Immediate Intercostal Artery Opacification with Multi-Fenestrated Physician-Modified Endografts During Hybrid Aortic Repair: Early Clinical Experience

Background: Extensive aortic coverage can compromise the spinal cord collateral network. We evaluated the preliminary technical feasibility of a multi-fenestrated physician-modified endograft (PMEG) during complex hybrid aortic repair and assessed immediate postoperative intercostal artery opacification. Methods: Six consecutive patients underwent single-stage hybrid repair combining open surgery and endovascular stent-graft implantation between July 2024 and February 2025. All underwent left subclavian artery revascularization. Approximately 3 mm fenestrations were distributed circumferentially over the distal half of the second endograft. Aortic coverage was measured along the postoperative three-dimensional computed tomography angiography (CTA) centerline. Completion aortographic counts represented bilateral intercostal artery pairs. Results: Technical success was achieved in all six patients. Median aortic coverage was 230.2 mm (range, 225.0–315.3). A median of 7.5 intercostal artery pairs (range, 7–9) lay within the covered segment, and a median of 5 pairs (range, 4–6) opacified on completion aortography. No spinal cord ischemia (SCI) or early endoleak was recorded. Two patients experienced stroke on postoperative day 3, with residual motor impairment at follow-up; one developed acute kidney injury. Median follow-up after discharge was 489 days (range, 379–575), with no reintervention, 30-day mortality or 1-year mortality. Available CTA showed stable endograft positioning without detected endoleak. Conclusions: This six-patient hybrid series documents preliminary technical feasibility and immediate postoperative intercostal artery opacification. Direct flow through individual fenestrations, sustained branch patency, structural durability and SCI protection remain unconfirmed.