A totally endovascular approach to complex aortic aneurysms using fenestrated and branched stent-grafts is a technically demanding alternative to open surgical repair of thoracoabdominal and pararenal aneurysms. Complications of these complex endovascular reconstructions are varied, from dislocation of the stent-graft to occlusion of the target vessels. Based on our growing experience with these procedures, we reviewed the causes leading to secondary procedures after ≥100 branched/fenestrated stent-graft repairs and now propose several alterations to the technique that could improve the results of this approach to complex aortic aneurysm repair.