Hemodynamic principles of arterial cannulation: Orientation,wall shear stress,turbulence,plaque destabilization,and cerebral microembolization

Abstract

Background

Arterial cannulation during cardiopulmonary bypass (CPB) significantly alters native aortic hemodynamics by generating a high-velocity jet that interacts with the ascending aorta and aortic arch geometry. These flow disturbances may influence wall shear stress (WSS), turbulence intensity, embolic trajectories, and cerebral perfusion. Cannula depth, orientation, and tip design have emerged as potentially important determinants of intra-aortic flow behavior.

Materials and methods

A structured narrative review of the literature was conducted. PubMed/MEDLINE, Scopus, and Web of Science were searched from January 1990 to April 2025. Keywords included combinations of “aortic cannulation,” “cardiopulmonary bypass,” “computational fluid dynamics,” “wall shear stress,” “turbulence,” “atherosclerotic plaque,” “cerebral perfusion,” “microembolization,” “gaseous emboli,” “NIRS,” and “transcranial Doppler.” Studies were included if they evaluated hemodynamic effects of cannulation strategies using computational, in vitro, or clinical models. Articles not directly related to CPB intra-aortic flow dynamics were excluded.

Results

The available evidence suggests that cannula positioning significantly influences intra-aortic flow behavior. Centrally aligned cannulation directed toward the descending thoracic aorta promotes axial flow and is associated with reduced jet-wall impingement and lower peak WSS. This configuration decreases arch turbulence and limits embolic transport toward supra-aortic vessels.

Conclusion

Arterial cannulation strategy during CPB is a modifiable determinant of flow behavior and potential cerebral embolic exposure. Hemodynamically informed cannulation principles may contribute to intraoperative neuroprotection, although prospective clinical validation is still required.

Keywords

Aortic cannulation cardiopulmonary bypass wall shear stress turbulence computational fluid dynamics cerebral perfusion microembolization gaseous emboli atherosclerotic plaque destabilization

Introduction

Cardiopulmonary bypass (CPB) alters physiological aortic hemodynamics by replacing pulsatile native cardiac output with continuous extracorporeal flow. The arterial inflow cannula introduces a high-velocity jet into the ascending aorta, disrupting organized helical flow structures and modifying pressure gradients, wall shear stress (WSS), turbulence intensity, and embolic transport patterns. Rather than representing a simple technical step, arterial cannulation should be considered an active hemodynamic intervention capable of influencing cerebral perfusion and embolic risk. Computational investigations have demonstrated that cannula depth significantly affects the intra-aortic transport of gaseous emboli. In a computational fluid dynamics (CFD) study, Ho et al. showed that more proximal cannula positioning increases recirculation zones and promotes embolic diversion toward supra-aortic branches, whereas deeper insertion modifies jet interaction with the aortic wall and reduces cerebral embolic transport.¹ In a related analysis, the same group demonstrated that cannula orientation is a critical determinant of embolic trajectories: cranially directed jets increase embolic delivery to carotid vessels, while descending-oriented flow reduces embolic burden to the brain.² Recently, patient-specific CFD modeling of carotid perfusion during CPB has confirmed that cannulation strategy significantly alters supra-aortic flow fractions depending on vascular anatomy, arch geometry, and jet direction.³ Numerical modeling in type A aortic dissection further demonstrated that alternative cannulation approaches produce distinct flow patterns and shear stress distributions within the true and false lumens, reinforcing the importance of inflow configuration.⁴ Experimental work in pediatric models has similarly shown that cannula tip orientation affects cerebral perfusion symmetry and magnitude, highlighting the sensitivity of carotid flow distribution to jet geometry.⁵ Beyond cannula position, device design may also influence perfusion patterns. Experimental and translational investigations have reported that optimized cannula tip geometry can improve flow uniformity, reduce focal WSS peaks, and promote more stable cerebral perfusion during CPB.^5–7 In addition, the selected inflow site may affect arch hemodynamics, since retrograde femoral perfusion can generate less favorable flow interactions in patients with extensive aortic atherosclerosis, whereas central cannulation provides antegrade systemic flow.⁸ Although the available evidence derives from heterogeneous computational, experimental, and clinical models, a consistent physiological rationale emerges: arterial inflow configuration influences flow organization within the aorta and may contribute to embolic exposure and cerebral perfusion asymmetry. On this basis, the present review summarizes current evidence on cannula position, orientation, insertion depth, tip design, and inflow site during CPB, with the aim of identifying clinically relevant hemodynamic principles for intraoperative neuroprotection.

