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Division of Cardiovascular Surgery, University of Pennsylvania School of Medicine, 6 Silverstein, 3400 Spruce St, Philadelphia, PA 19104
(Email: wooy{at}uphs.upenn.edu).
For two decades, the merits of antegrade cerebral perfusion (ACP) and retrograde cerebral perfusion (RCP) during aortic arch procedures have been championed [1, 2]. Although the use of isolated deep hypothermic circulatory arrest (DHCA) has receded, advocates still invoke its simplicity and operative field clarity. The easy addition of RCP extends safe DHCA time by providing a venous cooling jacket for the brain and flushes air and debris from the arterial vasculature. ACP provides neuronal metabolic nutrients by natural forward blood flow and pressure, further extends safe DHCA time, and facilitates moderate hypothermia, with only a slight risk of arterial emboli and atheroma disruption from selective cannulation.
A small prospective randomized study of RCP versus ACP found similar major outcomes [3]. Large retrospective comparisons suggest equivalence, particularly when circulatory arrest times are less than 45 minutes [4, 5]. Inherent to this field are confounding factors such as indirect correlation between cerebral malperfusion and neurologic events, extreme selection bias, and great variability in the magnitude of operations, which may range from simple open distal anastomosis during elective ascending aneurysm repair to complex redo multibranch total arch replacement with a Vascutek Siena graft (Terumo, Ann Arbor, MI) elephant trunk configured for interval thoracic endovascular aortic repair.
Misfeld and colleagues [6] at the Leipzig Heart Center compiled and analyzed a superb single-center 7-year database of 636 consecutive patients who underwent arch operations managed with isolated DHCA, DHCA with RCP or, more recently, moderate hypothermia with unilateral ACP or bilateral ACP. An impressively short overall mean circulatory arrest time of 20 minutes at a mean minimum temperature of 24 °C reflects the center's surgical skill and efficiency. Particularly notable, only 24/636 patients had circulatory arrest times greater than 60 minutes. Overall 30-day mortality was 11%, which did not vary among groups, and overall stroke rate was 11% but was 9% in patients who underwent ACP versus 15% in patients who did not (p = 0.035). Mortality and stroke rates are higher than in some series but likely reflect the highly complex substrate of this Leipzig series in which more than one third of patients had type A aortic dissection and nearly one third of patients underwent total arch replacement with an elephant trunk procedure. Dissection and operative complexity independently predicted stroke and early and late mortality. Interestingly, despite the short circulatory arrest times, strokes still occurred in all groups, reinforcing the concept that non–perfusion related events such as embolic phenomenon, reperfusion injury, intracranial vascular pathology, and perioperative hemodynamics contribute significantly to stroke etiology. Not surprisingly, unilateral ACP and bilateral ACP were equivalent. The effectiveness of unilateral ACP, even in moderate hypothermia, is well supported [7]. Ultimately in highly complex arch reconstruction, a customized combination of protection strategies, or integrated cerebral perfusion, entailing alternating RCP and ACP—unilateral or bilateral, or both—as dictated by unique pathologic features, convenience, expedience, and spatial geometric and cannula constraints, may prove most efficient.
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