Physician-Modified Custom Made Endograft Adding an Outer Branch to Correct a Fenestration Offset

Urgent setting may demand further modifications of readily available CMD, including the incorporation of branches in fenestrated stent grafts, in order to accommodate in patient's anatomy. Future standardization of the modification techniques may further expand their utilization.Clinical ImpactThis case introduces a physician-modified endograft technique incorporating an outer branch into pre-existing fenestrated custom-made device (CMD) for urgent complex aortic aneurysm repair. Using an available CMD instead of creating a new PMEG reduces preparation time and procedural complexity while maintaining technical success and target vessel patency. This practical, repoducible approach broadens the applicability of fenestrated technology in urgent settings lacking suitable off-the-shelf options.