The surgical approach to the treatment of distal aortic arch aneurysms is still a matter of controversy. Median sternotomy is usually selected when the patient has the pulmonary emphysema, and the atherosclerotic change involves the ascending aorta or the aortic arch as well as the distal aortic arch. However, when the end of the aneurysm is deep and distant, distal anastomosis becomes more difficult. Left thoracotomy is another approach, but in the patients with impaired respiratory function or when dense lung adhesions to the chest wall are anticipated because of a history of inflammation, the risk of intraoperative bleeding and postoperative respiratory complications becomes a major concern. Total arch replacement by an open stent graft insertion method through a median sternotomy has been devised as a procedure that overcomes these problems. However, since no ideal device for delivering long stent grafts beyond the aneurysm is available, we developed a new delivery system, and we successfully applied it clinically in a patient with an enlarged distal aortic arch.