Materials and methods

This study was designed as a structured narrative review aimed at synthesizing current evidence regarding arterial cannulation strategies during CPB, with specific focus on intra-aortic hemodynamics, WSS, turbulence generation, atherosclerotic plaque destabilization, embolic transport, and cerebral perfusion monitoring. Given the methodological heterogeneity of the available literature, a qualitative integrative approach was adopted to critically evaluate mechanistic coherence and translational implications. A comprehensive literature search was performed using PubMed/MEDLINE, Scopus, and Web of Science. The search covered the period from January 1990 through April 2025. Both controlled vocabulary terms (MeSH where applicable) and free-text keywords were used. The search strategy combined the following conceptual domains: (1) arterial or aortic cannulation; (2) CPB; (3) CFD, WSS, or turbulence; (4) cerebral perfusion, embolism, microembolization, or gaseous emboli; and (5) monitoring modalities such as near-infrared spectroscopy (NIRS) and transcranial Doppler (TCD). Boolean operators (AND/OR) were used to construct structured search strings. An example of a representative search string was: (“aortic cannulation” OR “arterial cannulation”) AND (“cardiopulmonary bypass”) AND (“computational fluid dynamics” OR “wall shear stress” OR “turbulence”) AND (“cerebral perfusion” OR “microembolization” OR “embolism” OR “gaseous emboli”). The study selection process was conducted in three sequential phases. First, titles and abstracts were screened to identify studies relevant to intra-aortic flow dynamics during CPB. Articles clearly unrelated to arterial inflow hemodynamics were excluded at this stage. Second, full-text versions of potentially eligible studies were reviewed to assess methodological rigor, relevance to the hemodynamic endpoints of interest, and contribution to mechanistic understanding. Third, final inclusion was based on predefined criteria emphasizing direct evaluation of cannulation-related flow patterns, WSS distribution, turbulence characteristics, embolic transport modeling, or cerebral perfusion outcomes. Reference lists of included articles were manually screened (snowballing technique) to identify additional relevant publications not captured by the initial database search. Inclusion criteria comprised peer-reviewed original research articles that met at least one of the following conditions: CFD modeling of arterial cannulation during CPB; experimental in vitro or in vivo studies evaluating cannula geometry, jet dispersion, or WSS; clinical observational studies assessing cerebral perfusion, embolization, or neurological outcomes associated with cannulation strategy; or foundational mechanistic studies on WSS and plaque biomechanics directly applicable to CPB-related hemodynamic perturbations. Exclusion criteria included case reports, non-English publications, editorials without original data, and studies focused exclusively on extracorporeal membrane oxygenation without relevance to ascending aortic inflow dynamics during CPB. For each included study, data were extracted regarding study design (CFD, in vitro, in vivo, clinical), cannulation site and orientation, cannula depth and tip characteristics, hemodynamic parameters (WSS magnitude, turbulence intensity, recirculation zones, flow symmetry), embolic transport outcomes, and cerebral monitoring findings where applicable. Data synthesis was qualitative and focused on identifying consistent mechanistic patterns across computational, experimental, and clinical evidence.

The structured literature search identified 312 records. After duplicate removal (n = 78), 234 abstracts were screened, and 61 full-text articles were assessed. Twenty studies met inclusion criteria and were included in the final synthesis (references 1–20). These comprised 11 CFD studies,^1–4,9–14 four experimental or translational investigations,^5–7,15 three clinical observational studies incorporating cerebral monitoring,^16–18 and two integrative state-of-the-art analyses.^8,19,20 Despite heterogeneity in modeling assumptions and clinical designs, strong mechanistic convergence was observed across five principal domains. The PRISMA flow diagram is shown in Figure 1.

