Since the introduction of endovascular techniques for the treatment of aortic pathologies, clinical application of these lesser invasive procedures has increased exponentially during the last two decades and changed daily vascular practice completely. Starting in the infra-renal aorta, the indications for endovascular repair have gradually extended to the suprarenal aorta, aortic arch, descending and thoracoabdominal aorta. In addition, other pathologies than aneurysms have been treated by endovascular means, including dissection, traumatic injuries, penetrating aortic ulcer, intramural hematoma and aorto bronchial fistula. With increased application, short-term and longer-term technical failures have developed, in the majority of cases managed by repeat endovascular techniques. However, these complications cannot always be solved by endotechniques, requiring conversion to open surgery. At present there are additional reasons why open surgical repair remains a mainstay in the treatment of complex aortic diseases. Younger patients might choose for traditional surgery because of the unknown durability of complex endovascular reconstructions. Patients with connective tissue disease suffer from vulnerable aortic tissue in which endografts might behave different as compared to degenerative aneurysms. Therefore, the modern vascular surgeon should not only be trained in endovascular procedures but also master the wide spectrum of open surgical techniques. Besides anatomical knowledge and standard vascular handling, the surgeon must be familiar with unusual variations and unexpected situations.