In tandem with a global movement towards minimally invasive techniques in all branches of surgery, endovascular techniques have become the treatment of choice for many aneurysmal conditions of the aorta. It is now nearly 20 years since the first reports of endovascular repair of aortic aneurysms1. The pace of technological evolution has been rapid. The initial stents were suitable only for treating infrarenal aortic aneurysms with long narrow necks, but sequential device evolution has led to the situation today where few aortic aneurysms cannot be treated by endovascular means. The first major advance in device construction was the evolution of suprarenal fixation systems. These consist of uncovered metal struts with fixation barbs that are positioned to lie above the renal artery origins. The benefit of these devices is that they provide enhanced fixation of the grafts and protect against device migration. These features allow aneurysms with shorter necks (15 mm upwards) to be treated. Some specialists have used devices with suprarenal fixation to treat aneurysms with necks as short as 5 mm, with acceptable short-term outcomes2. Despite suprarenal device fixation, many aneurysms remained unsuitable for endovascular repair because of inadequate neck length. In fact the percentage of patients with an abdominal aortic aneurysm and a proximal neck less than 15 mm has been reported as more than 50 per cent3. To address this problem, fenestrated devices emerged. These custom-designed devices are Fig. 1 Typical fenestrated endograft used in a type IV thoracoabdominal aneurysm repair with four fenestrations for the coeliac trunk, superior mesenteric artery and renal arteries. Balloon expandable covered stents are implanted in all four vessels through the fenestrations