The current conventional open TAAA repairs are performed by select centers around the world with good outcomes. However, lesser experienced centers often encounter difficulties in replicating similar results of open TAAA surgeries. The modified branch-first open repair of TAAA has shown to be effective in minimizing visceral and renal complications by providing continuous visceral blood flow throughout the procedure. By debranching the visceral vessels first, we can perform this complex aortic procedure in a more controlled manner as compared to the traditional clamp and sew technique which requires speed, precision and experience. The entire repair can be performed on beating heart by deriving native blood flow via a closed circuit or a modification of the left heart bypass and continuously perfusing the abdominal viscera, thus avoiding cardiopulmonary bypass or deep hypothermic circulatory arrest which helps minimize bleeding and overall morbidity associated with extensive TAA surgeries. Adequate pre-operative planning is imperative to prevent spinal cord complications and intra-operative emergencies.