Pararenal abdominal aortic aneurysms (pAAAs) are classified as juxtarenal or suprarenal based on the highest level of normal aorta. They account for 2–7% of all aortic aneurysms, with men affected twice as often as women. CT scanning with thin slices (<1 mm) is imperative to allow for operative planning. While endovascular therapy has become the primary treatment in many patients, there are many patients with unsuitable anatomy and there is a real risk of reintervention associated with endovascular repair that impacts midterm mortality rates. The morbidity of open surgical repair is most often related to renal insufficiency, which can be affected by reducing clamp time and considering cold renal perfusion. The operative mortality averages 5% being slightly greater than that accompanying open infrarenal aortic aneurysm repair.