Our study demonstrated the clinical impact in real-world practice of using In-situ fenestration TEVAR with the innovative dedicated perforation-needle technique, which is characterized by an immediate availability as off-the-shelf device, compatibility with the various pathologies and anatomies, as well as minimal invasiveness in comparison to the debranching bypass-procedure for the preservation of the supra-aortic vessels during the endovascular repair of aortic arch pathologies. According to center experience, this approach can applied in elective cases, however, due to its practicability, it can be especially valuable in emergencies, when the other methods are considered as an unfavorable.