044 - Physician-Modified Endovascular Grafts: Review of Indications, Technique, and Outcomes
Anna Hu, BS – Medical Student, George Washington University School of Medicine and Health Sciences; Deepak Iyer, BS – Medical Student, George Washington University School of Medicine and Health Sciences; Sunny Murthy, BS – Medical Student, University of Virginia School of Medicine; Hannah Gissel, MD – Resident Physician, George Washington University Hospital; Bohan Liu, MD – Resident Physician, George Washington University Hospital; Daniel Scher, MD – Interventional Radiologist, George Washington University Hospital; Shawn Sarin, MD – Interventional Radiologist, George Washington University Hospital
Purpose: The purpose of this review is to characterize the indications, technique, and outcomes for physician-modified endovascular grafts (PMEGs). Endovascular techniques have largely replaced open surgery as the preferred treatment for abdominal aortic aneurysm (AAA) in patients with suitable anatomy due to significant reduction in perioperative mortality. Conventional endovascular aneurysm repair (EVAR) requires 10-15 mm of proximal landing zone (distal to renal arteries) to accommodate standard devices. However, many patients present with complex AAAs as defined by juxtarenal/pararenal involvement and thus inadequate landing zone. PMEG is a new treatment option for complex AAAs, with the potential to extend survival benefit to patients even with challenging anatomy. Extensive pre-procedural planning is crucial, with utilization of imaging to determine size and position of visceral branch origins. This information is used by physicians to modify the graft with custom fenestrations tailored to the patient’s anatomy, marked by radiopaque suture for fluoroscopic visualization. During the procedure, the stent graft is positioned such that the fenestrations align with visceral branch origins. Once the stent graft is deployed, visceral branches are selected via contralateral groin access. Finally, covered stents are extended into the visceral branches to ensure adequate graft seal and maintain vessel patency.
Material and Methods: A review of the literature was performed using PubMed. Included in our analysis was a single-center prospective study of 43 PMEGs, a single-center retrospective study of 41 PMEGs and 41 conventional grafts, and a meta-analysis of 909 PMEGs.
Results: Overall technical success rate was 99.4% for PMEG. Survival at 30-days follow-up was 88%, with visceral branch patency rates ranging from 89-93% at a follow-up of 14±12 months. Major adverse events at 30-days follow-up occurred in 15.5% of patients. No differences in perioperative complications, overall length of stay, type I or III endoleak, or survival were observed between PMEG and conventional EVAR at 1-year follow-up.
Conclusions: PMEG is a viable option for management of complex AAAs, offering survival benefit and perioperative outcomes that are comparable to conventional EVAR techniques. Conclusions are limited by the current lack of high quality data and long-term follow-up. Further studies are necessary to investigate long-term outcomes of PMEGs.