Contemporary Management of the Aortic Arch: A Narrative Review

The aortic arch remains one of the most complex segments of the thoracic aorta to treat, demanding strategies that safeguard cerebral and spinal perfusion while achieving durable proximal and distal repair. Contemporary management strategies include open hemi/total arch replacement, hybrid approaches such as frozen elephant trunk (FET) or debranching with thoracic endovascular aortic repair (TEVAR), and fully endovascular repair using branched or fenestrated devices. Updated guidelines (American College of Cardiology/American Heart Association [ACC/AHA] 2022; European Society of Cardiology [ESC] 2024) emphasize multidisciplinary, patient-specific decision-making grounded in standardized imaging, genetics, and lifelong surveillance. Procedurally, selective antegrade cerebral perfusion with moderate-to-low hypothermia has replaced routine deep hypothermic circulatory arrest for most open arch operations. Zone-based planning using Ishimaru's map, complemented by the Modified Arch Landing Areas Nomenclature (MALAN), improves feasibility assessment and risk stratification, while entry-focused schemas like TEM (Type, Entry, Malperfusion) further refine management. Emerging data indicate that open repair remains the durability benchmark in younger populations and those with connective tissue disease, and FET enables single-stage treatment capability with acceptable early outcomes but requires vigilant neurologic protection and reintervention surveillance. An integrated, zone-driven approach guided by center expertise optimizes patient selection for open, hybrid, or endovascular options to maximize safety and durability.