We read with great interest the paper of Puma et al. [1], in which they propose an external longitudinal titanium support after sternochondroplasty for severe asymmetric pectus excavatum repair.

Management of the left subclavian artery (LSA) during aortic arch surgery is complex due to its deep anatomical location and potential pathological alterations, posing risks such as stroke, spinal cord injury, and recurrent laryngeal nerve damage. Revascularization of the LSA is critical in various clinical scenarios to maintain adequate perfusion to the vertebral arteries, spinal cord, and upper limb, especially in patients with anatomical variations, prior bypass surgeries, or increased risk of ischemia. Coverage of the LSA during thoracic endovascular repair (TEVAR) without revascularization significantly increases stroke and spinal cord ischemia rates. We provided a narrative review, evaluating contemporary open and endovascular options for the treatment of the aortic arch, and consequently of the LSA. Frozen elephant trunk (FET), endovascular strategies (branched and fenestrated TEVAR), but also emerging hybrid devices, are all valuable treatments with respective strengths and limitations to be understood to obtain the best patient-prosthesis match. Individualized treatment selection based on pathology, urgency, and patient factors is essential to optimize outcomes. This evolving paradigm integrates open and endovascular techniques to enhance patient care in complex aortic arch disease.