Current status of open arch replacement.

The role of open aortic arch replacement is evolving with technical advances in the endovascular domain. In the modern era, open surgery remains the gold standard for arch intervention given excellent contemporary surgical outcomes using techniques that have been honed since the first successful arch in the 1950s. Delivering these outcomes requires rigorous attention to operative scope and technique, particularly as relates to neurovascular protection of the brain. Anatomic considerations, patient factors, specific aortic disease pathology, durability, and institutional and surgeon experience must be collectively and thoughtfully considered when selecting the best mode of aortic arch intervention, whether it is open surgical or endovascular. Open aortic arch intervention remains favored in the setting of acute aortic syndromes, complex anatomy, heritable thoracic aortic syndromes, and in the young.