Severe atherosclerosis of the ascending aorta is associated with an increased incidence of stroke after cardiac surgery. Direct intraoperative epiaortic scanning is a rapid and accurate means for detection of ascending aortic atherosclerosis. When severe atheromatous disease is detected, graft replacement of the ascending aorta is our preferred method of management. During an 11-year period, 81 patients (mean age 71 years) who underwent coronary artery bypass were found to have severe ascending aortic atherosclerosis by epiaortic scanning. Using hypothermic circulatory arrest, 80 patients underwent partial (5) or complete (75) ascending aortic replacement. One patient underwent resection of a protruding aortic atheroma. In addition to partial or total replacement of the ascending aorta, 34 patients had replacement of the aortic arch, 19 had a valve replacement, and 6 had carotid endarterectomy. The 30-day mortality was 8.6% (7 patients). Four patients (4.9%) sustained perioperative strokes and 2 (2.5%) sustained transient perioperative ischemic neurological deficits. The 3-year survival rate was 40%. There was one stroke 4 months postoperatively that eventually led to late death. Elective resection and graft replacement of the severely atherosclerotic ascending aorta using hypothermic circulatory arrest in patients undergoing cardiac operations is a safe procedure, associated with an acceptable incidence of postoperative stroke. The procedure may provide long-term protection from subsequent embolic cerebral vascular events. However, long-term survival has been disappointing and is primarily related to generalized atherosclerosis.