Aortic arch repair, is a surgical challenge irrespective of which technique is applied. While open surgical repair is a major trauma and a technically difficult procedure that many elderly patients tolerate poorly, the branched and fenestrated stent-grafts remain complex to implant safely. Hybrid procedures combine some of the advantages of both open and endovascular techniques but also many disadvantages. The possibility of total arch replacement with a standard off-the-shelf thoracic stent-graft and preservation of precerebral vessels by in situ fenestration has recently been reported. Some technical issues remain but recent technical adjuncts seem to facilitate temporary cerebral shunting during implantation as well as piercing of the stent-graft fabric. The positioning of fenestrations is inherently accurate by this technique which may be associated with less material fatigue and improve durability. Preliminarily, this technology holds the promise of simpler implantation, less risk for stroke and improved durability of the devices.