Antegrade or retrograde cerebral perfusion as an adjunct during hypothermic circulatory arrest for aortic arch surgery.

Surgery of the aortic arch is a great challenge in cardiovascular surgery. Its partial or total replacement demands the temporary interruption of normal cerebral perfusion, with associated potential for neurological injury. Three methods of cerebral protection have been applied between 1975 and today: hypothermic circulatory arrest as a basic method, either alone or with antegrade cerebral perfusion (ACP), or retrograde cerebral perfusion (RCP) as an adjunctive method. After extensive research regarding the controversies that surround the ideal method of cerebral protection, it is obvious that ACP is superior to RCP for brain protection. ACP obtains a near-physiologic brain perfusion, with homogenous distribution of blood throughout the capillary beds, and extends the safe time of hypothermic circulatory arrest to 80 min, allowing the completion of whatever aortic arch work is necessary. By contrast, RCP perfuses a smaller brain territory than ACP, approximately 10-20%. Hence, RCP is, in our opinion, a 'smaller adjunct' to brain protection than ACP. Detailed evidence and future directions for further research are discussed.