During the past 15 years, endovascular methods of repair have assumed an ever more prominent role in the management of aortic aneurysms because they do not require direct exposure of the aneurysm and do not interrupt flow through the aneurysm. However, one cannot use endovascular techniques to exclude aneurysms that have branches to vital organs without first providing those branches with an alternative source of blood flow. One approach involves conventional surgical bypass to effectively “debranch” the affected segment. This approach has gained popularity because the endovascular part of the procedure is relatively simple and the surgical part does not necessarily require exposure of the aneurysm itself. The other approach involves endovascular bypass to the branches of the aorta through branches of the stent-graft. The relative merits of the two approaches depend largely on the morbidity of surgical debranching, which varies from segment to segment depending on the surgical accessibility of the branch arteries and the consequences of downstream ischemia. The authors generally favor the use of branched stent-grafts in the thoracoabdominal aorta and a combined approach in the aortic arch.