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Commentary: Physician-Modified Endografts: Surmounting Anatomical Challenges With Innovative Techniques to Optimize Treatment

Fenestrated and branched endograft technology has come a long way over the past few years, enabling the treatment of complex juxtarenal, thoracoabdominal, and arch pathologies. A significant number of innovations, in terms of both device and delivery optimization and technical tricks have been developed, including the introduction of lower profile fenestrated/branched endografts, the use of preloaded catheters and wires to facilitate easier catheterization, and alternative branch designs such as inner branches. These concepts have proven to work well when there is sufficient time to plan and manufacture a custom-made device for the patient. However, this is not the case in urgent or emergent cases, in which time to treatment is measured in hours. While the use of off-the-shelf technologies [eg, the t-Branch device (Cook Medical, Bloomington, IN, USA)] or chimney techniques have proven to be efficient in urgent situations, their use is not without limitations. Chimneys are associated with higher rates of type Ia endoleaks and target vessel occlusions, while off-the-shelf devices require coverage of a longer segment of the thoracic aorta and are not suitable for all anatomies. Back table modification of endografts began as early as 2006, and it did not take long for vascular surgeons to extend the technique, making the modifications even more complex by introducing reinforced fenestrations, mini cuffs, directional branches, inner branches, diameterreducing ties, and preloaded catheters and guidewires. The initial experience involving primarily the Zenith platform (Cook Medical) was extended with modifications to further commercially available endovascular grafts. From recent publications we know that physician-modified endografts (PMEGs) have shown technical and clinical results similar to patient-specific devices. The innovative work of the Mayo group is again pushing the limits of PMEGs. In the February 2020 issue of the JEVT, their use of inner branches enabled treatment of an anastomotic aneurysm within a normal-diameter aorta, achieving good seal within an aneurysmal segment while simultaneously avoiding extensive coverage of the aorta. Katsargyris et al were one of the first teams to report experience with inner branches, and relatively few patients have been treated with this technique worldwide. The indications for inner branches are limited. They are usually employed when the physician chooses to keep the endograft straight without downtapering at the level of the branches. This can be useful to avoid more proximal or distal extension of the repair if the seal is adequate, as in the case reported by D’Oria et al. Another indication includes fenestrated repairs in which difficulties with target vessel cannulation are anticipated and more space to manipulate the catheter around the target vessel could be helpful. Dissections treated with a fenestrated design for the vessels in the true lumen and a longer bridging distance to the vessel originating off the false lumen could also be good indications for this modification. Endograft modification is a useful tool in emergencies and should be a part of the armamentarium of a vascular surgeon dealing with complex aortic pathologies. Nevertheless, it should be reserved for acute patients unable to wait on manufacture of a custom-made device or 897007 JETXXX10.1177/1526602819897007Journal of Endovascular TherapyTsilimparis et al article-commentary2019