Five patients with aneurysm involving distal aortic arch underwent graft replacement of distal aortic arch and, in two patients, reconstruction of left subclavian artery through standard left postero-lateral thoracotomy with hypothermic retrograde cerebral perfusion. Retrograde cerebral perfusion with oxygen saturated venous blood could be performed by simply elevating central venous pressure to 20-23 mmHg in the Trendelenburg position and under controlling venous drainage from PA during deep hypothermic (19 degrees C) perfusion of the lower half of the body with the descending aorta occluded. Cardioplegia was induced by administration of cold blood cardioplegic solution into coronary circulation through Foley balloon catheter wedged in ascending aorta. Retrograde cerebral perfusion time was 30-77 min (mean 55 +/- 17 min), and pump time was 156-193 min (mean 168 +/- 15 min). There were no complications neurologically. In conclusion, this method rendered surgical repair of distal aortic arch aneurysm through left postero-lateral thoracotomy with both cerebral and cardiac protection able. Since any clamping of aortic arch and its branch was not necessary during above surgical procedure, cerebral emboli due to atheroma or luminal thrombus in aortic arch was prevented.