The Fundamental Principles of open thoracoabdominal aneurysm repair have remained remarkably stable with controlled hypothermia, spinal fluid drainage and optimized mean arterial pressure and cardiac function as the primary interventions to minimize paraplegia risk from surgical repair regardless of the technique of repair. The advent of thoracic endovascular repair made it possible to convert a more difficult Crawford type 2 repair to a type 3 or 4 repair, which is less stressful on the elderly patient; and the combined treatment options has significantly changed the way surgeons approach open repair. However, open thoracoabdominal aneurysm repair remains a very complex and high-risk surgery. In our centre we have highly experienced anesthesia, surgical, and intensive care teams working in concert to optimize probability of successful treatment.