Optimizing PMEG Technique: Enhancing Endovascular Repair With Pre-Manufactured Fenestrated Endografts

To evaluate the clinical application and outcomes of physician-modified endografts (PMEG) made from a prefenestrated custom-made device (CMD) from COOK Medical with one reinforced fenestration and prefabricated diameter-reducing ties for the treatment of complex abdominal aortic aneurysms.

All patients treated with this adapted PMEG technique were included in the study. The single prefabricated fenestration was located 57 mm from the proximal edge. Two proximal graft diameters (34 mm and 36 mm) tapered to 22 mm distally, with tapering beginning 67 mm from the top and extending 40 mm were used. All grafts had a fixed length of 160 mm.

Ten patients, of which 8 male (80%) and with a mean age of 74 (IQR: 70-78 y) were included. Indications included degenerative abdominal aortic aneurysms (n=6 [60%]), penetrating aortic ulcers (n=2 [20%]), and mycotic aneurysms (n=2 (20%). Three (30%) presented with contained rupture, six (60%) were symptomatic without rupture, and one (10%) was asymptomatic. Median diameter of the aneurysm was 53mm (IQR 48.3-73.2 mm). Physician modification involved creation of at least three additional fenestrations, all reinforced with Goose Snare wires and secured with sutures. All target vessels were successfully bridged. The median operating time was 208.5 min (IQR: 161.3-290 min), while the median modification time was 71.5 min (IQR 55-96 min). The in-hospital mortality rate was 20 %, both were patients with ruptured mycotic aneurysms. The remaining eight patients have all regained their baseline functional status and are currently undergoing follow-up (median follow-up time: 4.5 months; IQR: 1-13 months), with maintained patency of all target vessels to date. Postoperative CT revealed one type III endoleak, one type Ib, and two type II endoleaks. The type III endoleak between the TEVAR and the fenestrated aortic graft was treated with a giant Palmaz stent (one endovascular reintervention), while the others remain under follow-up.

Use of a simplified PMEG with one prefabricated fenestration and diameter-reducing ties is feasible and offers favorable early outcomes with technical advantages in modification and deployment.Clinical ImpactUsing an endograft with a single prefabricated fenestration as the outset graft for physician-modified endografts enhances procedural efficiency by reducing customisation time and simplifying the modification process. This approach lowers technical complexity, improves procedural reproducibility, and broadens the applicability of PMEG techniques. Consequently, PMEGs can be more readily used across a wider range of complex aortic anatomies, expanding endovascular treatment options for patients who might otherwise have limited or higher-risk surgical alternatives.