Between October 1990 and June 2001, 121 patients underwent surgery for thoracoabdominal aortic aneurysm (TAAA)-99 procedures were elective and 22 were for ruptured aneurysms. Between October 1990 and September 1997, the clamp-and-go technique was used for all aneurysms (43 patients), and from October 1997, clamp-and-go was reserved for type IV TAAAs, and atriofemoral bypass (AFB) was used for types I, II, and III (78 patients). Overall hospital mortality was 21.4% (26/121)-12% for the elective group and 64% for the ruptured group. Hospital mortality was associated with age (67 years in survivors vs. 73 years in nonsurvivors, p = 0.03), FEV1<2 L (RR 4.1, p = 0.01), CSF drainage (RR 5.0, p = 0.03), type II aneurysms vs. other aneurysms (RR 3.7, p = 0.02), and relative inexperience (mean rank in the series was 52 in survivors vs. 30 in nonsurvivors, p = 0.01). The overall incidence of neurologic deficits due to spinal cord ischemia was 6.2% (paraplegia in 4.4%). Temporary dialysis was necessary in 13% of patients, and chronic dialysis in 2%. In long-term follow-up of patients undergoing elective repair, 5-year survival was 80% and median survival was 7.9 years. Mortality and neurologic deficits have improved over time as a consequence of either increased surgical experience, the adoption of a protocolized strategy for repair, or secular improvements in ICU care. Long-term survival after elective TAAA repair is excellent.