Physician-Modified Endografts in Elective Care: A Report From the REgistry of MOdified Treo Endografts in Europe (REMOTE)

Objective: Physician-modified endografts (PMEGs) are widely accepted as a viable option in the urgent management of patients with complex abdominal aortic aneurysms (CAAAs). While PMEGs have emerged as the predominant repair modality for CAAAs in the United States, their acceptance in Europe remains limited—particularly in the context of elective repair. The aim of this study was to present the initial experience with elective cases at pioneering European centers offering this treatment. Methods: This is a retrospective observational study based on an international multicenter registry (REgistry of MOdified Treo endografts in Europe—REMOTE). Data were collected from 4 European centers on patients who underwent elective PMEG repair using the Treo device for CAAAs between August 2023 and February 2025. Demographic characteristics, clinical status, procedural details and follow-up data were recorded. Primary outcomes included technical success, overall and aortic-related mortality, and adverse events. Results: Twenty-eight patients (20 males; mean age 76.3±6.8 years) underwent elective PMEG repair with the Treo device. Most procedures incorporated at least 3 target vessels (68.3%). The average time required for device modification was 47.4±20.3 minutes. Technical success was achieved in 96.4% of cases. The single technical failure was associated with a lost accessory renal artery, with no acute kidney injury occurred nor endoleak observed. There were no in-hospital deaths or major adverse events. At short-term follow-up (mean 5.9±4.8 months), overall mortality was 3.6% (n=1, non–aortic-related). Freedom from reintervention was 92.9% (n=26). Aneurysm sac shrinkage was observed in 25% of patients (n=7), with the remainder showing stability. Primary and secondary target vessel patency rates were both 98.8% (n=81), with one renal stent occlusion noted on follow-up imaging. Conclusion: This multicenter retrospective observational study demonstrated that elective PMEG repair of CAAAs using the Treo device is associated with a high-technical-success rate and a low incidence of clinical complications, supporting the safety and feasibility of this approach in the elective setting. Clinical Impact REMOTE provides a multicentre European snapshot of elective PMEG-FEVAR on a single abdominal platform (Treo), showing high technical success with major clinical complications being uncommon, supporting feasibility in the elective setting. This could change practice by enabling experienced centres to offer a structured elective PMEG pathway and reduce decision-to-operation time from the 1–4 months often seen with CMD logistics to days (or even hours), thereby lowering interval-rupture risk and patient anxiety. For clinicians, this means a more predictable workflow that can shorten the learning curve and broaden access where CMD availability/cost is limiting.