Editor's Choice – European Society for Vascular Surgery (ESVS) 2025 Clinical Practice Consensus Statement on Ascending Thoracic Endovascular Aortic Repair

Objective: Diseases of the ascending thoracic aorta, including type A aortic dissection, type A intramural haematoma, fusiform aneurysm, pseudoaneurysms, and penetrating aortic ulcer, pose significant management challenges due to the complex anatomy and high pressure haemodynamics of the ascending aorta. While open surgical repair is the gold standard, efforts to improve access to therapy and reduce invasiveness have driven interest in thoracic endovascular aortic repair adapted for the ascending aorta (aTEVAR). However, the lack of evidence has led to variability in patient selection, procedural approaches, and outcomes. This consensus document aims to provide recommendations on the use of aTEVAR for the treatment of ascending thoracic aortic diseases. Methods: Pre-defined criteria were applied to develop the most relevant clinical questions, and a systematic literature review was performed. Consensus statements were developed using a nominal group technique, including structured Delphi type methodology involving two online meetings, followed by three survey rounds and a final in person meeting of the multidisciplinary panel of experts. Results: The consensus document provides aTEVAR recommendations in relation to topics including patient selection, risk stratification, procedural planning (e.g., landing zones and stent graft sizing), intra-operative strategies, and post-operative management. The document also highlights gaps in evidence and identifies areas requiring further research. Conclusion: This document provides expert consensus based guidance on aTEVAR as a treatment option for selected patients with ascending thoracic aortic diseases, particularly those at high surgical risk. By providing standardised recommendations and emphasising multidisciplinary care, the document aims to reduce variability in clinical practice, enhance procedural safety, and improve patient outcomes. Future research should focus on optimisation of procedural techniques, device specific data, long term outcomes, improving patient selection, and direct comparison of aTEVAR with matched cohorts undergoing open repair.