Objectives Endovascular procedures are now the standard of care for endovascular aortic aneurysm repair but treatment of hostile proximal neck anatomy is still challenging. New endografts were brought to the market specifically designed to accommodate severe neck angulation. Authors describe a preliminary experience and early results using the Gore Excluder Conformable endograft (W. L. Gore & Associates, Flagstaff, Ariz) and its active control system in severe neck angulation with a standardized technical approach to achieve precise deployment in this hostile anatomy. Methods From June 2019 to May 2020, five patients with abdominal aortic aneurysm and severe neck angulation (≥70°) were treated with the Gore Excluder Conformable endograft at two different centers. Deployment of this endograft in this kind of anatomy should be aggressive starting over the level of renal arteries due to risk of distal migration downward on the external curvature and difficulty in upward repositioning. Authors suggested a standard technique with a routine through-and-through axillary–femoral approach, using a floppy guidewire together with preventive cannulation of the lower renal artery if a short neck (<15 mm) is associated. Results Endovascular aortic procedures were successfully completed in all patients. Final deployment of the stent graft using our standardized technical approach was extremely precise in all cases even if redeployment of the graft was necessary in all cases. No other secondary procedures were needed. At 30 days, no type IA endoleak was recorded and no aneurysm-related secondary procedures were performed. Median follow-up for this group of patients was 5.2 months (range 1–11). Early results revealed no type IA endoleak and no migration at Ct angiogram. No aneurysm-related secondary procedures were required. Conclusion Routine use of through-and-through axillary–femoral guidewire associated with selective pre-cannulation of the lower renal artery allows a precise deployment of the Gore Excluder Conformable endograft in difficult anatomies possibly affecting early outcomes.

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Purpose: We describe the feasibility and early results of iliac stenting using a physician-modified endograft (PMEG) to preserve a transplant renal artery in patient with iliac occlusive disease. Case Report: A 70-year-old male patient, with sub-occlusive left common iliac artery stenosis at the level of the transplanted kidney arterial anastomosis, presented with left critical limb ischemia (CLI) and pseudo-transplant renal artery stenosis (pseudo-TRAS) symptoms. He was treated with a physician-modified fenestrated covered stent introduced percutaneously via ipsilateral femoral artery after failure of simple angioplasty (percutaneous transluminal angioplasty, PTA). The modified graft was created by performing a square fenestration graftotomy on a Medtronic iliac limb stent graft (Medtronic Cardiovascular, Santa Rosa, CA, USA). The procedure was technically successful with no intraoperative complications. Procedural time was 110 minutes, including 35 minutes for device modification. On short-term follow-up, the patient had early improvement of renal function and resolution of CLI. The iliac and transplant renal artery remained patent with no sign of stent migration or kinking on 6 months surveillance computed tomography angiography and 1 year color Doppler ultrasonography. Conclusion: Use of PMEG to preserve visceral branches in occlusive iliac disease is a feasible endovascular technique with encouraging technical success and satisfying early results.

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