A Contemporary Meta-Analysis of Antegrade versus Retrograde Cerebral Perfusion for Thoracic Aortic Surgery

Takagi, Hisato; Mitta, Shohei; Ando, Tomo

doi:10.1055/s-0038-1632389

Cited by 12 publications

(11 citation statements)

References 33 publications

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“…[1][2][3] Currently, 3 different cerebral protection strategies are available: isolated deep hypothermic circulatory arrest (DHCA), circulatory arrest coupled with retrograde cerebral perfusion (RCP), and circulatory arrest coupled with antegrade cerebral perfusion (ACP). The advantages and disadvantages of these cerebral protection techniques have been extensively studied, [4][5][6][7][8][9][10][11] but consensus on the optimal strategy is still lacking. Over the past 15 years, 8 meta-analyses have reported pairwise comparisons of DHCA, RCP, and ACP in different combinations.…”

Section: Perspectivementioning

confidence: 99%

See 1 more Smart Citation

Cerebral protection strategies in aortic arch surgery: A network meta-analysis

Hameed

Rahouma

Khan

et al. 2020

The Journal of Thoracic and Cardiovascular Surgery

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Section: Perspectivementioning

confidence: 99%

“…Over the past 15 years, 8 meta-analyses have reported pairwise comparisons of DHCA, RCP, and ACP in different combinations. [4][5][6][7][8][9][10][11] However, no meta-analysis has compared all 3 techniques.…”

Section: Perspectivementioning

confidence: 99%

Cerebral protection strategies in aortic arch surgery: A network meta-analysis

Hameed

Rahouma

Khan

et al. 2020

The Journal of Thoracic and Cardiovascular Surgery

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“…Despite the wide consensus about the use of SACP, Hameed and colleagues did not observe a difference in outcome between antegrade and retrograde CP (27). Accordingly, a metaanalysis by Takagi et al comparing antegrade and retrograde CP did not find a difference in postoperative ND either (28).…”

Section: Arch Surgery As a High-risk Proceduresmentioning

confidence: 97%

Risk factors for impaired neurological outcome after thoracic aortic surgery

Demal¹,

Sitzmann²,

Bax³

et al. 2022

J Thorac Dis

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Background: We aimed to identify risk factors for an impaired postoperative neurological outcome after thoracic aortic surgery.Methods: Data from all patients undergoing thoracic aortic surgery between 2010 and 2020 at our institution were collected and analyzed retrospectively. Logistic regression analysis was used to identify independent risk factors for permanent postoperative neurological deficit (ND) (stroke), which was defined as a ND lasting at least seven days.Results: Thoracic aortic surgery was performed in 1,334 patients. Of these, 286 (21.4%) underwent emergency surgery. The mean EuroSCORE II was 8.6±10.1. A perioperative stroke occurred in 94 patients (7.0%). Of all strokes, 62.8% (n=59) were considered of embolic and 24.5% (n=23) of hemodynamic origin.In elective procedures, stroke rates ranged from 0.5% after valve-sparing root replacement to 8.1% after arch surgery. Adjusted logistic regression identified advanced age [>70 years; odds ratio (OR), 1.83; P=0.009], acute type A dissection (ATAD) (OR, 1.69; P=0.0495), aortic arch surgery (OR, 3.24; P<0.001), concomitant coronary artery bypass grafting (CABG) (OR, 2.19; P=0.005), and high extracorporeal circulation (ECC) time (>230 min; OR, 1.70; P=0.034) as independent risk factors for all strokes. Secondary endpoint analyses revealed that risk factors for hemodynamic stroke were arch surgery, advanced age (>70 years), atherosclerosis, and ATAD. Risk factors for embolic stroke were arch surgery, concomitant CABG and preoperative cerebral malperfusion.Conclusions: Identified independent risk factors for all strokes were advanced age, ATAD, arch surgery, concomitant CABG, and high ECC time. Hemodynamic and embolic strokes show distinct risk profiles.

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“…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.…”

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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A Contemporary Meta-Analysis of Antegrade versus Retrograde Cerebral Perfusion for Thoracic Aortic Surgery

Abstract: In thoracic aortic surgery, postoperative incidence of stroke and mortality was similar between ACP and RCP, whereas a trend toward a reduction of TND incidence existed in ACP.

Cited by 12 publications

References 33 publications

Cerebral protection strategies in aortic arch surgery: A network meta-analysis

Cerebral protection strategies in aortic arch surgery: A network meta-analysis

Risk factors for impaired neurological outcome after thoracic aortic surgery

Commentary: Horseshoes and hand grenades

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