OBJECTIVE: To investigate the incidence and risk factors of acute renal failure (ARF) after operation of frozen elephant trunk and total arch replacement for acute thoracic aortic aneurysm and dissection (TAAD) with mild hypothermic circulatory arrest (MHCA), and to analyze the long-term survival rate of the patients with ARF. PATIENTS AND METHODS: From February 2009 to March 2015, patients with acute TAAD accepted operation of frozen elephant trunk and total arch replacement were enrolled. Those patients who were treated with renal replacement treatment (RRT) before the operation were excluded. The age, gender, cardiovascular disease history, preoperative serum creatinine and extracorporeal circulation duration in operation were recorded. On the basis of requiring RRT after TAAD operation, the patients were divided into ARF group and non-ARF group. The risk factors of ARF after TAAD operation were assessed by univariate and multivariate analysis. After completion of clinical follow-up, Kaplan-Meier curve was drawn to analyze five-year survival. RESULTS: A total of 524 patients were included in the study. 51 cases of them got postoperative ARF. The incidence was 9.7%. The mortality rate of ARF group in the hospital was significantly higher than non-ARF group (25.5% vs. 3.6%; p< 0.001). Univariate analysis showed that there was statistically significant difference in the age, gender, hypertension history, preoperative serum creatinine >= 200 mu mol/L, extracorporeal circulation duration >= 260 min and combined with coronary artery bypass surgery simultaneously (p< 0.05). Multiple logistic regression analysis showed that there were three independent risk factors of ARF after the operation, including hypertension (p= 0.031, OR= 2.377), preoperative serum creatinine >= 200 mu mol/L (p= 0.005, OR= 4.451) and extracorporeal circulation duration >= 260 min (p= 0.002, OR= 3.295). The total five-year survival rate of ARF group after the operation was 56%. There was no statistically significant difference in the five-year survival rate between preoperative serum creatinine >= 200 mu mol/L group and < 200 mu mol/L group (p> 0.05). CONCLUSIONS: The incidence of ARF after the operation was 9.7%. Preoperative serum creatinine >= 200 mu mol/L, hypertension history and extracorporeal circulation duration >= 260 min were independent risk factors of ARF after the operation. The five-year survival rate of ARF after the operation was 56%. The preoperative serum creatinine level had no influence on the postoperative long-term survival.