The Aortic Valve Crimper Technique Reduces Reloading Time Compared With the Tourniquet Method in Physician-Modified Endograft Preparation

Objective: Physician-modified endografts (PMEGs) are increasingly used for urgent or off-label repair of complex abdominal aortic aneurysms (AAAs) when custom-made devices are unavailable. A key technical step in PMEG preparation is reloading of the modified stent graft into its original delivery system. Aortic valve stent crimpers have recently been repurposed to assist in reloading, but direct comparisons are lacking with the traditional tourniquet technique. This study aims to compare the efficiency and reliability of tourniquet- and crimper-assisted reloading in a controlled benchtop setting. Methods: Eighteen reloading procedures were performed using a Medtronic Valiant 38×200 mm thoracic stent graft, with 9 per technique. Trained operators conducted the reloading under standardized conditions. The primary outcome was reloading time. The secondary endpoints included the infolding potential following deployment in simulated aortic models with oversizing conditions of 21%, 34%, and 42%. Postdeployment morphology was assessed by computed tomography (CT) imaging and reviewed by a blinded observer. Continuous data were analyzed using the Mann-Whitney U test and categorical data by Fisher’s exact test. Results: The crimper technique significantly reduced the reloading time compared with the tourniquet method (median 3.98 minutes, interquartile range [IQR=3.27–5.23] vs 11.48 minutes [IQR=8.82–17.35]; p=0.001). No infolding was observed in any of the 18 deployed grafts across all oversizing subgroups. Inadvertent proximal clasp release complicated the tourniquet technique (n=3), while this issue was absent with the crimper (n=0, p=0.206). Device integrity was preserved throughout, although the delivery system required replacement once after repeated reuse. Conclusion: This benchtop study demonstrates that the crimper technique provides a faster and more consistent alternative to the traditional tourniquet method for PMEG stent graft reloading. The use of an aortic valve crimper may enhance standardization and workflow efficiency, without infolding. Clinical Impact In this bench-top comparison of PMEG reloading techniques, a repurposed aortic valve stent crimper outperformed the traditional tourniquet method by reducing reloading time, without an increase in graft infolding. The improved efficiency associated with the crimper technique highlight its potential value as a standardized approach to PMEG preparation, particularly in time-critical scenarios.