The technique of antegrade cerebral perfusion has been adopted by many aortic centers as the routine method of brain protection with some variations in its implementation stemming from perfusion pressure, flow, temperature, pH management, hematocrit value, cannulation sites, and unilateral versus bilateral application

1. Brain Protection
Management – (in Aortic
Arch surgery )
Antegrade cerebral
perfusion
Jonathan Frimpong- Ansah

2. Basic Science of human brain
• Human brain weighs about 1,500 g and uses 15% of the total metabolic energy. This
demand can be supplied by an average blood flow of 50 mL (3 mLO2 ) per 100 g of brain
tissue per min.
• Autoregulation may be lost in deep hypothermia, resulting in a perfusion of the brain with
a risk of increased intracerebral pressures and cerebral oedema
• Cardiac arrest and hypothermic circulatory arrest with selective antegrade brain perfusion
to a core temperature of approximately 20°C
In the literature it is reported that improvement in brain protection is obtained through the application
of selective perfusion techniques, either in an anterograde manner through the carotid
arteries, unilaterally or bilaterally, or in a retrograde fashion via the superior vena cava​.

3. Cannulation/ Clamping
SVENSSON ET AL Ann Thorac Surge 1275 2004;78:1274–84
Axillary inflow plus graft reduces stroke and is method of choice for complex cardiac and cardioaortic
operations that necessitate circulatory arrest. Retrograde or antegrade perfusion is used selectively

4. Central cannulation – Fast and easy
with ultrasonic visualization, and a
straight course to the superior vena
cava (on the right)

5. Survey across European cardiac centers to evaluate the methods used for cerebral protection during aortic
surgery involving the aortic arch.
The most preferred site for arterial cannulation is the subclavian–axillary, both in acute and chronic
presentation.
The femoral artery is still frequently used in the acute condition, while the ascending aorta is a frequent second
choice in the case of chronic presentation.
Bilateral antegrade brain perfusion is chosen by majority of centers (2/3 of cases), while retrograde perfusion or
circulatory arrest is very seldom used and almost exclusively in acute clinical presentation.
the perfusate temperature is usually maintained between 22 and 26°C. One-third of the centers use lower
temperatures
Perfusate flow and pressure are slightly consistent among centers in the range of 10–15 ml/kg and 60 mmHg,
respectively. In 60% of cases, barbiturates are added for cerebral protection, while visceral perfusion still
receives little attention

6. Preferred arterial cannulation sites as a first choice (A) or as a second choice (B)

10. The technique of antegrade cerebral perfusion has been
adopted by many aortic centers as the routine method of
brain protection with some variations in its
implementation stemming from perfusion pressure, flow,
temperature, pH management, hematocrit value,
cannulation sites, and unilateral versus bilateral
application.