Physician-modified and in situ fenestration for visceral aorta repair: Combine techniques to overcome challenges

Urgent repair of complex aortic aneurysms not amenable to standard endovascular aneurysm repair is technically challenging and limited by existing technology. Physician-modified endografts are associated with challenges such as time-consuming preparation, the need for graft constraint, and the risk of misalignment—particularly in angulated aortas. In situ fenestration, although a valuable alternative, carries the risk of visceral ischemia. We present the case of a 78-year-old patient with a symptomatic pararenal abdominal aortic aneurysm treated by the combined modalities of a physician-modified endograft and in situ fenestration to overcome these challenges.