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Ann Thorac Surg 2004;77:79-80
© 2004 The Society of Thoracic Surgeons
Division of Cardiothoracic Surgery, Baylor College of Medicine, The Methodist DeBakey Heart Center, 6560 Fannin Street, Suite 1100, Houston, TX 77030, USA
e-mail: slemaire{at}bcm.tmc.edu
In terms of optimizing cerebral protection during aortic arch repair, the relative efficacy of the three primary perfusion techniques—hypothermic circulatory arrest (HCA) alone, antegrade cerebral perfusion (ACP), and retrograde cerebral perfusion (RCP)—remains controversial. The relative merits of these techniques are traditionally considered in terms of their direct impact during operation, including delivery of oxygen to the brain, maintenance of cerebral hypothermia, and prevention of cerebral emboli. In this paper, Neri and colleagues have explored a novel concept—that the perfusion technique used during arch repair may also enhance postoperative cerebral protection via its impact on cerebral autoregulation.
As an observational study that relied on surgeon preference to determine cerebral protection technique, meaningful intergroup comparisons are hindered by unavoidable variations in technique, heterogeneous patient groups, and other sources of bias. Therefore, the authors correctly emphasized that the apparent associations between cerebral perfusion method, impaired cerebral autoregulation, and neurologic complications must be interpreted with caution. Nevertheless, the data demonstrate that patients who underwent aortic arch repair with HCA alone or with RCP had impaired cerebral autoregulation that persisted for up to one week after surgery. These patients also had a higher incidence of neurologic complications, possibly related to their limited ability to maintain adequate cerebral perfusion during periods of postoperative hypotension. In contrast, patients who had ACP during arch repair had relative preservation of cerebral autoregulation and did not suffer neurologic complications. The compelling implications of this data warrant further investigation and will ultimately require validation via additional prospective comparative studies.
Unfortunately, definitive data demonstrating which perfusion technique yields the best clinical outcome remains elusive, largely due to the logistical barriers to performing adequately powered randomized trials. In the absence of clear evidence favoring any one method, many surgeons currently individualize the perfusion technique based on specific patient factors, such as the extent of aortic disease. The most recent major trend in cerebral protection, however, has been the increasing popularity of subclavian/axillary artery cannulation as a simplified means of providing ACP during aortic repair. In light of current clinical information, it is likely that this will ultimately become the technique of choice in most cases requiring circulatory arrest. Despite the acknowledged limitations, this provocative report supports this trend by suggesting that ACP may provide cerebral protection that extends well beyond the operating room.
This article has been cited by other articles:
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  D. D. Doblar Intraoperative Transcranial Ultrasonic Monitoring for Cardiac and Vascular Surgery Seminars in Cardiothoracic and Vascular Anesthesia, June 1, 2004; 8(2): 127 - 145. [Abstract] [PDF]
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