To address target vessels in pararenal and thoracoabdominal aortic aneurysms with fenestrated and branched grafts, two solutions are available: fenestrations (holes in the graft) and directional side-branches. Fenestrations work well for target vessels that have a close to 90-degree take-off from the aorta, and when the main graft at the level of the target vessel is adjacent or close to the aortic wall. Directional side-branches work well when target vessels have a steeper take-off angle and when there is a larger gap to be bridged. A third option of "inner branches" has been evaluated by our group to address target vessels that are not very suitable for either a fenestration or a directional side-branch. Most pararenal aneurysms are treated with fenestrated grafts, whereas thoraco-abdominal aneurysms are treated mostly by grafts incorporating both fenestrations and branches. In Nuremberg, 347 patients were treated with fenestrated/branched grafts for thoraco-abdominal aneurysms. A stent-graft with fenestrations only was used in 108 (31.1%) patients, a stent-graft with branches only in 104 (30.0%) patients, and a stent-graft with a combination of fenestrations and branches in 135 (38.9%) patients. For the RAs (N.=625) fenestrations were used in 408 (65.3%) and branches in 217 (34.7%). For the SMA (N.=341) fenestrations were used in 169 (49.6%) and branches in 172 (50.4%). For the CA (N.=297), fenestrations were used in 84 (28.3%), and branches in 213 (71.7%). Target vessel patency at 3 years was 98.2±0.9% for vessels targeted with fenestrations and 92.2±1.9% for vessels targeted with branches (P=0.009).