Endovascular Repair of the Ascending Aorta and Aortic Arch

Endovascular repair of the ascending aorta and aortic arch is an emerging field of aortic surgery currently reserved for patients not candidates for traditional cardiac surgery. Techniques to avoid hypothermic circulatory arrest, cardiopulmonary bypass, and even chest incisions range from total endovascular procedures to a panoply of surgical debranching procedures in combination with thoracic endovascular aortic repair (TEVAR). Here, we describe the indications, approach, techniques, and outcomes of ascending and arch TEVAR. Ascending TEVAR can be performed using existing endografts designed for the descending and abdominal aorta or investigational devices which are specifically designed for the ascending aorta. Techniques for arch TEVAR is determined by the method of great vessel revascularization and includes cervical (extra-thoracic) debranching, thoracic debranching, chimney stent grafting, and branched stent grafting. Current challenges include device durability and minimizing the rates of neurological, vascular, and cardiac complications. Device innovation and demonstration of long-term efficacy may lead to expansion of the indications for endovascular repair of the ascending aorta and aortic arch to candidates of lower surgical risk.