In an effort to improve upon morbidity following thoracic aortic aneurysm repair there has been an increased utilization of endovascular stent grafts as an alternative treatment option. This minimally invasive approach is desirable in patients at high-risk for conventional aneurysm repair. Attempts to offer this minimally invasive option to candidates with unsuitable anatomy may include a combination of conventional surgery and endovascular technology. A two-stage approach with an intial aortic arch replacement with "elephant trunk" reconstruction followed by a second stage endovascular repair of the descending throacic aorta is an example of such a combined treatment successfully tulized in a patient with a syphilitic aneurysm.