National Trends in Utilization of Surgeon Modified Grafts for Complex and Thoracoabdominal Aortic Aneurysms.

Custom branched/fenestrated grafts are widely available in other countries, but in the United States they are limited to a handful of centers, with the exception of a 3-vessel juxtarenal device (ZFEN). Consequently, many surgeons have turned to alternative strategies such as physician-modified endografts (PMEG). We therefore sought to determine how widespread the use of these grafts are. We studied all complex endovascular repairs of complex and thoracoabdominal aortic aneurysms in the VQI from 2014-2022 to examine temporal trends. There were 5,826 repairs during the study period; 1895 ZFEN, 3241 PMEG, 595 parallel grafting, and 95 where parallel grafting was used in addition to ZFEN, with a mean of 2.7±0.98 vessels incorporated. Over time, the number of PMEGs steadily increased, both overall and for juxtarenal aneurysms, whereas the number of ZFENs essentially leveled off by 2017 and has remained steady ever since. In the most recent complete year (2021), PMEGs outnumbered ZFENs by over 2:1 overall (567 to 256), and nearly twofold for juxtarenal repairs. In 3-vessel cases involving juxtarenal aneurysms, PMEGs were used as frequently as ZFEN (43% vs 43%), whereas the proportion of juxtarenal aneurysms repaired using a four-vessel graft configuration increased from 20% in 2014 to 29% in 2021 (P<.001). The differences in PMEG utilization were more pronounced as surgeon volume increased. Surgeons in the lowest quartile of volume performed <2 complex repairs annually, evenly split between PMEG and ZFEN. However, surgeons in the highest quartile of volume performed a median of 18 PMEG/year [IQR 10-21], but only 1.6 ZFEN/year [0.8-3.4]. The number of physician-sponsored investigational device exemption (IDE) trials of PMEGs has expanded from one in 2012 to 8 currently enrolling. As those data are not included in the VQI, the true number of PMEGs is likely substantially higher. Physician-modified endografts have become the dominant endovascular repair modality of complex abdominal and thoracoabdominal aortic aneurysms outside of IDEs. The field of endovascular aortic surgery, and patients with complex aneurysms would benefit from broader publication of PMEG techniques, outcomes and comparisons to custom manufactured grafts.

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