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Dr K. Craig Kent (New York, NY). Is this something that the average vascular surgeon can ever accomplish, or is this a procedure that is going to be taken care of in selective institutions around the world?

Dr Roy Greenberg. Well, I think that thoracoabdominal aneurysm repair is something that is done in centers with a lot of expertise. But I think that the actual technical requirements of doing a branched endograft are not that different than an open aneurysm repair, once you understand the principles.

Much like the presentation from Japan, where they have struggled with how to train someone to size an arch device, with all these complex branches, it requires knowledge, time, and understanding. They have a single individual to size all devices, while we prefer that the individual treating physician design each device. We have now developed the technology to support this to happen. How can we put it in the hands of everyone to say, okay, you want a branch device, here is how you design it. This is in the form of a computer program involving mathematical modeling. This was recently published in JVS (Journal of Vascular Surgery) and by IEEE (Institute of Electrical and Electronics Engineers) and it allows the physician to determine the proximal extent of the repair and then determines the geometric configuration of the specified branches. This allows for a semi-automated design.

Critically, it is the treating physician that is still making the decisions. This is a really important thing. It allows clinicians develop judgment based on who does well with different designs, and the amount of the aorta that can be repaired safely in a given patient and the extent of the repair. You can't send your films off to someone else and say design me a device, without any context of the patient and the other comorbidities.