (122-208), there were no instances of target vessel instability observed. One patient suffered a stroke within 30 days (11%), one patient developed pneumonia (11%), and one patient developed bowel ischemia that required laparotomy with resection of necrotic bowel (11%). No patients developed spinal cord ischemia. Four patients died within 30 days of the index intervention (44%), all presenting with acute aortic rupture. Two patients required a reintervention (22%).

PMEG for total endovascular arch repair presents a possible alternative to open surgical repair or existing company manufactured arch devices in selected patients. Perioperative stroke and mortality risk and rate of reintervention with total endovascular arch repair using a physician-modified device remain significant.