Three-vessel endovascular arch repair-Keys to success

Endovascular aortic arch repair has seen increasing application for the treatment of complex aortic arch pathology in patients with suitable anatomy who are considered high risk for open surgical repair. Ongoing technical advancements have refined stent design, enabling total endovascular incorporation of the supra-aortic vessels. Despite these advances, the procedure remains highly complex and presents unique technical and physiologic challenges related to arch anatomy, device constraints, and cerebral protection. The risk of stroke remains high in several experiences and is the main limitation to widespread utilization in lower-risk groups. A comprehensive understanding of all aspects of the perioperative process is therefore essential to achieve a safe and effective repair. Several key considerations include meticulous patient selection, thoughtful device design, rigorous preoperative planning, precise procedural execution, and diligent postoperative follow-up. Currently available three-vessel arch branch devices remain under investigational protocols, and the outcomes reported thus far largely reflect experience at high-volume aortic centers. This review aims to summarize the current principles and key considerations required to successfully perform a three-vessel endovascular arch repair, with a focus on practical strategies to optimize clinical outcomes and ensure durable results.