Challenging Paradigm Limits of Retrograde Cerebral Perfusion During Lower Body Circulatory Arrest

Published:November 30, 2022DOI:



      Retrograde cerebral perfusion (RCP) is a safe and effective technique to augment cerebral protection during lower body circulatory arrest in patients undergoing elective hemiarch replacement. However, recommendations guiding optimal temperature, flow rate, and perfusion pressure are outdated and potentially overly limiting. We report our experience using RCP for elective hemiarch replacement with parameters that challenge the currently accepted paradigm.


      This was a single-center, retrospective analysis of 319 adult patients who underwent elective hemiarch replacement between February 2010 and 2021 using hypothermic lower body circulatory arrest with RCP alone, RCP followed by antegrade cerebral perfusion (ACP), or ACP alone. Flow rates were adjusted to maintain cerebral perfusion pressure between 30 and 50 mm Hg for RCP and between 40 and 60 mm Hg for ACP.


      RCP was used in 22.6% (n = 72) of cases, whereas ACP alone was performed in 77.4% (n = 247) of cases. Baseline patient characteristics were similar between groups. Patients undergoing RCP demonstrated shorter cross-clamp time (97.0 min versus 100.0 min, P = 0.034) and shorter lower body circulatory arrest time (7.0 min versus 10.0 min, P < 0.0001) compared with ACP alone. Nadir bladder temperature was equivalent between groups (27.3°C versus 27.5°C, P = 0.752). There were no significant differences in postoperative complications, neurologic outcomes, or mortality.


