Abstract: A review of the research shows that 75% of aortic aneurysms are repaired surgically as elective procedures. Extra anatomic reconstruction has been replaced with endoaneurysmal approaches and anatomic in situ reconstruction using tube graphs that spare most of the aortic wall. Although paraplegia remains a significant challenge in the surgical treatment of thoracoabdominal aneurysms improved outcomes have been achieved. Heparinization, permissive mild hypothermia, left heart bypass, sequential aortic clamping, and reattachment of patent critical intercostals arteries have positively affected the treatment of thoracoabdominal aortic aneurysms.