Modern Physician-Modified Endograft Techniques for Renal and Mesenteric Vessel Incorporation

Anatomic suitability for endovascular aortic surgery has rapidly expanded to include the juxtarenal and paravisceral segment. Traditional infrarenal endovascular devices are not suitable for use in short neck, angulated, or complex aneurysms that involve the visceral-renal segment of the aorta due to lack of appropriate seal zones or coverage of visceral-renal arteries. There are few commercially available devices in the United States approved for treatment of these complex abdominal aortic aneurysms, one of which requires a 6-8 week waiting period for patient-specific custom fabrication. Physician-modified endografts (PMEGs) have been increasingly adopted as readily available solutions to offer expeditious repair of these anatomically complex aneurysms. PMEG can incorporate various modifications, including fenestrations and directional branches, to accommodate a wide range of anatomies, without need for waiting periods for device fabrication. The authors describe modern planning and technical methods for incorporation of visceral and renal arteries using PMEG created from commercially available endografts.