Bilateral antegrade cerebral perfusion may be the winner as an adjunct for brain protection.

Brain protection during open distal aortic arch replacement surgery is of utmost importance. Hypothermia in combination with cerebral perfusion offers optimal results by maintaining the brain's metabolic supply. Both retrograde cerebral perfusion and antegrade cerebral perfusion, used in combination with hypothermia, produce comparable results when the hypothermic circulatory arrest times are short; in contrast, for longer perfusion times, most aortic surgery centers are trending toward the use of antegrade rather than retrograde cerebral perfusion. Our own preference has been to use a bilateral mode of delivering antegrade cerebral perfusion instead of a unilateral approach, as bilateral perfusion appears to be more protective. We maintain that there is no harm in perfusing both brain hemispheres, so long as an appropriate balloon-tipped catheter is used carefully and manipulation of the head vessels is avoided.