Replacement of the aortic arch during repair of either extensive aortic aneurysmal disease or aortic dissection can be a major undertaking. Borst introduced an "elephant trunk" technique whereby a tubular aortic graft prosthesis was inserted into the distal aorta while repairing the ascending aorta and aortic arch. The distal elephant trunk prosthesis was then used for a second stage operation that involved replacement of sections of the distal aorta. Since then, a few problems have been encountered with the standard elephant trunk procedure and this has led to a modification of the elephant trunk technique, which enables a more accurate and secure distal aortic arch anastomosis to be performed. Using the standard technique described by Borst, the surgeon has to suture in the groove between the tubular graft and the aortic wall, which can increase the risk that torsion on the suture needle will tear the aortic wall resulting in aortic rupture. Indeed, this complication has been noted in the postoperative period when performing the standard technique. Subsequently, the technique was modified with inversion of the graft in itself, placement of the graft in the descending aorta, and performance of the distal anastomosis using a technique similar to that described by Griepp. This has improved the ease of performing the procedure and the results of the technique such that a better than 90% survival rate can be expected for the first and the second stage repairs.