The total arch replacement with frozen elephant trunk (TARFET) technique has emerged as a leading treatment for extensive aortic pathologies that span from the aortic arch to the proximal descending thoracic aorta. By enabling a single-stage repair that combines complete arch reconstruction and antegrade stent graft deployment under hypothermic circulatory arrest with selective cerebral perfusion, TARFET surgery presents unique and significant challenges to anesthesiologists and surgeons. Anesthesiologists must possess a comprehensive understanding of the surgical procedure and related physiological shifts, and they are vital in preoperative preparation, neurologic monitoring for neuroprotection, and hemodynamic management to support organ perfusion. In addition, anesthesiologists contribute to procedural success by actively evaluating stent graft placement and true lumen perfusion and by approximating the distal stent landing position with intraoperative transesophageal echocardiography. This narrative review highlights key perioperative anesthetic considerations and the role of anesthesiologists in TARFET surgery, focusing on the use of intraoperative transesophageal echocardiography and anesthetic management related to strategies for cerebral and spinal cord protection. Consistent, real-time collaboration within a multidisciplinary heart team and vigilant intraoperative monitoring may help support improved patient outcomes of this technically demanding and increasingly adopted procedure.