Antegrade (Selective) Cerebral Perfusion (ACP)

Date
September 11, 2025
URL
https://x.com/withascalpel/status/1966108543062356120?s=46
Categories
Cardiac SurgeryCoA

Antegrade (Selective) Cerebral Perfusion (ACP)

Antegrade (selective) cerebral perfusion is a brain-protection strategy for open aortic arch procedures in which oxygenated blood is delivered directly to the cerebral circulation—most commonly via the innominate artery—while systemic flow is reduced or interrupted. Compared with deep hypothermic circulatory arrest (DHCA) alone, ACP is associated with lower pooled operative mortality and disabling stroke in large meta-analyses and contemporary series, and it is widely favored in pediatric arch reconstruction where tolerance for prolonged DHCA is limited [1–4].

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Indications

Use ACP whenever the transverse arch or proximal great vessels must be opened or reconstructed: Norwood stage 1, interrupted or hypoplastic arch repair, complex coarctation, truncus arteriosus with arch involvement, re-do arch procedures, and selected adult congenital/acquired arch reconstructions. Pediatric cohorts and comparative studies support ACP as at least equivalent—and often superior—to DHCA for early neurologic outcomes in these contexts [2–4].

Physiologic Rationale

The immature brain has high oxygen demand and limited collateral reserve. ACP maintains antegrade hemispheric flow (typically innominate → right carotid → circle of Willis) while the distal aorta is cross-clamped or opened. Relative to DHCA alone, ACP shortens arrest intervals, enables titratable perfusion pressures, and mitigates ischemia–reperfusion injury; pooled data show lower risks of death and disabling stroke versus DHCA [1–3].

Temperature Strategy

Hypothermia remains essential to reduce cerebral metabolic rate. Most pediatric programs pair ACP with moderate hypothermia (~20–28 °C); adult and mixed-age reviews similarly recommend perfusate temperatures in this range with core cooling tailored to expected arrest duration [6]. Compared with DHCA alone, moderate hypothermia with ACP preserves neurologic outcomes with less total bypass/rewarming time [2–4,6].

Cannulation and Perfusion Technique

  • Flow. Start with ~40–60 mL/kg/min during moderate hypothermia and adjust to monitoring; flows <30 mL/kg/min are often inadequate in infants [5,6].
  • Perfusate temperature. Match systemic temperature; maintain hematocrit ~25–30% as per protocolized approaches [6].
  • Cannulation site. In infants, the innominate artery via a short side graft is common; in larger children, right axillary cannulation is an alternative. Direct innominate cannulation using a small pediatric cannula is a simple, effective option during hemiarch/arch work and can avoid axillary complications [9,10].
  • Laterality. Unilateral ACP via the innominate is generally adequate for shorter reconstructions. When ACP time is expected to exceed ~25–50 minutes, bilateral ACP (adding left carotid perfusion) reduces biochemical injury and may improve survival in longer cases, particularly when circle-of-Willis competence is uncertain [7,8].

Intraoperative Monitoring and Targets

  • Pressure target. Use the right radial arterial line as a practical surrogate during unilateral ACP; target 40–60 mmHg with adjustments for age, temperature, and neuromonitoring [6].
  • NIRS. Continuous cerebral NIRS to trend rSO₂, detect cannula malposition, and identify hemispheric asymmetry; add renal NIRS for distal body ischemia surveillance during prolonged arch work [6].
  • Adjuncts. Consider transcranial Doppler, EEG/aEEG, and mixed venous oximetry as context dictates.

Technical Considerations

Use a tension-free side graft or carefully executed direct innominate cannulation; de-air meticulously to reduce embolic risk. Ensure the ACP limb allows independent control of flow and temperature. During longer reconstructions, intermittent lower-body reperfusion can limit visceral/spinal cord ischemia. Before separation from bypass, confirm bilateral carotid patency, rule out innominate kinking, and verify restoration of physiologic head/neck pulsatility. Technique papers document safe, reproducible innominate strategies and compare direct cannulation with side grafts during hemiarch replacement [9,10].

Complications and Mitigation

Potential issues include hemispheric malperfusion (malposition, variant cerebrovascular anatomy), excessive or insufficient pressure/flow, air/atheromatous embolization, renal ischemia during prolonged lower-body arrest, and hyperperfusion during rewarming. Management hinges on prompt cannula repositioning, titration to pressure and NIRS trends, meticulous de-airing, controlled rewarming, and conversion to bilateral ACP when indicated. Pediatric cohorts note lower neurologic complications with SACP versus DHCA but a signal toward increased renal dysfunction, underscoring the value of distal perfusion strategies in longer cases [2].

