Background Porcine bioprosthesis (bioroots) are an attractive surgical strategy for ascending aorta and arch replacement. This study evaluated the perioperative and late outcomes using this strategy for proximal aortic aneurysmal disease. Methods Between March 1998 and November 2009, 170 patients (40% women; median age, 70 years) underwent proximal thoracic aortic replacement using the Freestyle (Medtronics Inc, Minneapolis, MN) bioroot, with graft extension in 149 (87.6%). Aneurysmal etiology included degenerative-atherosclerotic (91.2%), acute dissection (5.3%), and chronic dissection (3.5%); 78% had greater than moderate aortic insufficiency. Surgical procedures were bioroot alone or with aortoplasty (12.3%), bioroot with ascending aortic graft (38.2%), bioroot with hemiarch graft (44.1%), and bioroot with total arch (5.3%). Hypothermic circulatory arrest was required in 49%. Results The 30-day mortality was 4.7% (n = 8). The overall complication rate was 58% (n = 100), including stroke (6.5%), renal failure (9.2%), respiratory failure (25.9%), and postoperative bleeding (7.6%). Mean hospitalization was 10.5 ± 7.3 days; 38 were discharged to a rehabilitation facility (23.5%). Predictors of 30-day/hospital death were coronary artery disease ( p = 0.0003), renal insufficiency ( p < 0.0001), emergent/urgent procedure ( p = 0.02), and hypothermic circulatory arrest ( p = 0.002). The 1-year, 5-year, and 10-year survivals were 90%, 80%, and 35% respectively. Freedom from endocarditis and reoperation was 96% at 1 year and 94% and 95% at 5 years, respectively. Conclusions Proximal thoracic aortic replacement using a porcine bioroot as part of the repair can be achieved with low perioperative mortality and acceptable late survival in a predominantly elderly population.