Custom-made and off-the-shelf branched and fenestrated endovascular repair of the aortic arch: Current concepts and clinical outcomes

Endovascular repair of the aortic arch has evolved rapidly over the past decade, driven by the development of fenestrated and branched techniques, expanding treatment options for patients at high-risk for open or hybrid repair. This narrative review summarizes contemporary evidence on endovascular aortic arch repair, focusing on fenestrated and branched techniques using both custom-made and off-the-shelf devices, with emphasis on device design, anatomical considerations, clinical outcomes, limitations, and patient selection. Fenestrated endovascular repair is most commonly applied to distal arch pathology, particularly Ishimaru zone 2 and distal zone 1, and offers high technical success, and excellent target vessel patency. Branched endografts enable more extensive arch reconstruction and facilitate proximal landing in zone 0, at the cost of increased procedural complexity and higher stroke risk. Off-the-shelf platforms play an important role in urgent and emergent settings, while custom-made devices allow tailored solutions for elective cases. Across all strategies, outcomes are strongly influenced by patient selection, landing zone, and technical execution rather than device type alone. Endovascular aortic arch repair has become a viable treatment option for selected patients. Despite encouraging early and mid-term outcomes, stroke and reintervention remain key limitations, and long-term durability data are limited. Careful patient selection, meticulous planning, and multidisciplinary decision-making remain essential, while ongoing technological refinement are expected to further improve safety and expand applicability.