Endovascular procedures have emerged as an attractive alternative technique for the repair of abdominal aortic aneurysms with an increasing popularity and diffusion. Even if technology progresses are developing more and more efficient grafts and devices, at the moment the endovascular treatment is still not applicable to all patients. The most common reason for patient exclusion remains an unsuitable proximal implantation site. Endografts with suprarenal fixation were studied for solving the problem of the proximal neck but results seem to be not so encouraging. At the moment pararenal aortic aneurysms, involving ostia of renal or visceral arteries, are usually excluded from endovascular treatment. The solution could be a custom-made graft for each single patient, with fenestrations or branches for renal and visceral arteries. The first clinical use of a fenestrated graft was by Park in 1996 and some groups are now studying different kinds of grafts, both in experimental and clinical studies, which are opening attractive new possibilities. At present results are only preliminary but this would be the first step towards the potential substitution of the entire aorta through endovascular techniques.