Physician-modified endograft with a temporary aneurysm sac perfusion branch for late endograft failure 11 years after EVAR

Late endograft failure after endovascular aneurysm repair (EVAR) may require complex reintervention with proximal extension, renovisceral reconstruction, and substantially greater aortic coverage than standard infrarenal EVAR. Physician-modified endografts (PMEGs) can provide a patient-specific treatment strategy when open surgery is considered highly burdensome and manufactured devices are unavailable or anatomically unsuitable. A 68-year-old man was admitted to our institution with progressive abdominal distension and discomfort lasting six months. He had a prior history of EVAR for an abdominal aortic aneurysm (AAA) at another hospital in 2013. Computed tomography angiography (CTA) demonstrated a symptomatic pararenal abdominal aortic aneurysm measuring 83.4 × 102.8 mm, associated with late proximal endograft structural failure with migration, involving the superior mesenteric artery (SMA) and both renal arteries, with chronic celiac artery occlusion. A staged repair was performed using a PMEG incorporating a dedicated branch for temporary aneurysm sac perfusion (TASP). The first-stage procedure reconstructed the SMA and bilateral renal arteries and relined the failed endograft while leaving the dedicated perfusion branch patent. Approximately 3 weeks later, the dedicated perfusion branch was occluded. The patient remained neurologically intact. At 3-month follow-up, the aneurysm measured 83.4 × 97.7 mm. At 12 months, the aneurysm had regressed to 80.2 × 92.2 mm, all visceral bridging stents were patent without significant stenosis, kinking, compression, or graft migration, and no type I, II, or III endoleak was detected. This case demonstrates the technical feasibility of staged PMEG repair incorporating TASP in a selected patient with complex late endograft failure. The absence of spinal cord ischemia and favorable 12-month imaging findings are encouraging, but causality cannot be attributed to TASP in an uncontrolled single case. Safety, patient selection, optimal staging interval, and long-term durability require further evaluation.