Abstract Objective We attempted to identify predictors of adverse outcomes after traditional open and hybrid zone 0 total aortic arch replacement. Methods We performed multivariable analysis using 16 variables to identify predictors of adverse outcomes (mortality, permanent neurologic events, and permanent renal failure necessitating hemodialysis) in 319 consecutive patients who underwent total aortic arch replacement in the past 8.5 years and a subgroup analysis in 25 propensity-matched pairs. A total of 274 patients (85.9%) had traditional open repair, and 45 patients (14.1%) had hybrid zone 0 total arch exclusion. Results Operative mortality was 10.3% (n = 33): 11.1% (n = 5) in the hybrid group and 10.2% (n = 28) in the traditional group ( P  = .79). A total of 19 patients (5.9%) had permanent stroke (15 traditional 5.5% vs 4 hybrid 8.9%; P  = .32), and 2 patients (both traditional) had permanent paraplegia ( P  = 1.00). The hybrid group had more total neurologic events ( P  = .051) but not more permanent strokes ( P  = .32). Prior cardiac disease unrelated to the aorta ( P  = .0033) and congestive heart failure ( P  = .0053) independently predicted permanent adverse outcome (operative mortality, permanent neurologic event, or permanent renal failure). Concomitant coronary artery bypass grafting independently predicted permanent stroke ( P  = .032), as did previous cerebrovascular disease ( P  = .032). In multivariable analysis, procedure type (hybrid or traditional) was not an independent predictor of stroke ( P  = .09). During a median follow-up of 4.5 years (95% confidence interval, 3.9-4.9), survival was 78.7%, with no intergroup difference ( P  = .14). Conclusions Among contemporary cases, both traditional and hybrid total aortic arch replacement had acceptable results. Comparing these 2 different surgical treatment options is challenging, and an individualized approach offers the best results. Permanent adverse outcome was not significantly different between the 2 groups. Procedure type is not an independent predictor of permanent stroke. Prior cardiac disease, past or current smoking, and congestive heart failure predict adverse outcomes for total aortic arch replacement.