Physician Modified Inner Branched Endovascular Repair for Infected Thoraco-Abdominal Aortic Aneurysm Using the 'Squid Capture' Technique for Diameter Reduction: A Case Report.

Objectives: Endovascular repair of thoraco-abdominal aortic aneurysms in patients with hostile anatomy, such as saccular or infected aneurysms, is technically challenging. Difficulties arise from limited working space and the need for precise alignment with visceral branches. This report presents a case in which a physician modified branched endograft was successfully used, supported by three dimensional (3D) printing and the 'squid capture' technique. Methods: An 82 year old man with chronic heart failure, multiple previous coronary interventions, and pacemaker implantation for complete atrioventricular block presented with fever and back pain. Computed tomography imaging revealed a saccular, infected thoraco-abdominal aortic aneurysm involving the visceral segment. Due to high surgical risk, a fully endovascular approach was selected. A Zenith TX2 Dissection stent graft was physician modified to include four inner branches (two antegrade and two retrograde) using Viabahn stents. A patient specific aortic model was created with 3D printing to guide the precise orientation of inner branches to the visceral arteries. After graft deployment, the squid capture technique, using a homemade snare system composed of a 300 cm, 0.014 inch guidewire and a 6 F sheath, was used to create a working space within the aneurysm sac, facilitating safe visceral branch cannulation and serving as a rescue mechanism in case of visceral branch occlusion, particularly involving the superior mesenteric artery. Results: All target vessels were successfully stented. The patient completed six weeks of intravenous antibiotic therapy and was discharged in stable condition. Follow up imaging confirmed aneurysm exclusion and visceral branch patency. Conclusion: This case demonstrates how combining 3D printing and the squid capture technique can enhance the safety and precision of physician modified branched endovascular repair in anatomically challenging thoraco-abdominal aneurysms. Although off the shelf branched devices are expected to cover most cases in the future, physician modified endografts remain a valuable option for patients with complex vascular anatomy for whom commercial devices may not be suitable.