The authors attempt to bring scientific discourse to bear on a contentious and partisan issue citing a very high rate of “adjunctive” procedures as evidence that endovascular treatment of aortic disease should be performed in an operative environment. They provide an excellent overview of a well-developed aortic endograft program and the many surgical adjuncts that may be needed. Although we agree with the message, the argument is overstated. The series includes advanced complicated cases and covers a wide range of indications not representative of procedures performed at many institutions and certainly not by all specialties. The high rate of surgical interventions is due at least in part to an unusually heavy use of the AUI configuration, which requires a femorofemoral bypass. In addition, some procedures performed at a different encounter before endografting cannot be used to justify performing the subsequent transarterial intervention in the operating room. Many adjunctive procedures are clearly surgical procedures that no other specialty would dispute should be performed in the operating room, such as an elephant trunk or an aortoinnominate bypass. However, these procedures are planned procedures and do not necessarily have to be concurrent with the endovascular component. Others, such as tacking sutures, limited endarterectomies, or brachial cutdowns, clearly can be performed wherever femoral artery cutdowns are—hardly a justification for an operating room environment. In that same breath, should we count all femoral cutdowns as adjunctive procedures? Although the rate of adjunctive procedures quoted is artificially high and some procedures listed do not support the argument, it is unquestionable that unforeseen complications requiring more complex surgical intervention continue to occur, such as seven recent conversions in this series. These situations are better handled in a sterile controlled surgical environment with quick access to additional anesthesia support, operating room personnel, and surgical instruments. Our University of Pittsburgh Medical Center (UPMC) group performing aortic endografting is very diverse and has used a variety of setups to perform nearly 1800 procedures in the last decade. All specialties have access to all locations, thus precluding the choice of environment based on turf considerations. Although we come from different disciplines, we presently strongly believe that aortic endografting should be performed in the operating room irrespective of the operators’ specialty. Even a low incidence of adjunctive procedures is justification enough. We also believe that high-end fixed angiography equipment is clearly helpful in difficult cases. Outcomes and patient safety—not turf battles—should guide the choice of practice methods.