We conducted 2 cases of total aortic arch replacement with an isolated left vertebral artery (ILVA). A 71-year-old woman who had distal aortic arch aneurysm with chronic dissection (Stanford B), and a 70-year-old man had sacral arch aneurysm. Their preoperative computed tomography or angiogram could not identify ILVA. In both, surgery was done using 4-branched arch grafts with moderately hypothermic selective cerebral perfusion and systemic circulatory arrest. We perfused all cerebral branches including ILVA with small tubes. Selective cerebral perfusion times were 186 and 162 minutes respectively. All reconstructed ILVA anastomosed to the graft branch with the native left subclavian artery showed good patency. Neither of our patients had cerebral complications and they were discharged on the 20th and 11th postoperative days in good condition.