**1. Introduction**

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Total arch replacement (TAR) is still a challenging procedure for cardiovascular surgeons because of the high incidence of mortality and brain accident. We have developed a fast-track TAR technique which is completed within 3-4 hours. In the present chapter, we describe in detail our surgical procedure for improving TAR outcomes.

Historically, TAR has required deep hypothermic circulatory arrest (DHCA) or retrograde cerebral perfusion with DHCA during distal anastomosis. However, DHCA has been shown to have adverse effects upon multiple organ systems. Moreover, these techniques do not give the surgeon adequate time to complete the aortic arch repair, the safety margin for which is limited to 40 to 60 minutes.

The antegrade selective cerebral perfusion (SCP) technique has been applied worldwide with various modifications. However, there is no common guideline as to the temperature that should be achieved before extracorporeal circulation can be stopped and replaced by initiation of SCP. Many institutions have recently attempted to elevate body temperature and reported excellent results in SCP with mild to moderate hypothermic circulatory arrest. We have begun to use milder levels of hypothermia based on a tympanic temperature of 25-28℃. We present our experience of using an SCP technique with mild hypothermia in total arch replacement.
