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To analyze the outcome of surgeon-modified fenestrated and branched stent-grafts (sm-FBSG) in high-risk patients with symptomatic complex aortic pathology or contained rupture.A single-center retrospective analysis was conducted of 21 consecutive patients (mean age 70 years, range 58-87; 16 men) treated with a sm-FBSG from April 2014 to September 2016. The indications included 11 thoracoabdominal and 10 pararenal aortic pathologies, which presented as symptomatic in 8 and as contained rupture in 13 patients. The mean aneurysm diameter was 7.4±2.3 cm.Technical success was 100%. From 1 to 4 (mean 3) renovisceral branch vessels were targeted with fenestrations. The mean length of in-hospital stay was 19 days (range 1-78). There was 1 death within 30 days and 2 further in-hospital deaths. Two patients suffered permanent spinal cord injury, 2 developed respiratory failure, and 2 had renal failure requiring temporary or permanent dialysis. No myocardial infarction, stroke, or bowel ischemia occurred. Six early endoleaks (3 type II and 3 minor type III) were detected. Mean follow-up was 11.2 months (range 2-33) in 17 patients. One late aneurysm-related death occurred. All 13 follow-up imaging studies showed patent target renovisceral vessels, with 1 type I and 2 type II endoleaks.Sm-FBSG can be utilized for urgent treatment of complex abdominal and thoracoabdominal aortic pathologies in high-risk patients with anatomy unsuitable for commercially available stent-grafts.

The purpose of this paper is to describe the technique of transapical deployment of a thoracic endograft and to discuss the specifics of this access. The technique of endograft deployment through a transapical access is demonstrated in a patient with a symptomatic 14-cm aortic arch aneurysm. The 73-year-old patient, with concomitant chronic obstructive airway disease and cardiovascular disease, had been denied open surgery. Femoral artery access was deemed contraindicated because of a more distal concomitant type III thoracoabdominal aneurysm, borderline renal failure and heavily calcified iliac arteries. Bilateral iliac–subclavian debranching and thoracic endografting via a combined transapical and left subclavian access successfully excluded the thoracic aortic aneurysm. The patient died within 24 hours postoperatively due to a massive myocardial infarction. In conclusion, transapical access for thoracic endograft delivery is feasible. Combined with complex debranching procedures in a challenging aneurysmal anatomy, it carries a high risk for periprocedural complications.