OBJECTIVES: The authors aimed to clarify the incidence and risk factors of postoperative liver dysfunction (PLD) in patients undergoing total arch replacement combined with frozen elephant trunk implantation and to determine the association of PLD with short-term outcomes. METHODS: Data from 672 adult patients undergoing total arch replacement with frozen elephant trunk from January 2013 until December 2016 at Fuwai Hospital were analysed retrospectively. A multivariable logistic regression model was used to identify the risk factors for PLD. RESULTS: The overall incidence of PLD was 27.5%, which was associated with higher in-hospital mortality (PLD 4.9% vs No PLD 0.8%, P = 0.002) and 30-day mortality (PLD 9.2% vs No PLD 2.5%, P < 0.001) and a higher incidence of major adverse events (PLD 54.6% vs No PLD 23.4%, P < 0.001). In the multivariable analysis, preoperative hypotension [odds ratio (OR) 1.97, 95% confidence interval (CI) 1.14-3.41; P = 0.02), coronary artery disease (OR 2.64, 95% CI 1.17-5.96; P = 0.02), prolonged cardiopulmonary bypass duration (OR 1.01, 95% CI 1.00-1.01; P < 0.001), increased preoperative alanine transferase (OR 1.01, 95% CI 1.00-1.01; P < 0.001), preoperative platelet count <100 x 10(9)/l (OR 3.99, 95% CI 1.74-9.14; P = 0.001) and increased intraoperative erythrocyte transfusion (OR 1.07, 95% CI 1.01-1.12; P = 0.02) were identified as independent risk factors for PLD. CONCLUSIONS: PLD was associated with increased mortality and morbidity. Among the independent risk factors for PLD, cardiopulmonary bypass duration and erythrocyte transfusion could be modifiable. A skilled surgical team and an ideal blood protection strategy may be helpful to protect liver function.