<p>Open thoracoabdominal aortic replacement is one of the most technically demanding procedures in vascular surgery. Although fenestrated and branched endovascular techniques have assumed a substantial proportion of the treatment in recent years, open repair is still the reference procedure in selected clinical settings. These include young and fit patients, hereditary connective tissue disorders, infected prostheses, unsuitable anatomy and failure of prior endovascular treatment. Excellent outcomes depend not only on careful patient selection but also on standardized organ protection strategies. Key elements are sequential cross-clamping, distal and selective renovisceral perfusion, spinal cord protection using cerebrospinal fluid drainage and revascularization of relevant intercostal arteries and strict perioperative hemodynamic management. In contemporary high-volume center series, operative mortality is approximately 6–8%, permanent spinal ischemia is roughly 5% and kidney failure requiring permanent dialysis is 5–6%, whereas population-based outcomes are substantially worse.</p>