Evidence Snapshot (to guide practice)

  • Comparative efficacy. Meta-analysis of arch operations: unilateral ACP showed lower pooled mortality and disabling stroke than DHCA; bilateral ACP and RCP performed similarly or worse on these endpoints [1]. Pediatric and neonatal-infant series report low neurologic event rates with ACP, with some cohorts showing no short-term differences vs DHCA but favoring ACP for workflow and monitoring [3,4].
  • Parameters. Pediatric programs typically aim for 40–60 mL/kg/min at 20–28 °C, adjusting to NIRS and right radial pressure 40–60 mmHg; flows below ~30 mL/kg/min risk under-perfusion in infants [5,6].
  • Unilateral vs bilateral. For short ACP (<~25–40 min), unilateral ACP is usually adequate; when ACP is prolonged (≥25–50 min) or anatomy is uncertain, bilateral ACP reduces biochemical injury and may improve survival [7,8].

Key Points

  • ACP provides continuous, titratable cerebral perfusion during arch reconstruction and is especially advantageous in neonates and infants.
  • Combine ACP with moderate hypothermia, deliver flow via the innominate (or axillary) artery, target right radial 40–60 mmHg, and use NIRS to guide therapy [2,5,6].
  • Anticipate bilateral ACP when the circle of Willis is uncertain or ACP time will exceed ~25–50 min [7,8].
  • Attention to cannulation geometry, de-airing, and vigilant multimodal monitoring underpins safe neuroprotection [6,9,10].

References

[1] Abjigitova D, Veen KM, van Tussenbroek G, Mokhles MM, Bekkers JA, Takkenberg JJM, Bogers AJJC. Cerebral protection in aortic arch surgery: systematic review and meta-analysis. Interact Cardiovasc Thorac Surg. 2022;35(3):ivac128.

[2] Kornilov IA, Sinelnikov YS, Soinov IA, Ponomarev DN, Kshanovskaya MS, Krivoshapkina AA, Gorbatykh AV, Omelchenko AY. Outcomes after aortic arch reconstruction for infants: deep hypothermic circulatory arrest versus moderate hypothermia with selective antegrade cerebral perfusion. Eur J Cardiothorac Surg. 2015;48(3):e45-e50.

[3] Xie L, Xu Y, Huang G, Ye M, Hu X, Shu S, Lynn H. MHCA with SACP versus DHCA in pediatric aortic arch surgery: a comparative study. Sci Rep. 2020;10(1):4439.

[4] Gray WH, Sorabella RA, Padilla LA, Sprouse K, Shah SV, Clark MG, O’Meara C, Dabal RJ. Outcomes following deep hypothermic circulatory arrest versus antegrade cerebral perfusion during aortic arch reconstruction. J Thorac Cardiovasc Surg Open. 2024;22:379-385.

[5] Fraser CD Jr, Andropoulos DB. Principles of antegrade cerebral perfusion during arch reconstruction in infants. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 2008;11:61-68.

[6] Spielvogel D, Tang GHL. Selective cerebral perfusion for cerebral protection: what we do know. Ann Cardiothorac Surg. 2013;2(3):326-330.

[7] Li B, Hu X, Wang Z. The neurologic protection of unilateral versus bilateral antegrade cerebral perfusion in aortic arch surgery with deep hypothermic circulatory arrest: a study of 77 cases. Int J Surg. 2017;40:8-13.

[8] Angleitner P, Stelzmueller ME, Mahr S, Kaider A, Laufer G, Ehrlich M. Bilateral or unilateral antegrade cerebral perfusion during surgery for acute type A dissection. J Thorac Cardiovasc Surg. 2020;159(6):2159-2167.e2.

[9] Leung Wai Sang S, Beute TJ, Timek T. A simple method to establish antegrade cerebral perfusion during hemiarch reconstruction. JTCVS Tech. 2020;2:10-15.

[10] Gergen AK, Kemp C, Ghincea CV, Feng Z, Ikeno Y, Aftab M, Reece TB. Direct innominate artery cannulation versus side graft for selective antegrade cerebral perfusion during aortic hemiarch replacement. Aorta (Stamford). 2022;10(1):26-31.