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Purpose Peripheral nerve and brachial plexus injury can occur from compression or stretching during positioning for operative procedures. The aim of this study was to evaluate the safety of overhead upper extremity positioning to optimize imaging during fenestrated-branched endovascular aortic repair (FB-EVAR) of pararenal (PRA) and thoracoabdominal aortic aneurysms (TAAAs). Methods Forty-four consecutive patients enrolled in a prospective non-randomized study underwent FB-EVAR with overhead upper extremity positioning. Patients underwent intra-operative neuromonitoring of upper and lower extremities and neurological examination prior to discharge and at 2 months following the procedure. End points were peripheral or brachial plexus nerve injury, quality of lateral projection and cone beam computed tomography (CBCT) and major adverse event (MAEs). Results There were 28 (64%) male patients with mean age of 74 ± 8 years treated for 10 PRAs (23%) and 34 (78%) TAAAs. Mean body mass index was 29 ± 7 kg/m 2 , with 17 obese patients (39%). Open surgical upper extremity access was used in 19 patients (43%). Three patients (16%) had access-related complications, all focal brachial artery dissections treated by patch angioplasty. Two patients (5%) developed upper extremity changes in neuromonitoring, which immediately resolved with repositioning of the upper extremity. Technical success was 95%. Lateral projection and rotational CBCT were feasible in all patients with satisfactory imaging quality for catheterization and stenting of the celiac axis and superior mesenteric artery. There was one mortality (2%) at 30 days, and six patients (14%) had MAEs. There were no upper extremity neurological injuries. Conclusion Overhead upper extremity position allows optimal imaging on lateral projections and rotational CBCT during FB-EVAR. There were no upper extremity neurological injuries in this study.