Purpose: To evaluate outcomes of branch first aortic arch replacement (BFAAR) in patients undergoing emergency or elective surgery aortic pathology. This technique avoids total body circulatory arrest and profound hypothermia. Methods: Single surgeon series of BFAAR from December 2014 to December 2023 at a cardiothoracic unit in Wellington, NZ. First four years a total of 62 patients underwent BFAAR in the unit with one surgeon performing 49 of those. Next 5 years 84 cases with one surgeon performing 35 of those. Highlights the safety and reproducibility of the technique as it was widely adopted in the unit. Each case is performed in an identical manner with central or peripheral cardiopulmonary bypass with sequential debranching of arch vessels from innominate artery to the left subclavian artery using a modified trifurcation dacron graft with a side arm which is used for antegrade cerebral perfusion (ACP). During debranching, perfusion to the heart and distal organs is maintained. Once the proximal and distal aortic anastomosis is completed, the common stem of the trifurcation graft is anastomosed to the neo ascending aorta. Mean age was 61.9. Fourty five cases (53.6%) were acute and the remaining cases were performed for enlarging aneurysms or for chronic type B dissections that required debranching for safe TEVAR landing zone. Fifteen patients (17.8%) underwent a redo operation. Results: There were six mortalities (7.1%), all in the emergency group. Two patients (2.3%) had a post operative stroke. Six patients (7.1%) returned to theatre for bleeding, wound closure or pleural wash out. One patient (1.1%) required an intra-aortic balloon pump and six patients (7.1%) required haemo-filtration for renal support. Conclusion: BFAAR enables us to treat the full extent of the diseased aorta with results comparable to traditional techniques and elective surgery. We are comparing our results with standard techniques in the unit.