Physician-Modified Custom Made Endograft Adding an Outer Branch to Correct a Fenestration Offset

To describe the use of a physician-modified endograft (PMEG) through the incorporation of an outer branch within a fenestrated custom-made device (CMD) originally designed for another patient with similar anatomy.

An 80-year-old male, with a symptomatic 80 mm juxtarenal aneurysm, was managed urgently using a readily available fenestrated CMD, designed for a different patient. While 3 of the 4 fenestrations were appropriately aligned with the intended target vessels (TVs), the fourth fenestration, targeting the left renal artery, was incorporated 15 mm lower than the vessel's orifice. To overcome this offset, a 6 mm covered stent (Viabahn, Gore & Associates, Flagstaff, Arizona) was latero-terminal sutured to the fenestration, creating a retrograde outer branch. The procedure was successful, followed by an uneventful postoperative course. Predischarge computed tomography confirmed the patency of the TV and the freedom from endoleak.

Urgent setting may demand further modifications of readily available CMD, including the incorporation of branches in fenestrated stent grafts, in order to accommodate in patient's anatomy. Future standardization of the modification techniques may further expand their utilization.Clinical ImpactThis case introduces a physician-modified endograft technique incorporating an outer branch into pre-existing fenestrated custom-made device (CMD) for urgent complex aortic aneurysm repair. Using an available CMD instead of creating a new PMEG reduces preparation time and procedural complexity while maintaining technical success and target vessel patency. This practical, repoducible approach broadens the applicability of fenestrated technology in urgent settings lacking suitable off-the-shelf options.