      Moderate hypothermic lower body circulatory arrest combined with RCP at target perfusion pressures of 30-50 mm Hg in patients undergoing elective hemiarch replacement results in equivalent neurologic outcomes and overall morbidity to cases using ACP alone. These results challenge the currently accepted paradigm for RCP, which typically uses deep hypothermia while keeping perfusion pressures below 25 mm Hg.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Surgical Research
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Okita Y.
        • Minatoya K.
        • Tagusari O.
        • Ando M.
        • Nagatsuka K.
        • Kitamura S.
        Prospective comparative study of brain protection in total aortic arch replacement: deep hypothermic circulatory arrest with retrograde cerebral perfusion or selective antegrade cerebral perfusion.
        Ann Thorac Surg. 2001; 72: 72-79
        • Svensson L.G.
        • Blackstone E.H.
        • Apperson-Hansen C.
        • et al.
        Implications from neurologic assessment of brain protection for total arch replacement from a randomized trial.
        J Thorac Cardiovasc Surg. 2015; 150: 1140-1147.e11
        • Ganapathi A.M.
        • Hanna J.M.
        • Schechter M.A.
        • et al.
        Antegrade versus retrograde cerebral perfusion for hemiarch replacement with deep hypothermic circulatory arrest: does it matter? A propensity-matched analysis.
        J Thorac Cardiovasc Surg. 2014; 148: 2896-2902
        • Kaneko T.
        • Aranki S.F.
        • Neely R.C.
        • et al.
        Is there a need for adjunct cerebral protection in conjunction with deep hypothermic circulatory arrest during noncomplex hemiarch surgery?.
        J Thorac Cardiovasc Surg. 2014; 148: 2911-2917
        • Milewski R.K.
        • Pacini D.
        • Moser G.W.
        • et al.
        Retrograde and antegrade cerebral perfusion: results in short elective arch reconstructive times.
        Ann Thorac Surg. 2010; 89: 1448-1457
        • Okita Y.
        • Miyata H.
        • Motomura N.
        • Takamoto S.
        A study of brain protection during total arch replacement comparing antegrade cerebral perfusion versus hypothermic circulatory arrest, with or without retrograde cerebral perfusion: analysis based on the Japan Adult Cardiovascular Surgery Database.
        J Thorac Cardiovasc Surg. 2015; 149: S65-S73
        • Sugiura T.
        • Imoto K.
        • Uchida K.
        • Minami T.
        • Yasuda S.
        Comparative study of brain protection in ascending aorta replacement for acute type A aortic dissection: retrograde cerebral perfusion versus selective antegrade cerebral perfusion.
        Gen Thorac Cardiovasc Surg. 2012; 60: 645-648
        • Leshnower B.G.
        • Rangaraju S.
        • Allen J.W.
        • Stringer A.Y.
        • Gleason T.G.
        • Chen E.P.
        Deep hypothermia with retrograde cerebral perfusion versus moderate hypothermia with antegrade cerebral perfusion for arch surgery.
        Ann Thorac Surg. 2019; 107: 1104-1110
        • Ghincea C.V.
        • Aftab M.
        • Ikeno Y.
        • Mesher A.L.
        • Reece T.B.
        Cerebral protection in type A aortic dissection.
        J Vis Surg. 2020; 7
        • Usui A.
        • Oohara K.
        • Liu T.L.
        • et al.
        Determination of optimum retrograde cerebral perfusion conditions.
        J Thorac Cardiovasc Surg. 1994; 107: 300-308
        • Nojima T.
        • Magara T.
        • Nakajima Y.
        • et al.
        Optimal perfusion pressure for experimental retrograde cerebral perfusion.
        J Card Surg. 1994; 9: 548-559
        • Brown J.A.
        • Navid F.
        • Serna-Gallegos D.
        • et al.
        Long-term outcomes of hemiarch replacement with hypothermic circulatory arrest and retrograde cerebral perfusion.
        J Thorac Cardiovasc Surg. 2021; (Epub ahead of print)
        • Lau C.
        • Gaudino M.
        • Iannacone E.M.
        • et al.
        Retrograde cerebral perfusion is effective for prolonged circulatory arrest in arch aneurysm repair.
        Ann Thorac Surg. 2018; 105: 491-497
        • Ueda Y.
        • Miki S.
        • Kusuhara K.
        • Okita Y.
        • Tahata T.
        • Yamanaka K.
        Surgical treatment of aneurysm or dissection involving the ascending aorta and aortic arch, utilizing circulatory arrest and retrograde cerebral perfusion.
        J Cardiovasc Surg. 1990; 31: 553-558
        • Safi H.J.
        • Letsou G.V.
        • Iliopoulos D.C.
        • et al.
        Impact of retrograde cerebral perfusion on ascending aortic and arch aneurysm repair.
        Ann Thorac Surg. 1997; 63: 1601-1607
        • Coselli J.S.
        • LeMaire S.A.
        Experience with retrograde cerebral perfusion during proximal aortic surgery in 290 patients.
        J Card Surg. 1997; 12: 322-325
        • Ueda Y.
        A reappraisal of retrograde cerebral perfusion.
        Ann Cardiothorac Surg. 2013; 2: 316-325
        • Seese L.
        • Chen E.P.
        • Badhwar V.
        • et al.
        Optimal circulatory arrest temperature for aortic hemiarch replacement with antegrade brain perfusion.
        J Thorac Cardiovasc Surg. 2021; (Epub ahead of print)
        • Xu S.
        • Liu J.
        • Li L.
        • et al.
        Cardiopulmonary bypass time is an independent risk factor for acute kidney injury in emergent thoracic aortic surgery: a retrospective cohort study.
        J Cardiothorac Surg. 2019; 14: 90
        • Madhavan S.
        • Chan S.P.
        • Tan W.C.
        • et al.
        Cardiopulmonary bypass time: every minute counts.
        J Cardiovasc Surg. 2018; 59: 274-281
        • Nadeem R.
        • Agarwal S.
        • Jawed S.
        • Yasser A.
        • Altahmody K.
        Impact of cardiopulmonary bypass time on postoperative duration of mechanical ventilation in patients undergoing cardiovascular surgeries: a systemic Review and regression of metadata.
        Cureus. 2019; 11: e6088
        • Usui A.
        • Abe T.
        • Murase M.
        Early clinical results of retrograde cerebral perfusion for aortic arch operations in Japan.
        Ann Thorac Surg. 1996; 62 (discussion 103-4): 94-103