Endovascular technology for aortic arch repair: from innovation to integration

Treatment of aortic arch pathology is one of the most challenging areas in cardiovascular surgery due to the complex anatomy and proximity to critical cerebral vessels. Open aortic arch replacement with cardiopulmonary bypass and deep hypothermic circulatory arrest remains the gold standard but can be associated with significant perioperative morbidity and mortality, particularly in elderly and comorbid patients. Over the past two decades, thoracic endovascular aortic repair (TEVAR) has become the gold standard for most descending aortic pathologies. As a result, TEVAR use has expanded into the aortic arch, facilitated by hybrid approaches that combine supra-aortic vessel debranching with endovascular stent-grafting. Following this approach, TEVAR, in combination with the use of chimney and snorkel grafts, was developed in an attempt to treat the aortic arch with a complete endovascular approach. However, these techniques have been associated with complications such as stent-graft occlusion, collapse, endoleaks, and strokes. Further developments have led to in situ laser fenestrations, and branched and fenestrated endografts, thus enabling total endovascular reconstruction. Contemporary series demonstrate high technical success with acceptable early outcomes in selected high-risk patients. In addition, an increasing experience has been reported with hybrid approaches to the aortic arch, often involving a zone 2 arch replacement followed by completion TEVAR when indicated. While hybrid and endovascular strategies expand the therapeutic armamentarium, careful patient selection, meticulous procedural planning, and preservation of cerebral and spinal perfusion are paramount to minimizing neurological complications. Emerging device technologies, including off-the-shelf branched systems and modular delivery platforms, along with advanced imaging and computational planning, continue to improve procedural safety and feasibility. Lastly, the impact of stiff stent-grafts on the cardiovascular system is largely unknown but raises concerns, as it diminishes the Windkessel function of the proximal aorta. This appears to lead to increased left ventricular afterload, new-onset hypertension, adverse cardiac remodeling, and increased strain in adjacent aortic segments. This keynote lecture reviews the evolution of endovascular technology for aortic arch repair from innovation to integration, discusses current treatment strategies, and highlights future directions that may further optimize endovascular therapy in modern aortic practice.