Current options and recommendations for the treatment of aortic arch diseases

Background: Diseases of the aortic arch represent some of the most complex conditions in cardiovascular medicine due to the segment’s unique anatomy and its involvement in cerebral perfusion. Although isolated aortic arch pathology is relatively uncommon, the arch is frequently affected as part of more extensive thoracic aortic disease, including aneurysms, acute and chronic aortic dissections as well as penetrating aortic ulcers. The close relationship of the arch to the supra-aortic vessels and adjacent mediastinal structures contributes to the significant morbidity and mortality associated with these conditions and complicates therapeutic decision-making.
Methods: This review provides a comprehensive overview of the spectrum of diseases involving the aortic arch and summarizes contemporary treatment strategies. Particular emphasis is placed on anatomical considerations and classification systems, including the Ishimaru zones and variations in aortic arch morphology, which are essential for standardized reporting and procedural planning. Key pathological entities discussed include aortic arch aneurysms, acute and chronic dissections involving the arch, and residual aortic dissection following repair of type A dissection.
Results: Current treatment options encompass guideline-directed medical therapy, open surgical reconstruction, and evolving endovascular approaches. Open aortic arch replacement, often performed with hypothermic circulatory arrest and selective antegrade cerebral perfusion, remains the reference standard for patients with acceptable operative risk due to its durability and favorable long-term outcomes. In parallel, technological advances have enabled the development of branched thoracic endovascular aortic repair (B-TEVAR) and fenestrated thoracic endovascular aortic repair (F-TEVAR) devices, including both custom-made and off-the-shelf solutions, expanding treatment possibilities for patients at high surgical risk.
Conclusions: Careful patient selection based on anatomical characteristics, disease acuity, comorbidities, and institutional expertise is essential to optimize outcomes. Contemporary management of aortic arch disease therefore requires an individualized, multidisciplinary approach integrating both open and endovascular strategies.