A 60 year old female was admitted because of extensive aneurysm involving the ascending, arch, and thoracoabdominal aorta. The treatment was staged surgical reapir. In stage one, the ascending and arch aneurysms were repaired using car-diopulmonary bypass, profound hypothermia, circulatory arrest, and retrograde cerebral perfusion via the superior vena cava. The "elephant trunk" technique was used. Two months later, the patient was readmitted for repair of her thoracoabdominal aortic aneurysm which was accomplished using the adjunct distal aortic perfusion and CSF drainage.