Abstract Thoracic and thoracoabdominal aortic aneurysms often require surgical repair depending on the size of the aneurysm and the acuity of progression. The involvement of the aortic arch makes consideration of surgical approaches challenging, as it contains the vessels that provide cerebral perfusion. Risk factors for growth and rupture of thoracoabdominal aneurysms include aneurysm size, rapid aneurysm growth, aortic dissection, older age, female sex, chronic obstructive pulmonary disease, cigarette smoking, pain, and a positive family history. Without surgical repair, there is a risk of fatal rupture. Planning the appropriate surgical approach is complex, and protection of the spinal cord from ischemic complications is of paramount importance.