Innovative Approach: Common Channel Inner Branch for Bilateral Renal Arteries and Superior Mesenteric Artery Fenestration in Physician-Modified Endograft for Symptomatic Type 1a Endoleak Treatment Postchimney Endovascular Aneurysm Repair: A Case Report

Physician-modified endografts (PMEGs) have emerged as an alternative solution for complex aortic aneurysms in anatomically challenging or urgent situations. We report an innovative PMEG approach using a common channel inner branch for treatment of symptomatic type 1a endoleak (T1aEL) following chimney endovascular aneurysm repair (ChEVAR). The objective of this study is to demonstrate the feasibility and effectiveness of a PMEG with a common channel inner branch for treatment of T1aEL after ChEVAR. A 79-year-old man previously underwent ChEVAR for a symptomatic 7-cm infrarenal abdominal aortic aneurysm in 2021. In January 2024, he presented with abdominal pain, and computed tomography angiography revealed T1aEL caused by inadequate proximal sealing. Complex anatomy included a chimney graft adjacent to the right renal artery and closely positioned celiac and superior mesenteric artery (SMA) ostia. A PMEG was designed with an SMA fenestration and a common channel inner branch for both renal arteries. The PMEG was successfully delivered via bilateral femoral and right axillary access. Following celiac artery embolization, the SMA and bilateral renal arteries were sequentially cannulated and bridged using covered stents. Final angiography demonstrated successful exclusion of the endoleak without branch compromise. The patient recovered uneventfully, required 1 day of intensive care, and was discharged on postoperative day 5. At 8-month follow-up, computed tomography angiography demonstrated patent visceral branches, stable stent position, and no recurrent endoleak. PMEG with a common channel inner branch is a feasible and effective option for managing complex T1aEL after ChEVAR in patients with hostile anatomy.