Aortic aneurysms continue to be a major source of morbidity and mortality despite advances in operative and perioperative technology. Endovascular stent graft repair of abdominal aortic aneurysms has been widely adopted since its initial report in 1991. Improvements in device delivery systems and development of modular bifurcated stent grafts have greatly facilitated repair, and broadened the applicability of these techniques. However, aneurysmal involvement of critical branch vessels can be problematic. Experience is growing with custom-made branched endografts to maintain antegrade perfusion to critical arteries in treatment of thoracoabdominal and complex aortoiliac aneurysms. The use of branched devices allows for extension of the sealing and fixation portions of the graft into more stable aorta, while simultaneously maintaining branch vessel patency. Much remains to be learned regarding the long-term durability of these repairs; however, as additional devices are developed, it is evident that the limitations of endovascular aortic aneurysm repair will continue to diminish.