Percutaneous approach to aortic disease: EVAR, TEVAR and newer techniques for more proximal disease

Advances in device design, imaging and vascular-closure technology have driven a progressive shift from surgical femoral exposure to totally percutaneous strategies for endovascular aortic repair. This narrative review summarises contemporary evidence and practical considerations for percutaneous access across the spectrum of aortic disease, from infrarenal endovascular aneurysm repair (EVAR) to thoracic endovascular aortic repair (TEVAR), fenestrated/branched repair and endovascular treatment of the aortic arch. Percutaneous femoral access is now supported by randomized evidence, large registries and administrative cohorts showing high technical success, fewer wound complications, shorter operative times and shorter hospital stay compared with routine surgical cutdown, and real-time ultrasound-guided puncture has become a guideline-endorsed standard of care. Major contemporary developments include computed tomography-based access planning centred on calcification burden and sheath-to-artery ratio; an individualised, anatomy-driven choice between suture- and plug-based closure devices; endovascular preparation of hostile iliofemoral anatomy with pave-and-crack, endoconduits and intravascular lithotripsy; low-profile endografts that have widened transfemoral eligibility; and percutaneous axillary and carotid routes that enable complex TEVAR, fenestrated/branched and selected arch repairs in experienced centres, although evidence for these latter applications remains largely observational. Looking ahead, further reductions in delivery-system profile, dedicated large-bore closure technologies, image-fusion guidance and off-the-shelf branched devices are expected to extend fully percutaneous repair to increasingly complex anatomy, while prospective, aortic-specific and device-level comparisons with standardized anatomical metrics and long-term follow-up are needed to refine patient selection and confirm durable limb and target-vessel patency.