Open surgical repair of complex aortic aneurysms, such as juxtarenal or thoracoabdominal aortic aneurysms, is a highly demanding procedure. They frequently require major surgical exposure through both the thoracic and the abdominal cavities, suprarenal or supraceliac aortic cross-clamping, and exposure of the visceral and renal arteries. Endovascular aortic repair and thoracic endovascular aortic repair have become the mainstay of treatment for infrarenal abdominal aortic aneurysms and descending thoracic aneurysms. However, the obvious need to maintain perfusion of the visceral and renal arteries has limited application of endovascular techniques to treatment of more complex aneurysms. Fenestrated and branched stent grafts are being developed to address this need and enable repair of complex aneurysms involving branch vessels exclusively using minimally invasive techniques. Although these devices remain investigational in the United States, they have recently become commercially available in other countries and play an increasing role in the management of complex aortic aneurysms.