Physician-Modified Endografts for Non-deferrable Complex Abdominal Aortic Aneurysm Repair Using the Endurant Platform: Templates and Initial Results

Introduction and objectives: Complex abdominal aortic aneurysm (AAA) repair often requires the use of fenestrated and branched endografts, which can be influenced by factors such as device availability, cost, and operator expertise. This study aims to evaluate the preliminary results with physician-modified endografts (PMEGs) utilizing the Medtronic Endurant platform. Methods: Retrospective analysis of consecutive patients unsuitable for other techniques or custom-made devices, in which a PMEG Endurant was used for repair between 2021 and 2024. Bidimensional templates of the Endurant endograft were developed to ensure precise fenestration placement, which was confirmed intraoperatively with a 3D-printed aortic template. Endpoints were technical success, mortality, reinterventions, and target vessel patency. Results: Thirty-seven target vessels in 18 patients (mean age 79.4 ± 9 years, 94% male) were treated with Endurant main bodies (n=10, 55.6%), abdominal tubes (n=4, 22.2%), or aortic extensions (n=4, 22.2%). Mean aneurysm diameter was 70.0 ± 23 mm. Mean number of fenestrations was 2.1 ± 1 (33.3% 3-FEN or 4-FEN). The most frequent bridging stents were iCover (n=15, 40.5%), BeGraft (n=10, 27.0%), and VBX (n=9, 24.3%). Mean implantation time was 198.9 ± 90 minutes. Technical success was achieved in all but one case (n=17, 94%), with no 30 day mortality, no reinterventions, and 100% target vessel patency at a median follow-up of 10 months. Three patients (16.7%) died of non aortic-related causes. One residual type IA endoleak was adverted in computed tomography scan controls and was left untreated according to patient’s decision. Conclusion: PMEG utilizing the Medtronic Endurant endograft, supported by bidimensional templates and 3D-printed confirmation models, provided safe and effective short-term outcomes for complex, non-deferrable AAA repair. Long-term data and a prospective study on PMEG with a standardized protocol would allow for evidence to arise on this technique, facilitating adequate comparisons with custom-made and off-the-shelf devices. Clinical Impact This short series highlights the initial outcomes of physician-modified endografts (PMEG) using the Medtronic Endurant platform. Dedicated 2D templates for all Endurant sizes are provided as supplementary material, offering valuable assistance to practitioners in the vascular community. A standardized modification protocol, based on these templates along with the double-check of a sterile 3D-printed model, has allowed to achieve satisfactory short term outcomes. These outcomes are comparable to those of custom-made devices, even in scenarios requiring non-deferrable repairs and involving challenging anatomic constraints, such as type 1A endoleaks.