Background Aortic arch reconstruction is associated with high neurological morbidity. Our purpose is to describe our experience using a 4-branched graft and selective antegrade brain perfusion (SABP) for total aortic arch replacement (TAR). Methods We retrospectively reviewed the medical records of 12 patients who received TAR, with or without ascending aorta replacement, with a 4-branched graft for Stanford type A dissection ( n = 9) or aortic arch aneurysm ( n = 3). In all patients surgery was performed with deep hypothermic circulatory arrest (DHCA) with or without retrograde brain perfusion, and selective antegrade brain perfusion (SABP) via the subclavian artery or axillary artery. Results There were 8 males and 4 females with an average age of 63.14 years. Emergent operations were performed in 9 patients with acute type A aortic dissections. Of all 12 patients, 2 deaths occurred and 1 patient experienced lower extremity paraplegia resulting in an in-hospital mortality rate of 16.6% and a permanent neurological deficit rate of 8.3%. Conclusions The use of a 4-branched graft, hypothermic circulatory arrest, and SABP is a useful operative method for aortic arch replacement with acceptable morbidity and mortality.