Open surgical reconstruction is the most important, the most frequently used and the most efficient therapeutic approach in patients with thoracoabdominal aortic aneurysms, due to high mortality and morbidity accompanying this condition. However, the therapeutic procedure itself is accompanied by significant complication risks. Complications are mostly the result of the aortic “clamping time” and the resulting ischemic organ damages, primarily of spinal cord, with development of paraparesis or paraplegia. Various additional protective methods (adjuncts) have been developed, which decrease morbidity and mortality of the open reconstruction, like distal aortic perfusion, cerebrospinal fluid drainage, selective visceral perfusion, local and systemic hypothermia, the use of medications and others. Distal aortic perfusion methods enable the decrease of haemodynamic instabilities and consequential ischemic complications, provide the opportunity for prolonging the aortic clamping time and some of the methods simplify reimplantation of aortic branches to a graft. Regardless of the isolated benefits of the distal aortic perfusion, the approach to the treatment of thoracoabdominal aortic aneurysms is mostly multimodal with the concomitant use of several protective methods in order to achieve the best possible postoperative outcome. Thus, the combination of distal aortic perfusion and cerebrospinal fluid drainage is the most widely used and studied method, with high efficiency in preventing ischemic damages to the spinal cord. Despite all the mentioned methods, vascular surgical reconstructions of thoracoabdominal aortic aneurysms are still a great challenge in the vascular surgery, so additional efforts should be put in to find the best combinations of the existing protective techniques, but also to search for and find new techniques.