Initial Experience With the Punch Card For Multi-vessel Physician-modified Endograft

Physician-modified endografts (PMEGs) are increasingly used for juxtarenal aortic disease. 3D models might help to position the fenestrations over a strutless area of the aortic device during the creation of multi-vessel PMEGs. We developed the punch card technique, which is a transparent film with a proportionally scaled fenestration diagram acting as a 3D model that can be created using simple office tools, omitting the need of a 3D printing workflow (Fig 1). The aim of this study was to evaluate the technical success rate of the punch card technique. We performed a retrospective cohort study of all the patients who underwent PMEG repair in our tertiary center using the punch card technique since its introduction in March 2023. Basic demographic and clinical data, aortic device type, number of incorporated vessels, and preparation time were collected. Technical success was defined as successful modification and reloading of the aortic device and successful cannulation and stenting of the target arteries. A total of 28 reinforced fenestrations were created in nine patients (8 male; 78.2 ± 7.2 years) using the punch card technique between 1 Mar 2023 and 6 Oct 2023 resulting in 3.1 incorporated vessels per procedure. Indication for repair was juxta/pararenal aneurysm in six cases (67%), accessory renal preservation in two cases (22%), and aortic arch repair in one case (11%). Thoracic device was used as a PMEG in four cases (44%, Medtronic Valiant), whereas abdominal device was modified in five cases (56%, Terumo Aortic Treo in 3 cases [33%] and Medtronic Endurant in 2 cases [22%]). Preparation time was 68 ± 27 minutes. Devices were created and reloaded, and all target arteries were cannulated and stented successfully resulting in a nine of nine (100%) per patient and 28 of 28 (100%) per vessel technical success rate. No target artery was lost, nor fenestration left unstented (0%). The punch card technique may help to increase the precision of device preparation during PMEG repair, especially if multi-vessel incorporation is performed. Technical success rate achieved so far is exceptional. The 3D model improves the positioning of the fenestrations over a strutless area without the need of a 3D printing workflow or performing manual arc length measurements.