Between November 2000 and January 2002, two patients with aneurysms that involved the distal part of the aortic arch including the left subclavian artery were treated at our institution. Patient 1 had an aneurysm of 5.8 cm extending to the proximal descending aorta. Patient 2 had a 6.8 cm type II thoracoabdominal aneurysm extending proximal to the aortic bifurcation. Both patients had left subclavian-to-carotid transposition in preparation for distal aortic arch replacement. Complete replacement of the descending thoracic and abdominal aorta was carried out in patient 2. Both cases were done with distal aortic perfusion, spinal catheter drainage, and dual lumen endotracheal anesthesia. There was no mortality. There were no cerebrovascular complications in spite of the fact that patient 1 required aortic cross-clamping between the innominate and left carotid artery. There was no paraplegia, renal failure, or mesenteric or lower extremity complications. Patient 1 had postoperative vocal cord palsy, eventually requiring medialization procedure. He recovered normal voice. Both patients remain alive and well at the time of last follow-up (7 to 20 months). Carotid subclavian reconstruction in preparation for distal aortic arch replacement facilitates the performance of the proximal anastomosis and attempts to maintain flow through the left vertebral system during aortic cross-clamping. This may reduce the risk of stroke during distal aortic arch replacement.