Aortic arch replacement has been safely performed by moderate hypothermic circulatory arrest, and antegrade selective cerebral perfusion. To prevent permanent neurological deficit, it is important to precisely evaluate brain, neck vessels and atherosclerotic thoracic aorta by computed tomography(CT), magnetic resonance imaging (MRI)and intraoperative epiaortic echography, which can lead the safest cannulation site, careful manipulation of cerebral perfusion catheters. It is also important to make good exposure of surgical site, especially in distal anastomosis, and irrigate and flush atheromatous debris. Since 1991 to 2013, our consecutive 410 cases of total and hemi arch replacement of aorta, including 57 emergency cases, result in 22 cases( 5.4%) of mortality( 3.1% of elective, 19.3% of emergency) and 10 cases( 2.4%) of stroke( 2.3% of elective, 3.5% of emergency). Mortality and morbidities are more likely be occurred in emergency cases. It is possible to keep good operative results with reliable brain protection of selective antegrade cerebral perfusion which gives enough time for secure open distal anastomosis to every surgeon, but atheroemborism from shaggy aorta remains as a problem yet to be solved.