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