Figure 1.

PRISMA flow diagram.

Results

Jet orientation and insertion depth: Determinants of intra-aortic flow architecture

Across CFD investigations,^{1–4,9–11,13,14} cannula orientation consistently emerged as the dominant determinant of intra-aortic flow behavior during CPB. Cranially directed or eccentrically positioned jets produced focal impingement against the anterior ascending aortic wall, generating high local velocity gradients and promoting boundary layer separation. These effects resulted in the formation of secondary vortical structures within the curvature of the aortic arch.¹¹ Ho et al.² demonstrated that cannula orientation significantly modifies embolic trajectories, with cranially oriented jets increasing embolic diversion toward supra-aortic branches. In a subsequent study, cannulation depth was shown to influence proximal recirculation zones and embolic transport dynamics (Figure 2).¹ Patient-specific CFD models further confirmed that vascular anatomy modulates but does not override the influence of jet direction on arch flow topology.^3,13 Numerical simulations in aortic arch surgery settings similarly showed that inflow configuration alters regional flow distribution and shear stress patterns.⁹ Earlier CFD analyses comparing ascending and subclavian inflow sites also demonstrated that inflow alignment determines supra-aortic flow fractions and turbulence generation.¹⁴ In contrast, centrally aligned cannulation directed toward the descending thoracic aorta promoted axial flow propagation with reduced direct wall impingement. This configuration consistently attenuated proximal recirculation and limited secondary vortex formation within the arch¹⁰ (Figure 2).

Figure 2.

(A-B) Computational fluid dynamics (CFD) visualization of intra-aortic flow patterns under different cannula orientations during cardiopulmonary bypass. (A) Centrally aligned cannulation directed toward the descending thoracic aorta. Axial jet propagation is preserved with reduced wall impingement. Proximal recirculation zones are attenuated, secondary vortex formation is limited, and flow continuity toward the descending aorta is maintained. (B) Cranially directed/eccentrically oriented aortic cannulation. The inflow jet impinges on the anterior ascending aortic wall, generating focal regions of elevated velocity gradients and boundary layer separation. Secondary vortical structures develop within the curvature of the aortic arch, with increased flow diversion toward supra-aortic branches. Original schematic illustration created by the authors based on concepts reported in literary works.^1,2,10

Wall shear stress distribution and plaque destabilization

Nine studies addressed WSS distribution under varying cannulation strategies.^{4,9–12,14,19,20} Peak WSS values were spatially correlated with jet-wall impingement sites. Cranially oriented jets generated localized shear magnitudes exceeding physiological pulsatile levels, particularly along the anterior ascending aorta and arch curvature. Experimental and computational studies have demonstrated that dispersive cannula designs reduce focal WSS peaks compared with conventional jet cannulas.^12,15 Assmann et al.¹² showed that dispersive cannulas significantly decrease aortic WSS, potentially reducing the mechanical forces that contribute to plaque destabilization (Figure 3). These findings align with established biomechanical models of shear-mediated plaque vulnerability.^19,20 Foundational CFD analyses of aortic arch flow confirm that curvature-induced secondary flows amplify shear stress heterogeneity when high-momentum jets are misaligned.¹¹ In aortic dissection modeling, altered inflow configuration also modified shear stress distribution across the aortic wall.⁴ Autopsy data demonstrating iatrogenic embolization following cardiac intervention further support the clinical relevance of minimizing aortic wall stress during CPB.¹⁸

Figure 3.

Comparative computational analysis of WSS distribution and plaque response under different arterial cannulation designs during cardiopulmonary bypass. (A) Conventional jet cannula. CFD visualization demonstrates focal high-magnitude wall shear stress localized at the site of jet-wall impingement along the anterior ascending aorta and proximal arch curvature. Elevated WSS and steep spatial gradients promote flow separation and secondary vortex formation. The inset illustrates mechanical disruption and fragmentation of an atherosclerotic plaque subjected to concentrated shear forces, consistent with shear-mediated plaque destabilization. (B) Dispersive cannula. Flow field analysis shows more homogeneous WSS distribution with reduced peak shear stress values and attenuated wall impingement. The dispersive jet pattern promotes smoother axial flow propagation and minimizes localized stress concentration. The inset depicts preserved plaque integrity under lower and more evenly distributed shear stress conditions. Color scale represents wall shear stress magnitude (Pa). Original schematic illustration created by the authors based on data from literary works.^12,15 WSS: wall shear stress; CFD: computational fluid dynamics.

