We present a surgical case of 61-year-old man with distal aortic arch aneurysm. Under selective cerebral perfusion in deep hypothermia, we approached to the aneurysm through median sternotomy. Dilated distal aortic arch and proximal descending aorta with mural thrombus in the aneurysmal lumen were found. The aortic occlusion balloon catheter was inserted into the descending aorta. A Cooley woven Dacron graft (26 mm in diameter) was anastomosed at 5 cm above its distal end loosely to the descending aorta with five interrupted mattress sutures, and the distal portion of the graft was pushed down into the distal aorta ("elephant trunk" technique). Postoperative course was uneventful and the dead space around the graft in aneurysm was filled with thrombus. Six months later, however, emergent operation was performed because of compression of the bronchus and the esophagus by enlargement of the aneurysm due to leakage. The second operation was approached through 5th left intercostal thoracotomy and median sternotomy. The aneurysm was opened, and the thrombus was amounted to 500 g. The distal end of the graft was anastomosed end-to-end to the mid-portion of the descending thoracic aorta. Postoperative course was uneventful and the patient was discharged. It is concluded that Elephant trunk technique is effective and the postoperative control of hypertension is very important.