Intraoperative Physician-Modified Iliac Limb With Fenestration to Rescue a Misplanned FEVAR.

Background Custom-made fenestrated endografts are an established endovascular treatment for juxtarenal aortic aneurysms. Recently, physician-modified endografts have become more frequently used to accommodate complex anatomies in acute settings. Case Summary A 77-year-old man with previous open infrarenal repair with a tube graft developed proximal and distal anastomotic aneurysms, requiring bifurcated fenestrated endovascular aortic aneurysm repair (FEVAR) for aneurysm exclusion. A custom 4-fenestration instead of 5-fenestration FEVAR was planned and manufactured. Intraoperative angiography revealed an additional lower right renal artery. To preserve it, a physician-modified iliac limb with a single fenestration was created intraoperatively. Completion angiography confirmed aneurysm exclusion, proper graft positioning and sealing, and the absence of type I and III endoleaks. Discussion This case highlights the importance of physician modification as an adjunctive alternative during complex endovascular procedures. Take-home Message Physician-modified endografts can salvage incomplete custom-made FEVAR planning without partially sacrificing kidney function.