A physician modified branched thoracic endograft is a commercially available, off-the-shelf endograft that has been altered at the time of the procedure by creating reinforced fenestrations in the graft through which covered stent grafts can be deployed to preserve blood flow into visceral branch vessels. The graft is deployed on a sterile working table in the operating room. The locations of the fenestrations are marked on the graft according to the pre-procedure measurements. The graft fabric is cut and simultaneously heat sealed using thermal Cautery. These fenestrations/cuffs are marked with medical grade metal markers to facilitate fluoroscopic visualization during the procedure. Furthermore, the fenestrations are reinforced with a short ring of PTFE. This added material is essential as it strengthens the fenestration and creates a ring within which the branch grafts can seal. After the fenestrations have been created, marked, and reinforced, additional metal radio-opaque markers are sewn to the graft to assist in device orientation under fluoroscopy. Additional sutures may be used at that time to constrain the endograft, either in a temporary or permanent fashion to facilitate subsequent deployment. The device is the re-constrained and re-sheathed within the original Zenith® TX2® delivery sheath.