A Novel Surgical Software Tool to Improve the Physician-Modified Endograft Workflow

Three-dimensional models are increasingly used to facilitate the positioning of fenestrations on a physician-modified endograft (PMEG) during the fenestrated endovascular aortic repair (FEVAR) of complex abdominal aortic aneurysms (CAAA). The punch card technique was developed to eliminate the 3D printing workflow while preserving the benefits of having a 3D model. The objective of the current study is to evaluate the performance of the purpose-built software EndoDraft compared to manual punch card design.

An experimental study was performed to compare software-assisted and manual punch card creation. Fenestration data of readily available procedural plans were used for patients who underwent elective FEVAR for CAAA from May 2023 to September 2024. Time needed to complete punch card planning was recorded as well as inaccuracies of the manual technique were evaluated by measuring the vertical and circumferential position of the fenestrations on the punch card.

A total of 76 punch cards and 288 fenestrations were made based on 38 patients' fenestration data. Preparation time was 233.0 ± 40.3 seconds for the manual group, whereas 63.2 ± 21.5 seconds for the software-aided group (p<0.001). Longitudinal imprecision of the manual punch card was 0.8 ± 0.6 mm for the celiac axis (CA), 1.0 ± 0.6 mm for the superior mesenteric artery (SMA), 0.8 ± 0.5 mm for the right renal artery (RRen), whereas 1.0 ± 0.6 mm for the left renal artery (LRen). Circumferential errors of the same fenestrations were 0.4 ± 0.4 mm for the CA, 0.4 ± 0.4 mm for the SMA, 0.6 ± 0.5 mm for the RRen, and 0.5 ± 0.4 mm for the LRen. No significant difference between the completion time recorded at the beginning and at the end of the software's learning curve was detected (77.8 ± 29.4 s vs 55.8 ± 18.5 s, p=0.15).

The software-assisted design of the punch card is associated with higher precision and a vast improvement in speed compared to the manual technique during PMEG planning for the endovascular treatment of CAAAs. The purpose-built EndoDraft tool was made freely available in an online repository offering a more streamlined workflow.Clinical ImpactEndoDraft® could meaningfully streamline the PMEG-FEVAR workflow by replacing manual punch-card drafting with rapid, software-generated, proportionally scaled templates that are produced in about one minute rather than several minutes, while reducing the small but measurable positioning errors inherent to hand drawing. For clinicians, this means a more reproducible planning step, less cognitive load and "ruler time" during preparation, and a workflow that is easier to standardize across operators with a short learning curve. The key innovation is purpose-built automation with integrated 2D/virtual 3D visualization and direct PDF output, made freely available to support wider adoption.