Treatment of acute type A aortic dissection with emergency total aortic arch graft replacement remains controversial. Between December 1988 and July 1993, 30 patients with this fatal disease underwent graft replacement of both the ascending aorta and total aortic arch on an emergency basis. All operations were performed with the aid of extracorporeal circulation, blood cardioplegia, selective cerebral perfusion, and open distal anastomosis. The overall early mortality rate was 23.3% (7 patients), but that in patients with complications with shock and renal/mesenteric ischemia was 57% and 66.7%, respectively. On the other hand, the mortality rate in the 23 patients (77%) in whom neither of these two risk factors was present was low (8.7%). The overall 4-year survival rate was 66.5% +/- 8.7%, and that for patients without these two risk factors was 87.0% +/- 7.0%. The present data suggest that simultaneous total arch replacement may be justified in selected patients with acute type A aortic dissection.