Total arch replacement and classic elephant trunk in a patient with an anomalous left vertebral artery.

This video tutorial explains how to treat an aortic aneurysm affecting the arch, descending, and thoracoabdominal segments, in the presence of an anatomical aortic arch variation. The procedure involves replacing the entire aortic arch and ascending aorta using the classic elephant trunk technique, creating a platform for a planned staged endovascular treatment. Special emphasis is placed on cerebral protection strategies, including preservation of an anomalous left vertebral artery and special reinforcement of a distal arch anastomosis. The presence of an anomalous artery arising directly from the aortic arch increased the technical difficulty, requiring customized revascularization to ensure appropriate left posterior cerebral circulation. This case reinforces the idea that open techniques can be safe for selected elderly patients with complex anatomies, highlighting the importance of tailored strategies and careful surgical execution.