Embolic transport dynamics

Eight CFD studies modeled embolic transport during CPB.^{1,2,4,9,10,13,14} Ho et al.^1,2 demonstrated that both cannula orientation and insertion depth significantly influence the distribution of simulated gaseous emboli. Cranially directed jets increased embolic entry into supra-aortic vessels, while descending-oriented jets reduced cerebral embolic fractions. Endoluminal perfusion modeling confirmed that jet direction and turbulence intensity directly affect embolic dispersion within the arch.¹⁰ Patient-specific modeling in extracorporeal support settings similarly demonstrated that inflow geometry determines embolic trajectories toward cerebral vessels.¹³ Numerical simulations applied to aortic arch surgery further showed that alternative cannulation configurations redistribute flow toward carotid arteries, altering embolic exposure.⁹ Across studies, although absolute embolic percentages varied, the directional consistency was robust: centrally aligned descending orientation reduced simulated cerebral embolic burden (Figure 4).

Figure 4.

(A-B) Computational simulation of embolic transport dynamics under different arterial cannulation strategies during cardiopulmonary bypass. (A) Cannula centrally aligned and directed toward the descending thoracic aorta.Axial flow propagation is preserved with reduced proximal wall impingement and more organized downstream flow patterns. Simulated microemboli predominantly remain within the central lumen and are preferentially transported toward the descending aorta, with limited embolic entry into supra-aortic vessels. Color-coded streamlines represent instantaneous velocity magnitude. (B) Cannula positioned in the ascending aorta with cranially directed inflow. Computational fluid dynamics (CFD) streamlines demonstrate focal jet impingement against the anterior ascending aortic wall with subsequent redistribution of flow toward supra-aortic branches. Simulated microemboli (yellow spheres) are transported proximally within the aortic arch and preferentially diverted into the supra-aortic trunks, illustrating increased potential cerebral embolic exposure. Flow velocity magnitude is represented by the color scale (m/s). Original schematic illustration created by the authors based on concepts reported in literary works.^1,2,9,13

Cerebral perfusion distribution and monitoring correlations

Cerebral perfusion implications were evaluated in CFD studies^3,5,7,14 and correlated with clinical monitoring data.^16,17 Lu et al.³ demonstrated that cannulation strategy significantly affects carotid perfusion distribution, with anatomical variability influencing magnitude but not direction of effect. Hugenroth et al.⁷ combined in silico, in vitro, and in vivo testing and reported improved cerebral perfusion stability with optimized cannula design.⁶ Menon et al.⁵ used a pediatric bypass model and demonstrated that cannula tip orientation significantly altered carotid flow symmetry. Clinically, TCD has been validated as a surrogate for cerebral blood flow during cardiac surgery,¹⁷ and prospective data show that alterations in cerebral hemodynamics correlate with postoperative neurological function.¹⁶ Asymmetric flow configurations predicted by CFD were associated with interhemispheric NIRS variability and Doppler flow asymmetry.

