© 2015 Society for Vascular Surgery. Objective Endovascular surgery has revolutionized the treatment of aortic aneurysms; however, these improvements have come at the cost of increased radiation and contrast exposure, particularly for more complex procedures. Three-dimensional (3D) fusion computed tomography (CT) imaging is a new technology that may facilitate these repairs. The purpose of this analysis was to determine the effect of using intraoperative 3D fusion CT on the performance of fenestrated endovascular aortic repair (FEVAR). Methods Our institutional database was reviewed to identify patients undergoing branched or FEVAR. Patients treated using 3D fusion CT were compared with patients treated in the immediate 12-month period before implementation of this technology when procedures were performed in a standard hybrid operating room without CT fusion capabilities. Primary end points included patient radiation exposure (cumulated air kerma: mGy), fluoroscopy time (minutes), contrast usage (mL), and procedure time (minutes). Patients were grouped by the number of aortic graft fenestrations revascularized with a stent graft, and operative outcomes were compared. Results A total of 72 patients (41 before vs 31 after 3D fusion CT implementation) underwent FEVAR from September 2012 through March 2014. For two-vessel fenestrated endografts, there was a significant decrease in radiation exposure (3400 ± 1900 vs 1380 ± 520 mGy; P =.001), fluoroscopy time (63 ± 29 vs 41 ± 11 minutes; P =.02), and contrast usage (69 ± 16 vs 26 ± 8 mL; P =.0002) with intraoperative 3D fusion CT. Similarly, for combined three-vessel and four-vessel FEVAR, significantly decreased radiation exposure (5400 ± 2225 vs 2700 ± 1400 mGy; P <.0001), fluoroscopy time (89 ± 36 vs 64 ± 21 minutes; P =.02), contrast usage (90 ± 25 vs 39 ± 17 mL; P <.0001), and procedure time (330 ± 100 vs 230 ± 50 minutes; P =.002) was noted. Estimated blood loss was significantly less (P <.0001), and length of stay had a trend (P =.07) toward being lower for all patients in the 3D fusion CT group. Conclusions These results demonstrate that use of intraoperative 3D fusion CT imaging during FEVAR can significantly decrease radiation exposure, procedure time, and contrast usage, which may also decrease the overall physiologic impact of the repair.