Selective antegrade cerebral perfusion during aortic arch surgery confers survival and neuroprotective advantages

Shihata, Mohammad; Mittal, Rohan; Senthilselvan, A.; Koshal, Arvind; Mullen, John C.; MacArthur, Roderick

doi:10.1016/j.jtcvs.2010.06.047

Cited by 14 publications

(14 citation statements)

References 20 publications

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“…The stroke rate in arch surgery has been reported to be 0% to 15%. [8][9][10][11][12] Our results are well within this range. One randomized control study compared the cerebral protection strategies in aortic arch surgery 7 and showed that DHCA alone was superior in postoperative long-term neurocognitive tests.…”

Section: Discussionsupporting

confidence: 78%

“…Multiple retrospective studies have shown contradictory outcomes in mortality and neurologic complications. 8,[10][11][12] Even in a study showing a survival benefit with ACP, this benefit was limited to total aortic arch surgery. 9 The Achilles heel of DHCA alone as a cerebral protection strategy has been that the risks of neurologic dysfunction increase after a short period.…”

Section: Discussionmentioning

confidence: 99%

“…However this study had a small number of patients (n ¼ 10) in each group. Some retrospective studies have shown increased neurologic dysfunction with DHCA alone, 11,12,17 but most studies included both hemiarch and total arch surgery. Increasing DHCA time is a risk factor for stroke 18 ; therefore, noncomplex hemiarch surgery with shorter DHCA time should be associated with fewer neurologic events.…”

Section: Discussionmentioning

confidence: 99%

“…Multiple studies have been conducted to identify the safest cerebral protection strategy, and the answer remains controversial. [7][8][9][10][11][12] No randomized control study has been conducted to demonstrate the superiority of 1 technique over the other. Most of the previous studies have compared the outcomes in the aortic arch, which combines the outcomes of both total arch replacement and hemiarch replacement.…”

mentioning

confidence: 99%

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Is there a need for adjunct cerebral protection in conjunction with deep hypothermic circulatory arrest during noncomplex hemiarch surgery?

Kaneko

Aranki

Neely

et al. 2014

The Journal of Thoracic and Cardiovascular Surgery

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Section: Discussionsupporting

confidence: 78%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

See 2 more Smart Citations

Is there a need for adjunct cerebral protection in conjunction with deep hypothermic circulatory arrest during noncomplex hemiarch surgery?

Kaneko

Aranki

Neely

et al. 2014

The Journal of Thoracic and Cardiovascular Surgery

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“…This supports currently available data, primarily that ACP and RCP yield superior neuroprotection results to those of isolated DHCA. [7][8][9] Most surgeons agree that for arch repairs with short periods of cerebral ischemia (ie, <25 minutes), the use of either ACP, RCP, or isolated DHCA provides sufficient protection. Similarly, the consensus opinion is that for arch repairs with longer ischemic times, some sort of brain perfusion, whether it be ACP or RCP, is beneficial.…”

mentioning

confidence: 99%

Commentary: Horseshoes and hand grenades

Coselli¹,

Huu²

2020

The Journal of Thoracic and Cardiovascular Surgery

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To better understand the ideal use of neuroprotection strategies during aortic arch surgery, Hameed and colleagues 1 used an innovative new study design known as network meta-analysis, which facilitates direct and indirect comparison among multiple comparative studies within a single overarching analysis. This is a dramatic departure from established meta-analyses of aortic arch repair that rely solely on direct evidence, permitting the appraisal of only 2 modalities of cerebral protection. [2][3][4][5][6] Use of network meta-analysis enabled Hameed and colleagues 1 to simultaneously evaluate 3 approaches to cerebral protection: antegrade cerebral perfusion (ACP), retrograde cerebral perfusion (RCP), and isolated deep hypothermic circulatory arrest (DHCA). 1 The research included 26,968 patients from 68 publications, including 6 randomized controlled trials and 62 observational studies. Their findings suggest that the use ACP or RCP did not significantly influence postoperative stroke or mortality, the duration of circulatory arrest correlated with the effect of ACP and RCP, and the use of unilateral or bilateral ACP and temperature target for circulatory arrest did not influence the operative outcomes. This supports currently available data, primarily that ACP and RCP yield superior neuroprotection results to those of isolated DHCA. 7-9 Most surgeons agree that for arch repairs with short periods of cerebral ischemia (ie, <25 minutes), the use of either ACP, RCP, or isolated DHCA provides sufficient protection. Similarly, the consensus opinion is that for arch repairs with longer ischemic times, some sort of brain perfusion, whether it be ACP or RCP, is beneficial.The study by Hameed and colleagues, 1 although compelling, is unable to definitively determine the optimal strategy for the anticipated prolonged ischemic times necessitated by total transverse aortic arch repair. This is due to inherent limitations in the substrate data. Most publications contain a mixture of patients undergoing hemiarch and total transverse aortic arch replacement-vastly divergent procedures that often have different neurologic outcomes. The majority of surgeons will concur that cerebral protection strategies deemed adequate for a typical hemiarch repair may not be sufficient for more complex operations. Grouping these operations together renders it difficult to elucidate the precise role of ACP, RCP, and bilateral ACP for repairs with prolonged ischemic times. In addition, standard definitions of hypothermia are frequently absent from published studies and serve as a significant confounding variable. Following the consensus developed by Yan and colleagues 10 (ie, deep hypothermia defined as 14.1 C-20 C, moderate hypothermia as 20.1 C-28 C, and mild hypothermia as 28.1 C-34 C) would facilitate future investigations by creating a level playing field.Currently, there is significant disparity worldwide in strategies used during aortic arch repair: flow rates, temperature targets, cannulation sites, cerebral perfusion (including unilater...

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Anesthetic Management in Aortic Arch Surgery and Neuroprotection

Gregory

Cheung

2020

Evidence-Based Practice in Perioperative Cardiac Anesthesia and Surgery

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Selective antegrade cerebral perfusion during aortic arch surgery confers survival and neuroprotective advantages

Abstract: Antegrade cerebral perfusion was associated with improved survival and neurologic outcomes in patients undergoing aortic arch surgery, especially for cases requiring prolonged aortic arch repair periods.

Cited by 14 publications

References 20 publications

Is there a need for adjunct cerebral protection in conjunction with deep hypothermic circulatory arrest during noncomplex hemiarch surgery?

Is there a need for adjunct cerebral protection in conjunction with deep hypothermic circulatory arrest during noncomplex hemiarch surgery?

Commentary: Horseshoes and hand grenades

Anesthetic Management in Aortic Arch Surgery and Neuroprotection

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