Physician Modified Endovascular Grafts

15,000 Americans die suddenly each year from rupture of an aneurysm in the aorta,which is the
ninth leading cause of death in men over age 55. Aortic aneurysms are four times more common
in men than in women and usually occur in those over age 50. Approximately one percent of men
between the ages of 55 and 64 will have a significant aneurysm, and the likelihood increases
to about four to six percent of those men over the age of 75. In a recent population-based
study of Medicare beneficiaries, 83.2% of patients undergoing endovascular repair of their
aortic aneurysm were male. Furthermore, 11.9% of patients were 67 to 69 years of age, 26.8%
70 to 74, 35.7% 75 to 79, 15.8% 80 to 84 and 9.8% > 85 years of age. Ninety-six percent of
patients were White, 3% Black and the rest either Hispanic or "Other". We have reason to
believe that the current population of patients in the Pacific Northwest harboring abdominal
aortic aneurysms match these statistics. Thus, women and minorities will definitely be
under-represented in this study primarily due to the epidemiology of the disease process.

Our institution treats a large number of patients with aortic pathology including a large
number of patients with symptomatic or ruptured abdominal aortic aneurysms. We recently
published our results on the implementation of a protocol for managing these patients with
endovascular techniques and have been able to reduce the mortality rate in half for the first
time in over 30 years. Unfortunately, not all patients presenting with symptomatic or
ruptured aortic aneurysms are candidates for endovascular repair. Reasons for exclusion
predominantly involve lack of a suitable proximal aortic neck. Solutions to this problem
involve multi-branched or "fenestrated" endografts which are being assessed in other clinical
trials. However, grafts in these trials require between 6 and 12 weeks to manufacture and
deliver to the investigational site.

On-site physician modification has also been described but is currently considered outside
the Instructions For Use for the intended devices. Our institution's quality improvement
department recently performed an objective review of 47 consecutive PMEG cases in patients
presenting with asymptomatic, symptomatic or ruptured aortic aneurysms with highly
encouraging results (See Many patients in our region do not have access to clinical trials
involving emerging aortic endovascular therapies, and some have no other option due to urgent
presentation or poor open surgical candidacy. For these important reasons, we seek to
evaluate the safety and efficacy of PMEG using FDA-approved, off-the-shelf device in order to
increase the applicability of these technologies to more patients and thus save more lives.

Inclusion Criteria:

All patients must meet all of the following inclusion criteria to be eligible for
enrollment into this study:

1. Patient is > 18 years of age

2. Patients who are male or non-pregnant female (females of child bearing potential must
have a negative pregnancy test prior to enrollment into the study)

3. Patient or Legally Authorized Representative has signed an Institutional Review Board
(IRB) approved Informed Consent Form

4. Patient is considered by the treating physician NOT to be a candidate for elective
open surgical repair of the Juxtarenal AAA (i.e., category III or greater per American
Society of Anesthesiology (ASA) classification; please refer to Appendix III: ASA
Classification System). ASA category IV patients may be enrolled provided their life
expectancy is greater than 1 year.

5. Patient has a juxtarenal abdominal aortic aneurysm that meets at least one of the
following:

- Abdominal aortic aneurysm >5.5 cm in diameter

- Aneurysm has increased in size by 0.5 cm in last 6 months.

- Maximum diameter of aneurysm exceeds 1.5 times the transverse dimension of an
adjacent non-aneurysmal aortic segment

6. Patient has patent iliac or femoral arteries that will allow endovascular access with
the physician modified endovascular graft.

7. Patient has a suitable non-aneurysmal proximal aortic neck length of > 2 mm inferior
to the most distal renal artery ostium.

8. Patient has a suitable non-aneurysmal distal iliac artery length (seal zone) of >15
mm. The resultant repair should preserve patency in at least one hypogastric artery.

9. Patient has a suitable non-aneurysmal proximal aortic neck diameter between 20 and
32mm, averaged across the diameters at the Celiac, SMA, at the lowest patent renal
artery and at the midpoint of the renal arteries.

10. Patient has suitable non-aneurysmal distal common iliac diameters between 8 and 20 mm.

11. Patient has juxtarenal aortic neck angulation < 60º

12. Patient must be willing to comply with all required follow-up exam-

Exclusion Criteria:

Patients that meet ANY of the following are not eligible for enrollment into the study:

1. Patient has a mycotic aneurysm or has an active systemic infection

2. Patient has unstable angina (defined as angina with a progressive increase in
symptoms,new onset at rest or nocturnal angina, or onset of prolonged angina)

3. Patient has a major surgical or interventional procedure planned within +/- 30 days of
the AAA repair.

4. Patient has history of connective tissue disease (e.g., Marfan's or Ehler's-Danlos
syndrome).

5. Patient has a known hypersensitivity or contraindication to anticoagulation or
contrast media that is not amenable to pre-treatment.

6. Patient has a known allergy or intolerance stainless steel or gold

7. Patient has a body habitus that would inhibit X-ray visualization of the aorta

8. Patient has a limited life expectancy of less than 1 year

9. Patient is currently participating in another investigational device or drug clinical
trial

10. Patient has other medical, social or psychological conditions that, in the opinion of
the investigator, preclude them from receiving the pre-treatment, required treatment,
and post-treatment procedures and evaluations.