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OBJECTIVE: The objective of this study was performed to demonstrate the feasibility and effectiveness of a custom-manufactured stent graft (CMSG) with directional multibranches for the treatment of a complex thoracoabdominal aortic aneurysm (TAAA) patient. METHODS: A 73-year-old man presented with Crawford Type V TAAA was treated with a CMSG with four down-going directional branches including two proximal directional branches for the celiac artery and superior mesenteric artery and two distal side directional branches for the bilateral renal arteries. RESULTS: Postoperative course was unremarkable and 6-month follow-up demonstrated sac regression, absence of endoleaks, and all of the visceral branches remained patent. CONCLUSIONS: Total endovascular repair using CMSG with directional multibranches is a suitable alternative in higher risk patients with TAAA who are not suited for open surgery. Longer follow-up is needed to confirm the preliminary results.