Management of the aortic arch: A review of current endovascular devices available worldwide

The last two decades have seen a dramatic rise in the use of fenestrated and branched devices designed for endovascular treatment of aortic arch pathology, expanding treatment options for patients at high risk for open repair. This narrative review includes data from peer-reviewed English language articles with >10 patients treated with off-the-shelf and custom-made devices, searched across PubMed, Medline, Embase, Cochrane, and ClinicalTrials.gov. Fenestrated endovascular aortic arch repair has high technical success rates and relatively lower neurological risk but is more commonly applied to the distal arch, heavily reliant on precise alignment, and requires customization. Branched configurations allow for more proximal and extensive arch reconstruction, and off-the-shelf endografts enable treatment in urgent and emergent settings. Contemporary data have demonstrated improved rates of technical success, decreased operative times, and decreased major adverse events across all stent-graft platforms. However, peri‑procedural stroke remains the Achilles' heel of this technique and a limitation to broad commercial applicability. Midterm outcomes are encouraging, but longer term durability data are needed. Device heterogeneity as well as differences in clinical outcome definitions make direct comparisons difficult, but in all cases, successful results will depend on appropriate patient selection, aortic arch/landing zone anatomy, careful procedural planning, and ongoing device refinement to maximize outcomes.