Aortic arch surgery remains a complex procedure associated with significant morbidity and mortality. This review aims to provide insights into the current concepts and evidence regarding organ protection during this procedure.

A non-systematic approach was used to identify relevant literature across three databases. Inclusion criteria comprised case reports/series, observational cohorts, or randomized controlled trials investigating perfusion strategies and other factors that influence clinical outcomes in aortic arch surgery, as well as experimental studies and key reviews pertinent to the topic.

Although hypothermic circulatory arrest (HCA) remains the current gold standard, interest in using higher temperatures in aortic arch surgery is increasing. To enable this, cerebral, myocardial, and visceral protection remain crucial, prompting the development of several strategies to facilitate higher-temperature surgery. A growing body of predominantly observational, single-center evidence has explored warmer, continuous multi-organ perfusion strategies. These emerging approaches have been associated with favorable outcomes in selected cohorts but have not been validated against the guideline-concordant standard.

Advancements in cardiopulmonary bypass and perfusion techniques have driven an evolving interest in continuous normothermic organ perfusion as an emerging strategy rather than an established alternative to HCA in selected cases. Continuous normothermic multi-organ perfusion represents an intriguing and potentially important direction, but its adoption should remain selective until comparative clinical evidence becomes stronger.