Physician-Modified Fenestrated Endovascular Aortic Repair for the Preservation of Hypogastric Artery Perfusion and Efficacy of Hydrogel Coil Fenestration Reinforcement

Background: Extending the distal sealing zone into the external iliac artery is sometimes necessary during endovascular abdominal aortic repair. As the use of an iliac branch device is contingent upon certain anatomical requirements, the application of this device is not universal. Herein, we present an alternative method to preserve hypogastric artery perfusion using a physician-modified fenestrated (PMF) AFX limb (Endologix, Inc., Irvine, CA, USA) with hydrogel coil reinforcement. Methods: Patients undergoing PMF endovascular abdominal aortic repair for the preservation of hypogastric artery perfusion between October 2022 and October 2023 at a single center were prospectively enrolled. The clinical endpoint was technical success, defined as successful revisualization of the hypogastric artery through the created fenestration and the absence of type 3c endoleaks. Furthermore, hypogastric artery patency and newly developed endoleaks were investigated during the follow-up period. Results: Overall, 16 hypogastric arteries from 15 patients were protected with this technique. The patients' average age was 76.9 +/- 10.4 years. The indications for PMF endovascular abdominal aortic repair were common iliac artery aneurysm (n = 6), hypogastric artery aneurysm (n = 3), correction of type 1b endoleak following previous endovascular abdominal aortic repair (n = 4), and abdominal aortic aneurysm with an inappropriate common iliac sealing zone (n = 3). All patients were considered unsuitable candidates for commercially available iliac branch devices. All fenestrations were reinforced with hydrogel coils. The technical success rate of PMF endovascular abdominal aortic repair was 100%. No branch occlusion or type 3c endoleak developed during the follow-up period (average: 11.6 months). Conclusions: Our preliminary experience suggests that PMF endovascular abdominal aortic repair with hydrogel coil reinforcement for the preservation of hypogastric artery perfusion may be a safe and effective option for extending the sealing zone to the external iliac artery. Further experience and identification of possible complications are necessary to explore the potential for the expanded use of this technique.