There is no agreement at present as to which is the optimal site for artery cannulation for cardiopulmonary bypass in repair of acute aortic dissection (AAD). We have employed right axillary artery cannulation (RAAC) in combination with femoral artery cannulation to overcome the drawbacks of single cannulation. From January 2000 to August 2006, 88 patients underwent emergency surgical repair of the aortic arch (mean age 65+/-13 years, 37 men) for AAD. All operations were performed under hypothermic circulatory arrest with antegrade selective cerebral perfusion. Preoperatively, nine patients were in shock and 18 patients showed malperfusion. The average duration of circulatory arrest was 52+/-17 min and that of myocardial ischemia was 135+/-53 min. Total aortic arch replacement was done in 47 patients and hemiarch aortic replacement in 41. The hospital mortality rate was 2.3% (2 of 88); the fatal cases were among those who were in shock preoperatively. The perioperative stroke rate was 5.7% (5 of 88). The hospital mortality rate of the 25 patients with preoperative malperfusion was 4.0% (1 of 25); the fatal case had coronary malperfusion. Our approach for AAD was associated with a low mortality even in patients with malperfusion.