The patient is a 60 year old male with repair of a high risk type I thoracobdominal aortic aneurysm. The aneurysm was particularly large, measuring 19 cm at its widest diameter, and was repaired with resection and graft replacement and reattachment of intercostals arteries. We show the adjuncts of cerebral spinal fluid drainage and distal aortic perfusion (left atrial to left femoral bypass) with which we have had great success in reducing postoperative neurological complications.