Emergency physician-modified endograft for ruptured thoracoabdominal aneurysms: Should renal preservation always be pursued?

Fenestrated and branched endovascular devices have expanded the treatment options for complex aortic pathology, and physician-modified endografts (PMEGs) have emerged as a potential alternative for urgent repair. However, an important unresolved question is whether renal artery preservation should always be pursued during emergent repair. We report two cases of ruptured thoracoabdominal aneurysms treated with PMEGs at Hospital Geral Roberto Santos between January and February 2026. Based on computed tomography angiography, fenestrations were created using electrocautery and reinforced with a snare catheter loop, whereas directional branches were constructed using self-expanding covered stents. Both patients presented with ruptured Crawford type IV aneurysms and retroperitoneal hematomas. In the first case, a 26-year-old man underwent PMEG repair with preservation of the celiac trunk and superior mesenteric and right renal arteries, while the left renal artery was intentionally sacrificed. In the second case, a 68-year-old woman underwent repair with directional branches to the superior mesenteric artery and celiac trunk, without preservation of the renal arteries. Technical success was achieved in both cases; however, clinical outcomes differed substantially. Emergency repair of ruptured thoracoabdominal aneurysms using PMEGs is a feasible strategy when custom devices are unavailable. Although renal artery preservation remains an important objective, these two cases illustrate that intentional renal artery sacrifice may occasionally be unavoidable in critically unstable patients with unfavorable renal anatomy.