Open thoracic and thoracoabdominal aortic repair represents one of the major surgical challenges with respect to the operative technique. Despite increasing use of fenestrated and branched stent prostheses, open aortic replacement is the gold standard for specific indications, such as young and fit patients, patients with connective tissue diseases, unsuitable anatomy for endovascular treatment or failure of endovascular treatment, tumor surgery, and prosthesis infections. In specialized centers the morbidity and mortality can be reduced by the use of intraoperative organ-protective measures, such as stepwise cross-clamping, selective renovisceral and distal perfusion, revascularization of spinal arteries, and the use of cerebrospinal fluid drainage, as well as adequate hemotherapy and volume therapy.