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Deep hypothermia or circulation arrest is widely used during total aortic arch replacement. However, conventional procedures have high morbidity and mortality.1 We use the “branch-first” technique2,3 combined with clamping the distal aorta, incorporating a stented elephant trunk to avoid deep hypothermia and circulation arrest. This technique brings us closer to the goal of arch surgery without cerebral or visceral circulatory arrest and the morbidity of deep hypothermia. Early results are encouraging.