The treatment of aortic aneurysm disease using endovascular stent grafts has evolved over the past 20 years. Extending this approach to aneurysms involving the visceral aorta has required development of fenestrated endografts. By creating branches to accommodate visceral vessels, the proximal landing zone can be chosen based on the adequacy of the aortic wall, rather than the constraints of visceral vessels. This allows for a more stable repair, and permits a minimally invasive approach in even very complex aneurysms. As the technology becomes more widespread, the use of these grafts has emerged from an experimental form to standard of care in some jurisdictions. Thus, many patients who might have previously been considered high risk for aneurysm repair are now candidates for surgery. This article outlines the basic concepts behind the development of fenestrated endografts, their current use, and the future of the technology.