In contrast to Crawford extent IV thoraco-abdominal aortic aneurysm (TAAA) repairs, which involve replacing only the abdominal aorta, extent I, II, and III repairs involve replacing portions of both the thoracic and abdominal aortic segments. These more extensive repairs remain a particular challenge to the surgeon because of the associated risks posed by distal ischemia, including its most serious complications — paraplegia and renal failure. Consequently, several adjuncts and technical strategies have been developed to mitigate ischemic complications: systemic and localized hypothermia, moderate heparinization, aggressive reattachment of segmental arteries, sequential aortic clamping, cerebrospinal fluid drainage, motor evoked potential monitoring, left heart bypass to provide distal aortic perfusion, and selective visceral perfusion. Although we use a multimodal approach to optimize organ protection during all TAAA repairs, particular techniques are selected according to each patient’s risk factors and anatomy, and the extent of aortic replacement. Therefore, although the approaches to Crawford extents of repair I, II, and III are similar, there remain distinct differences among them. In our contemporary series of 307 patients who underwent extents I, II, and III TAAA repairs with our current organ-protection strategies during 2006–2009, the early mortality rate was 6.2%, the prevalence of paraplegia at discharge was 2.9%, and the prevalence of acute renal failure necessitating dialysis at discharge was 3.6%.