The surgical treatment of ascending aortic and arch aneurysms, even though technically complex and requiring care to avoid neurological sequelae, is well established. Nevertheless, the presence of a significant innominate artery trunk aneurysm implies an adaptation of the surgical options available. We report a case of an aortic aneurysm that involved the ascending aorta, the proximal transverse arch and the brachiocephalic trunk with cranial displacement of the right subclavian and common carotid arteries. This pattern, meant that it was mandatory to change the usual surgical approach. We resected the ascending aorta and the proximal aortic arch replacing them with a dacron prosthesis in a usual fashion. Nevertheless, we were compelled to perform the anastomoses of the innominate trunk branches in an extrathoracic fashion. Furthermore, to ensure an uninterrupted cerebral perfusion, the usual surgical steps were personalized. The anatomical findings, computed tomographic images, surgical technique, cerebral protection and postoperative evaluation are described.