[Fight with Neurological Complication in Total Arch Replacement].

The surgical outcomes of total arch replacement in patients both with atherosclerotic aneurysm and Stanford type A acute aortic dissection have been improved. The development of brain protection contributed to excellent results in aortic arch surgery. Total arch replacement with four branched vascular graft using antegrade selective cerebral perfusion under mild hypothermia has been standardized in Japan, resulting in lower operative mortality and perioperative cerebral complications. However, severely atherosclerotic aorta with diffuse ulcers, "shaggy aorta", still has a potential high-risk for neurological deficits. Herein, the strategies to prevent neurological complications in total arch replacement, including preoperative images, cannulation/cerebral perfusion, temperature, monitoring systems are discussed. Finally, surgical approaches to shaggy aorta are reviewed. The combination of each step can lead to satisfactory surgical outcomes.