Physician modification of a Gore endograft for accessory renal artery preservation

Accessory renal arteries arising within the proximal seal zone complicate endovascular repair of infrarenal abdominal aortic aneurysms, particularly in patients with chronic kidney disease. We report the case of 76-year-old man with diabetes, hypertension, coronary artery disease status post coronary artery bypass graft, and stage 3a chronic renal failure (estimated glomerular filtration rate, 49-55 mL/min/1.73 m²) who presented with a 5.5-cm infrarenal abdominal aortic aneurysm with gradual growth on surveillance. The infrarenal neck measured 22 to 24 mm in diameter and 27 mm in length, with circumferential wall calcification and atheroma. Two accessory renal arteries originated in the middle of the seal zone, each supplying a significant proportion of the renal parenchyma. The main renal arteries were small (4.1/4.2 mm at the origin) and somewhat diseased with ostial calcification. Open repair with possible suprarenal clamp was considered higher risk for renal dysfunction. Endovascular aneurysm repair using a physician-modified endograft with fenestrations created using a punch biopsy device was performed. The procedure was technically successful, with no type I or III endoleak and no change in the estimated glomerular filtration rate at the 2-month follow-up.