Ascending Thoracic Endovascular Aortic Repair: A Widening Gap Between Clinical Demand and Device Availability

Abstract Open surgical repair remains the gold standard for ascending aortic disease, yet many patients are unsuitable for surgery, and the absence of dedicated endovascular devices has left clinicians reliant on improvised and off-label solutions. This narrative review traces the evolution of devices and techniques used in ascending thoracic endovascular aortic repair (aTEVAR), the anatomic and biomechanical challenges unique to the ascending segment, and the growing mismatch between clinical demand and available technology. aTEVAR has been performed with increasing frequency over two decades, predominantly using off-label, physician-modified, and custom-made devices. The only dedicated device to reach clinical use, the Cook Zenith Ascend, has been discontinued, leaving the Gore Ascending Stent-graft as the sole device in active pivotal investigation. Ex vivo and computational studies suggest a clinically relevant compliance mismatch between native ascending tissue and current stent-graft materials. The field may be approaching an inflection point: clinical use is growing and a consensus framework now exists, yet the device landscape remains underdeveloped. Accelerated investment in dedicated device development, prospective registries, and biomechanically informed design appears urgently required.