| Summary: | Introduction: Fenestrated branched endovascular aortic repair with custom manufactured devices (CMDs) has been applied to treat post-dissection thoraco-abdominal aortic aneurysms (TAAA), but the long waiting period for device manufacture limits its application in symptomatic or contained ruptured aneurysms. Report: A 59 year old female presented with a 7 cm chronic post-dissection extent II TAAA. The patient underwent first stage total arch repair with the elephant trunk technique. At the time of the initial placement of the thoracic stent graft a fenestration was created in the septum to perfuse the right renal artery, which originated from the false lumen. A second stage procedure was planned with a CMD, but the patient presented with severe chest pain and lower extremity weakness, which was attributed to compression of the true lumen below the renal arteries due to increased flow into a pressurised false lumen. The patient underwent successful repair using a physician modified endograft (PMEG) with four fenestrations and preloaded guidewires. Follow up at 21 months showed no complications and a widely patent stent graft. Discussion: The Zenith Alpha has several advantages over the TX2 platform for modification, notably lower profile fabric and wider Z tents, which provide greater flexibility for the creation of fenestrations or branches. In this case, the creation of a larger fenestration during the first stage procedure probably contributed to pressurisation of the false lumen. PMEGs remain a valuable option for TAAA repair, including chronic post-dissection aneurysms. Their application is particularly useful in symptomatic patients who are not candidates for an off the shelf endograft and cannot wait for a device to be manufactured.
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