Physician Modification of the TREO Stent Graft Using a Customized 3D-Printed Template (TREO FIT, Terumo Aortic, UK)

Fenestrated physician-modified endovascular grafts (PMEGs) offer a solution by modifying an off-the-shelf stent graft according to patient's anatomy, enabling rapid intervention. We report here the use of a novel 3-dimensional (3D)-printed template (TREO FIT, Terumo Aortic, UK) of a patient's reno-visceral aorta to facilitate the precise placement of the fenestrations in PMEG.

We treated successfully a type Ia endoleak, 12 years after EVAR, and maximal aneurysm diameter of 12 cm, by using a standard off-the-shelf TREO aortic cuff, modified into 3× fenestrated PMEG with the help of a 3D-printed and sterilized silicone template of a patient's reno-visceral aorta. Fenestrations were created using a scalpel, and reinforced using sutures and snare capture loops to enhance fluoroscopic visibility. The PMEG was reloaded, introduced percutaneously via a right-sided transfemoral access, and deployed under fluoroscopic guidance. Using a 7 Fr steerable sheath via contralateral femoral access, balloon-expandable covered bridging stents were successfully deployed in all 3 target vessels. Both completion angiogram and postoperative computed tomography scan confirmed accurate PMEG positioning, vessel patency, and the absence of type I or III endoleak.

The use of a customized 3D-printed and sterilized silicone template of patient's reno-visceral aorta facilitates the creation and precise position of the fenestration in PMEG. Further development should aim to improve the template respecting aortic kinking/angulation.Clinical ImpactThe use of a customized TREO FIT silicone template for PMEG preparation represents a promising advancement in the treatment of high risk and symptomatic complex AAAs. By enhancing procedural precision and ensuring consistency, this approach has the potential to improve patient outcomes and expand the scope of endovascular repair techniques.