Elephant trunk anastomosis between left carotid and subclavian arteries for aneurysmal distal aortic arch

There is an increased risk of rupture with attempting a distal anastomosis when the distal aortic arch exceeds 5 to 6 cm. To circumvent this problem, we describe performing the anastomosis between the left common carotid and the left subclavian arteries and, at the second-stage operation, interposing a tube graft between the left subclavian artery and the descending aortic tube graft.