If you're comfortable handling the (typo)graphical aspects of the PDF yourself and have the ability to consume a C++ library, I've had good experiences using the Apache-licensed qpdf[1] library to handle the low-level structural aspects of the PDF standard. It's particularly convenient when your application requires structure-preserving integration of existing PDF content.
Simple example applications, each completed in 2–3 days, both in C#, using C++/CLI to integrate libqpdf:
1. Overlaying fixed-format text on pre-existing blank PDF form pages, ensuring the content of each distinct form page is embedded exactly once, and that all necessary assets (fonts, images, etc.) from the blank form PDF pages are included in the output PDF.
2. Losslessly combining a sequence of PDF, TIFF, and JPEG images into a single PDF with bookmarks pointing to the first page of each source file and existing image compression maintained where possible. In this application, only the source TIFFs were anything other than arbitrary (i.e., the TIFFs were more-or-less baseline images coming from a small number of scanning systems, but the JPEGs and PDFs came from all sorts of different applications).
Simple example applications, each completed in 2–3 days, both in C#, using C++/CLI to integrate libqpdf:
1. Overlaying fixed-format text on pre-existing blank PDF form pages, ensuring the content of each distinct form page is embedded exactly once, and that all necessary assets (fonts, images, etc.) from the blank form PDF pages are included in the output PDF.
2. Losslessly combining a sequence of PDF, TIFF, and JPEG images into a single PDF with bookmarks pointing to the first page of each source file and existing image compression maintained where possible. In this application, only the source TIFFs were anything other than arbitrary (i.e., the TIFFs were more-or-less baseline images coming from a small number of scanning systems, but the JPEGs and PDFs came from all sorts of different applications).
[1] https://github.com/qpdf/qpdf