Abstract
Single-stage extended replacement from the ascending to the distal descending aorta or beyond is a formidable operation that should be preserved for those who have no other option or those who are physically fit, and should be performed in the experienced centers. Hybrid operations combining open surgical repair with thoracic endovascular aortic repair through a median sternotomy incision are preferable because these operations are less invasive than the extended open aortic repair and the risk of spinal cord ischemia is lower compared with the frozen elephant trunk operation. However, these operations are associated with the inherent demerits of endovascular aneurysm exclusion. When the underlying aortic pathology necessitates extended open aortic repair in a single stage, approaches such as the anterolateral partial sternotomy, straight incision with rib cross, and extended thoracotomy with sternal transection may be useful to provide sufficient exposure for both aortic reconstruction and organ protection, with less surgical stress to the patients.