BACKGROUND: Control of hemorrhage in patients with active bleeding from rupture of the aortic arch is difficult, because of the location of the bleeding and the impossibility of cross-clamping the aorta without interfering with cerebral perfusion. A precise and swift plan of management helped us salvage some patients and prompted us to review our experience. METHODS: Six patients with active bleeding of the aortic arch in the mediastinum and pericardial cavity (5 patients) or left pleural cavity (1 patient), treated between 1992 and 1996, were reviewed. Bleeding was reduced by keeping the mediastinum under local tension (3 patients) or by applying compression on the bleeding site (2 patients), or both (1 patient) while circulatory support, retransfusion of aspirated blood, and hypothermia were established. The diseased aortic arch was replaced during deep hypothermic circulatory arrest, which ranged from 25 to 40 minutes. In 3 patients, the brain was further protected by retrograde (2 patients) or antegrade (1 patient) cerebral perfusion. RESULTS: Hemorrhage from the aortic arch was controlled in all patients. Two patients died postoperatively, one of respiratory failure and the other of abdominal sepsis. Recovery of neurologic function was assessed and complete in all patients. The 4 survivors are well 8 to 49 months after operation. CONCLUSIONS: An approach relying on local tamponade to reduce bleeding, rapid establishment of circulatory support and hypothermia, retransfusion of aspirated blood, and swift repair of the aortic arch under circulatory arrest allows salvage of patients with active bleeding from an aortic arch rupture.