This video demonstrates a re-engineered operation for repair of type III and Type IV thoracoabdominal aortic aneuysms. The depicted trifurcated graft technique was developed to decrease end-organ ischemia that is commonly associated with these complex vascular reconstructions. This case teaches the value of maintaining visceral and renal perfusion through tangential thoracic aortic clamping, individual aortic branch vessel reconstruction and separate distal revascularization.