Three-dimensional printing-guided fenestrated endovascular aortic aneurysm repair using open source software and physician-modified devices

Fenestrated endovascular aneurysm repair is frequently used for juxtarenal and pararenal aortic aneurysms. In urgent cases, however, the use of premanufactured patient-specific devices is not an option. Physician-modified endografts may be used to treat these patients but require experience and a steep learning curve for accurate planning to position fenestrations and to perform the graft modifications. Despite experience, a margin of error in placing fenestrations always exists, and a mismatch possibility between the fenestration and vessel ostium can lead to increased cannulation time and stent complications, including target vessel loss. Aortic three-dimensional printing has been widely described in medicine for simulation, training, and surgical planning. Commercial software is currently under investigation for planning of fenestrated endovascular aneurysm repair at high costs. We describe an effective and inexpensive technique using free computer-aided design software to create a real 1:1 aortic 3D model that can easily be printed and quickly sterilized. This aortic model can be used to create a physician-modified endograft and to place fenestrations in an accurate way, with potential for shorter and more precise procedures and better long-term results. Two cases are presented to illustrate the technique, demonstrating that 3D printing is a valuable tool to plan, design, and create fenestrated devices more accurately.