Background <p>Ascending aortic cannulation is the standard arterial inflow strategy for cardiovascular surgery that requires cardiopulmonary bypass. However, this approach can be problematic in patients with extensive atheromatous disease of the ascending aorta, commonly referred to as shaggy aorta, because of the increased risk of thromboembolic complications. Therefore, alternative cannulation strategies are required in such high-risk settings.</p> Case presentation <p>A 75-year-old woman presented with a 55-mm distal aortic arch aneurysm accompanied by an extensively shaggy aorta involving the ascending aorta. Ascending aortic arch replacement using the frozen elephant trunk technique was performed, and the transatrial left ventricular cannulation technique for arterial inflow. Cardiopulmonary bypass was established while preserving the spontaneous cardiac activity with epicardial pacing during cooling. Additional embolic prevention strategies include temporary retrograde cerebral perfusion before selective antegrade cerebral perfusion and controlled blood evacuation via the femoral artery during reperfusion. The operative, cardiopulmonary bypass, cardiac arrest, and circulatory arrest times were 326, 185, 91, and 61&#xa0;min, respectively. The postoperative course was uneventful, and no thromboembolic complications, including cerebral infarction, were observed. Postoperative imaging confirmed the complete exclusion of the aneurysm without endoleaks.</p> Conclusion <p>Thoracic aortic aneurysm surgery in patients with a shaggy ascending aorta carries a substantial risk of embolism. The present case demonstrates that transatrial left ventricular cannulation combined with multiple embolic prevention strategies might be a safe and effective option for aortic arch surgery in this high-risk population.</p>