Central versus peripheral cannulation

Comparative analyses of femoral versus central cannulation demonstrate distinct hemodynamic behaviors.^8,14 Retrograde femoral perfusion increases turbulence within the arch and may enhance mechanical stress on atherosclerotic segments.⁸ Central ascending cannulation allows more controlled antegrade flow propagation. CFD comparisons of inflow sites confirm that central cannulation, when properly aligned toward the descending aorta, reduces arch recirculation and pathological shear gradients.¹⁴

Integrated hemodynamic synthesis

Across the included studies, a consistent pattern emerged: unfavorable jet alignment increased wall impingement, shear stress heterogeneity, and embolic diversion, whereas optimized central inflow promoted more organized flow and lower simulated cerebral embolic exposure. Dispersive cannula designs further reduced focal shear concentration. Although outcome trials are lacking, these findings support the physiological relevance of cannulation strategy during CPB.^12,19,20

Discussion

The present synthesis supports the concept that arterial cannulation during CPB represents a hemodynamically relevant intervention rather than a purely technical step. Across computational, experimental, and clinical investigations, cannula orientation, insertion depth, and tip geometry consistently emerged as important determinants of intra-aortic flow organization, influencing WSS distribution, embolic transport pathways, and cerebral perfusion stability.^{1–4,9–11,13,14} One of the most consistent observations across the available literature is the relationship between jet alignment and aortic wall interaction. Malpositioned or cranially directed inflow tends to increase focal wall impingement, recirculation, and shear stress heterogeneity, whereas more favorable alignment promotes a more organized longitudinal flow field with lower simulated embolic diversion toward supra-aortic vessels.^{1–4,9,10,13,14} Although derived largely from CFD studies, this mechanistic consistency strengthens the physiological relevance of cannulation strategy during CPB. The potential clinical implications of these findings are multifactorial. Peak WSS localizes to sites of jet-wall interaction, suggesting a possible role in plaque destabilization and embolic release in susceptible aortas.^12,18–20 In parallel, embolic transport simulations indicate that unfavorable inflow direction may increase cerebral embolic exposure, while optimized alignment favors distal axial transport.^1,2,10 In addition, experimental and translational studies suggest that improved cannula geometry may enhance cerebral flow symmetry and hemodynamic stability during bypass.^5–7 Importantly, these hemodynamic principles should be interpreted within the constraints of real-world surgery. Precise control of cannula orientation may be limited by calcific aortic disease, ascending aortic diameter, arch angulation, cross-clamp position, restricted operative exposure, and other patient-specific anatomical factors. Therefore, the proposed configuration should be viewed as a hemodynamic target rather than a universally achievable technical standard. Finally, neurological injury during CPB remains multifactorial, and cannulation strategy represents only one modifiable component of a broader protective framework. Nevertheless, integration of patient-specific imaging, intraoperative monitoring, and hemodynamically informed cannulation planning may help refine neuroprotection strategies and deserves prospective clinical evaluation.

Limitations

Several limitations should be acknowledged. These references do not directly investigate CPB-specific jet flow conditions, but provide mechanistic insight into the relationship between abnormal shear stress and plaque vulnerability. CFD simulations rely on assumptions regarding wall compliance, flow pulsatility, and rheological modeling that may not fully replicate intraoperative conditions. Clinical evidence remains largely observational and lacks randomized comparisons specifically addressing cannula orientation geometry. Moreover, neurological injury during CPB is multifactorial, influenced by perfusion pressure, temperature management, hematocrit, inflammatory response, and baseline cerebrovascular reserve. Cannulation strategy represents one modifiable component within this broader physiological framework. Despite these limitations, the mechanistic coherence across fluid dynamic theory, computational modeling, experimental validation, and clinical monitoring is compelling. The integrated evidence suggests a plausible mechanistic sequence: jet misalignment leads to focal wall impingement and elevated WSS, promotes turbulence and vortex formation within the arch, increases embolic diversion toward cerebral vessels, and may destabilize vulnerable atherosclerotic plaques. Conversely, central lumen alignment with descending anterograde orientation preserves axial flow propagation, attenuates shear concentration, limits secondary vortex formation, and reduces simulated cerebral embolic exposure. Future investigations should focus on integrating patient-specific imaging with computational planning tools to guide cannulation strategy, as well as conducting prospective studies comparing cranial versus descending-oriented central cannulation with standardized neurological endpoints and multimodal cerebral monitoring (Table 1).

Table 1.

Summary of hemodynamic effects of arterial cannulation strategies during cardiopulmonary bypass.

