The modified multiple branched graft was constructed by suturing three grafts to the openings in a straight graft in an end-to-side fashion with running 4–0 polypropylene. Therefore, it comprised a main graft and three branches. The first branch was perpendicular to the other two branches, and the third branch was bifurcated into two limbs (Fig. 1).

The sizes and attachment of the main graft and three branches were showed in Fig. 2.

Patient was in the right lateral decubitus position with the lower body slightly tilted to the left, and a left thoracoabdominal incision was performed. The cardiopulmonary bypass was established by a venous cannula placed in the right atrium through the left femoral vein and 2 arterial return cannulas inside both femoral artery and ascending aorta. If the proximal thoracic descending aorta was not involved by the aneurysm and was long enough for both clamping and anastomosis (usually Crawford extent III TAAA), proximal aortic anastomosis was performed under mild hypothermic cardiopulmonary bypass and beating heart. otherwise, it was performed using an open technique with profound hypothermic circulatory arrest.

During our modified multiple branched graft replacement of TAAA, the proximal aortic anastomosis was performed first. After a proximal aortic clamp was placed just distal to the left subclavian artery or profound hypothermic circulatory arrest was established, a distal aortic clamp was positioned above the diaphragm. The aorta was transected proximal to the diseased segment and the proximal end of the choiced modified multiple branched graft was cut to the appropriate length. Then, the anastomosis between the proximal aorta and the proximal end of the modified multiple branched graft was performed with a continuous 4–0 polypropylene suture. As this proximal aortic anastomosis was completed, the air was evacuated from the graft, and a graft clamp was placed under this proximal aortic anastomosis.

Next, the distal aortic clamp was repositioned just above the ostia of the visceral arteries. The T6 to T12 intercostal arteries were isolated with a full-thickness patch of aorta. After this aortic patch was sutured to the first branch of the modified multiple branched graft, the graft clamp was released and replaced below the first branch to permit perfusion of those implanted intercostal arteries. During the graft clamp movement, air was evacuated from the graft. Then, the distal aortic clamp was repositioned above the aortic bifurcation. Orifices of celiac, superior mesenteric, and right renal arteries were joined at a single aortic patch, and this aortic patch was anastomosed to the distal end of the main graft. Thereafter, the graft clamp below the first branch was removed and air was evacuated from the graft, and both second and third branches were individually clamped. When this step was completed, perfusion to the viscera and right kidney was restored. The second branch was anastomosed to the left renal artery, and then the blood supply was restored to the left kidney after the second branch clamp removal and air evacuation Finally, the third branch was anastomosed to the normal distal abdominal aorta or it’s two limbs to the bilateral iliac arteries after the third branch or it’s limbs were trimmed in the suitable length.