AP GRIPFLOW catheter with a balloon (Fuji Systems, Japan) was interpolated into the graft, and the balloon was inflated to stop the reversal of blood flow from the descending aorta. Antegrade lower body perfusion (1 L/min) was initiated through the AP flow catheter, and systemic circulation was restarted. Subsequent procedures, including quadrifurcated graft anastomosis, reconstruction of the 3 arch vessels, and weaning from CPB, were performed using standard routine procedures, and the patient recovered without any complications, such as hemagglutination or hemolysis associated with cold agglutinins.Currently, cardiac surgeries requiring cardiac arrest with CPB and CP are simply performed under normothermic conditions without any special preoperative interventions, such as plasma exchange 5 or procedural changes for patients with cold agglutinins at a low titer and low thermal amplitude. 3 However, if systemic hypothermia or cold CP is required, as in this case of aortic arch repair, specific meticulous strategies need to be considered 3-7 to keep the patient cool enough to reduce the metabolism for organ protection but warm enough to maintain the body temperature above the thermal amplitude.We performed RCP and subsequent antegrade lower body perfusion with an inflatable occlusion balloon in the descending aorta to decrease the overall duration of systemic circulatory arrest, which lasted from the time of aortic tissue resection to the time of balloon inflation. Additional RCP is simple but easily enables a better view and space for subsequent procedures. Antegrade lower body perfusion is expected to improve outcomes 8 and, indeed, both remarkably reduced the total systemic ischemic time and provided a bloodless field for distal anastomosis in this case.In conclusion, hypothermic systemic circulatory arrest supported by RCP and lower body perfusion above the thermal amplitude could be an optimal procedure for cases complicated with cold agglutinins. Written informed consent was obtained from the patient for this article.