Hemodynamic domain	Cannulation variable	Primary flow effect	Mechanistic consequence	Clinical relevance
Intra-aortic flow architecture	Cranially directed or eccentric jet orientation	Focal anterior wall impingement; high local velocity gradients; boundary layer separation; arch vortex formation	Increased turbulence intensity; altered supra-aortic flow redistribution	Potential increase in cerebral flow disturbance and embolic exposure
	Central lumen alignment directed toward descending thoracic aorta	Preserved axial jet propagation; reduced wall collision; attenuated proximal recirculation	More organized longitudinal flow; limited secondary vortex formation	Improved hemodynamic stability and physiologic arch flow pattern
WSS distribution	Conventional single-orifice jet cannula	Localized peak WSS at impingement sites; steep spatial shear gradients	Increased mechanical stress on atherosclerotic plaques; potential cap strain	Plaque destabilization risk and possible embolic release
	Dispersive cannula design	Homogeneous WSS distribution; reduced focal shear concentration	Lower stress concentration factor at aortic wall	Potential mitigation of shear-mediated plaque disruption
Embolic transport dynamics	Cranially oriented inflow	Vortex-mediated embolic entrainment toward supra-aortic vessels	Increased simulated cerebral embolic fraction	Higher theoretical cerebral microembolic burden
	Descending-oriented anterograde inflow	Preferential distal embolic transport toward descending aorta	Reduced supra-aortic embolic diversion	Decreased simulated cerebral embolic exposure
Cerebral perfusion distribution	Asymmetric jet impingement	Unequal carotid flow fractions; altered arch flow partitioning	Interhemispheric perfusion imbalance	Variability in NIRS signals and Doppler flow velocities
	Optimized orientation and cannula geometry	Symmetric supra-aortic flow distribution	Stabilized cerebral hemodynamics	Improved intraoperative cerebral monitoring stability
Cannulation site	Retrograde femoral inflow	Complex arch flow interaction; turbulence amplification	Increased wall stress in atherosclerotic segments	Patient-dependent risk of embolization
	Central ascending aortic inflow (descending alignment)	Controlled antegrade flow propagation	Reduced recirculation and pathological shear gradients	Hemodynamically favorable strategy in suitable anatomy

CPB: cardiopulmonary bypass; CFD: computational fluid dynamics; WSS: wall shear stress; NIRS: near-infrared spectroscopy.

Conclusion

Arterial cannulation during CPB should be regarded as a hemodynamically relevant component of extracorporeal support rather than a purely technical maneuver. Available computational, experimental, and clinical evidence indicates that cannula orientation, insertion depth, and tip design may influence WSS, embolic transport, and supra-aortic perfusion. Although prospective outcome studies are still needed, incorporation of hemodynamically informed cannulation principles may help refine neuroprotection strategies during cardiac surgery.

Footnotes

ORCID iDs

Ignazio Condello

Michele Dell'Aquila

Youssef El Dsouki

Sotirios Prapas

Ethical approval

Not applicable.

Informed consent

Not applicable.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

References

McDonald

Pauls

, et al. Effect of aortic cannulation depth on air emboli transport during cardiopulmonary bypass: a computational study. Perfusion 2023; 38: 993–1001. Epub 2022 May 21. PMID: 35603520.

McDonald

Pauls

, et al. Aortic cannula orientation and flow impacts embolic trajectories: computational cardiopulmonary bypass. Perfusion 2020; 35: 409–416. Epub 2019 Dec 9. PMID: 31814525.

Xing

Liu

, et al. The impact of arterial cannulation strategy on carotid perfusion during cardiopulmonary bypass: a computational fluid dynamics analysis from the perspective of vascular anatomy. Perfusion 2025; 40: 1856–1869. Epub 2025 Apr 14. PMID: 40227017.

Deng

Qin

Guan

, et al. Computational numerical analysis of different cannulation methods during cardiopulmonary bypass of type A aortic dissection model based on computational fluid dynamics. Ann Transl Med 2021; 9: 67. Erratum in: Ann Transl Med. 2022 Apr;10(8):500. doi: 10.21037/atm-2022-10. PMID: 33987365; PMCID: PMC8106110.

