Open stent grafting is an alternative treatment for extensive thoracic aortic replacement. However, this procedure is associated with a high incidence of spinal cord injury, which has limited its application. Multiple factors have been suggested to explain the risk of spinal cord injury, including deep delivery of the stent graft, history of operation of the downstream aorta, and postoperative low blood pressure. Cerebrospinal fluid drainage or a hybrid operation in combination with trans-femoral thoracic stent grafting is useful for preventing spinal cord injury. Open stent grafting remains an alternative treatment for atherosclerotic aneurysms with dilatation of the ascending aorta. Open stent grafting for acute aortic dissection is effective for remodeling of the false lumen. The graft diameter for aortic dissection should be 90 % of the total diameter of the aorta, and the distal landing zone should be limited to the T7 vertebral level to prevent new intimal tears or spinal cord injury. Open stent grafting seems a feasible bailout strategy for the treatment of retrograde aortic dissection after TEVAR for type B aortic dissection. Newly designed devices for open stent grafts include the Matsui-Kitamura stent graft or branched open stent graft, which is produced in Japan. The effectiveness of open stent grafting in the treatment of Marfan syndrome remains unclear. A commercially available device for open stent grafting would be desired in Japan. In conclusion, an open stent graft remains an alternative treatment for complex thoracic aortic pathologies.