Transition From Fenestrations and Outer Branches to a Novel Mini Inner Branch Technique for Internal Iliac Artery Preservation Using Physician-modified Endurant Limbs

Abstract

Purpose:

To report early outcomes of physician-modified Endurant limbs for IIA preservation, highlighting a novel mini-inner branch design.

Materials and Methods:

From January 2023 to April 2025, 12 patients with aortoiliac aneurysms and common iliac artery bifurcation diameters ≤18 mm underwent EVAR using one of 3 Physician-Modified Endograft(PMEG) configurations: (1) single fenestration, (2) outer branch with a 6 × 10-mm PTFE graft, or (3) mini-inner branch with a 6 × 5-mm obliquely cut PTFE graft. The outer branch was chosen when commercial devices were unavailable, offering a slightly smaller profile than most off-the-shelf devices. Outcomes included technical success, IIA patency, and type I/III endoleaks.

Results:

Technical success was achieved in all cases, with no type I or III endoleaks. The mini-inner branch improved sealing and simplified resheathing.

Conclusion:

PMEG configurations are feasible alternatives for IIA preservation in narrow or resource-limited settings. The mini-inner branch offers a promising balance between sealing and procedural simplicity, but long-term evaluation is warranted.

Clinical Impact

This study presents a novel mini-inner branch design for physician-modified Endurant limbs, offering a practical solution for internal iliac artery preservation in patients with narrow iliac anatomy. The design improves sealing and simplifies resheathing without requiring larger sheaths. It expands endovascular options where standard iliac branch devices are not feasible, supporting safer and more adaptable aneurysm repair in challenging anatomies.