Menon

Antaki

Undar

, et al. Aortic outflow cannula tip design and orientation impacts cerebral perfusion during pediatric cardiopulmonary bypass procedures. Ann Biomed Eng 2013; 41: 2588–2602. Epub 2013 Jul 2. PMID: 23817768.

Kaufmann

Schlanstein

Moritz

, et al. Development of a hemodynamically optimized outflow cannula for cardiopulmonary bypass. Artif Organs 2014; 38: 972–978. Epub 2014 Feb 17. PMID: 24533575.

Hugenroth

Borchardt

Ritter

, et al. Optimizing cerebral perfusion and hemodynamics during cardiopulmonary bypass through cannula design combining in silico, in vitro and in vivo input. Sci Rep 2021; 11: 16800. PMID: 34408243; PMCID: PMC8373878.

Werner

Winter

Coti

, et al. State-of-the-Art review: advantages and disadvantages of femoral versus central cannulation. Innovations (Phila) 2025; 20: 148–157. Epub 2025 Apr 22. PMID: 40261087; PMCID: PMC12090206.

De Lazzari

Capoccia

Cheshire

, et al. Evaluation of different cannulation strategies for aortic arch surgery using a cardiovascular numerical simulator. Bioengineering (Basel) 2023; 10: 60. PMID: 36671632; PMCID: PMC9854437.

10.

Malinowski

Fournier

Horbach

, et al. Computational fluid dynamics analysis of endoluminal aortic perfusion. Perfusion 2023; 38: 1222–1229. Epub 2022 May 12. PMID: 35549763; PMCID: PMC10466979.

11.

Numata

Itatani

Kanda

, et al. Blood flow analysis of the aortic arch using computational fluid dynamics. Eur J Cardiothorac Surg 2016; 49: 1578–1585. Epub 2016 Jan 20. PMID: 26792932.

12.

Assmann

Gül

Benim

, et al. Dispersive aortic cannulas reduce aortic wall shear stress affecting atherosclerotic plaque embolization. Artif Organs 2015; 39: 203–211. Epub 2014 Sep 10. PMID: 25205180.

13.

Ahmed

Lynch

Haft

, et al. Patient-Specific computational modeling of different cannulation strategies for extracorporeal membrane oxygenation. ASAIO J 2022; 68: e179–e187. Epub 2022 Nov 3. PMID: 36326700.

14.

Kaufmann

Hormes

Laumen

, et al. The impact of aortic/subclavian outflow cannulation for cardiopulmonary bypass and cardiac support: a computational fluid dynamics study. Artif Organs 2009; 33: 727–732. PMID: 19775264.

15.

Grooters

Thieman

Schneider

, et al. Assessment of perfusion toward the aortic valve using the new dispersion aortic cannula during coronary artery bypass surgery. Tex Heart Inst J 2000; 27: 361–365. PMID: 11198309; PMCID: PMC101105.

16.

Wen

Wang

, et al. Cerebral hemodynamic changes and postoperative brain function in patients undergoing cardiac valve surgery with cardiopulmonary bypass: a prospective cohort study. Cureus 2025; 17: e91327. PMID: 41035605; PMCID: PMC12481624.

17.

Weyland

Stephan

Kazmaier

, et al. Flow velocity measurements as an index of cerebral blood flow. Validity of transcranial Doppler sonographic monitoring during cardiac surgery. Anesthesiology 1994; 81: 1401–1410. PMID: 7992909.

18.

Hickey

Honig

Ostry

, et al. Iatrogenic embolization following cardiac intervention: postmortem analysis of 110 cases. Cardiovasc Pathol 2019; 40: 12–18. Epub 2019 Jan 19. PMID: 30769235.

19.

Finol

Amon

. Flow-induced wall shear stress in abdominal aortic aneurysms: part II–pulsatile flow hemodynamics. Comput Methods Biomech Biomed Engin 2002; 5: 319–328. PMID: 12186711.

20.

Yang

Wang

, et al. Shear stress in atherosclerotic plaque determination. DNA Cell Biol 2014; 33: 830–838. PMID: 25165867.