Acceptance of endovascular technology has followed a predictable pattern in the treatment of aortic aneurysm disease. Initially, endovascular aneurysm repair (EVAR) was used to treat infrarenal abdominal aortic aneurysms (AAA) only in patients deemed medically unsuitable for open surgical repair (OSR). With improvement in device design, increased operative experience and favorable mortality benefits in randomized control trials, EVAR is now the preferred method for treatment of AAA worldwide. As the results with OSR are even worse as one ascends the aorta into the visceral segment and above, it stands to reason that EVAR technology to accommodate the aortic branches should have a similar adoption in treatment of proximal AAA and thoraco-abdominal aortic aneurysm (TAAA) disease. The first devices trialed and approved for treatment of the visceral aorta are custom manufactured and have had excellent results in complex pathology. However, there are several temporal, engineering and anatomic limitations to custom, manufactured branched and fenestrated endografts. Surgeon modified endovascular aneurysm repair (SM-EVAR) is able to overcome many of these constraints and expands this technology to more patients with excellent short term results in select centers.