Over the last 15 years the endovascular repair of thoracic aortic pathologies has been developing as the treatment of choice, but it requires appropriate anatomy. Proximal and distal landing zones are essential for fixation and sealing. In order to extend the proximal landing zone for the stent-graft and achieve an adequate seal, the left subclavian artery (LSA) is often covered, with or without concomitant subclavian artery revascularization. In this article the authors review the LSA anatomy and consequences of LSA coverage as scenery for a discussion of the ramifications of LSA coverage during endovascular thoracic aortic repair (TEVAR). Summarizing the currently available literature, the authors reveal that there is no consensus regarding a preparatory left carotid-subclavian bypass or a transposition of the left subclavian artery to the left common carotid artery. Various management strategies are offered.