Comparison between antegrade and retrograde cerebral perfusion or profound hypothermia as brain protection strategies during repair of type A aortic dissection

Stamou, Sotiris C.; Rausch, Laura A.; Kouchoukos, Nicholas T.; Lobdell, Kevin W.; Khabbaz, Kamal R.; Murphy, Edward; Hagberg, Robert

doi:10.21037/acs.2016.04.02

Cited by 23 publications

(21 citation statements)

References 22 publications

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“…All 3 studies concluded that incidence of TND/PND and mortality was similar between the 2 cerebral protection adjuncts (TND, RCP 0-38% vs. ACP 1-34%; PND, RCP 1-9% vs. ACP 3-12%; mortality, RCP 3-6% vs. 2-4%). Retrospective studies composed of combined hemiarch and total arch replacement or limited to total arch replacement demonstrated similar results, with no significant difference between RCP and ACP regarding rates of mortality, TND, or PND as shown in the Table 1 (19,(23)(24)(25)(26)(27)(28). Of note, circulatory arrest time in recent reports is relatively short compared to decades ago, and this may have biased the difference between the 2 cerebral protection adjuncts.…”

Section: Comparison To Acpmentioning

confidence: 87%

Simple retrograde cerebral perfusion is as good as complex antegrade cerebral perfusion for hemiarch replacement

Tanaka

Estrera

2018

J. Vis. Surg.

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Cerebral complication is a major concern after aortic arch surgery, which may lead to death.Thus, cerebral protection strategy plays the key role to obtain respectable results in aortic arch repair.Deep hypothermic circulatory arrest was introduced in 1970s to decrease the ischemic insults to the brain.However, safe duration of circulatory arrest time was limited to 30 minutes. The 1990s was the decade of evolution for cerebral protection, in which two adjuncts for deep hypothermic circulatory arrest were introduced: retrograde and antegrade cerebral perfusion (ACP) techniques. These two cerebral perfusion techniques significantly decreased incidence of postoperative neurological dysfunction and mortality after aortic arch surgery. Although there are no large prospective studies that demonstrate which perfusion technique provide better outcomes, multiple retrospective studies implicate that ACP may decrease cerebral complications compared to retrograde cerebral perfusion (RCP) when a long circulatory arrest time is required during aortic arch reconstructions. To date, many surgeons favor ACP over RCP during a complex aortic arch repair, such as total arch replacement and hybrid arch replacement. However, the question is whether the use of ACP is necessary during a short, limited circulatory arrest time, such as hemiarch replacement? There is a paucity of data that proves the advantages of a complex ACP over a simple RCP for a short circulatory arrest time. RCP with deep hypothermic circulatory arrest is the simple, efficient cerebral protection technique with minimal interference to the surgical field-and it potentially allows to flush atheromatous debris out from the arch vessels. Thus, it is the preferred adjunct to deep hypothermic circulatory arrest during hemiarch replacement in our institution. arch surgery to obtain respectable outcomes. History of retrograde cerebral perfusion (RCP)Profound hypothermic circulatory arrest was introduced to aortic arch surgery in 1970s by Dr. Griepp and colleagues (3). Hypothermia minimizes the ischemic insults to the brain by suppressing its metabolic demand of glucose and oxygen. Circulatory arrest provided simplicity to the aortic arch surgery. However, safe duration of this technique soon became a concern. temporary neurologic dysfunction (TND) was often observed in patients with more than 25 minutes of profound hypothermic circulatory arrest, and its incidence was correlated with the duration of circulatory arrest by an odds ratio of 1.06 per minute (4). Svensson and colleagues reviewed outcomes of 656 patients and reported that the occurrence of PND significantly increased after 40 minutes of circulatory arrest time and the mortality rate significantly increased after 65 minutes of circulatory arrest (5). Thus, safe duration of profound hypothermic circulatory arrest time was recommended to limit up to 30 minutes.To augment the cerebral protection during the profound hypothermic circulatory arrest, in 1990 Ueda and colleagues introduced continuous RCP techn...

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Section: Comparison To Acpmentioning

confidence: 87%

Simple retrograde cerebral perfusion is as good as complex antegrade cerebral perfusion for hemiarch replacement

Tanaka

Estrera

2018

J. Vis. Surg.

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“…10 Using multivariable logistic regression, we found that independent predictors of operative mortality were hemodynamic instability and CPB time, not type of cerebral protection used. 10 The strongest negative effect of DHCA originates from increased CPB times and subsequent length of operation in comparison with MH. [11][12][13] Extended CPB times during cardiac surgery are implicated in increased risk of acute renal insufficiency, stroke, and mortality.…”

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confidence: 89%

“…These findings raise questions as to whether hypothermic temperature may also play a confounding role, as supported by a recent study by the senior author. 10 We compared survival between 324 patients undergoing AAAD repair with either DHCA, retrograde, or anterograde cerebral perfusion. 10 Using multivariable logistic regression, we found that independent predictors of operative mortality were hemodynamic instability and CPB time, not type of cerebral protection used.…”

mentioning

confidence: 99%

“…10 We compared survival between 324 patients undergoing AAAD repair with either DHCA, retrograde, or anterograde cerebral perfusion. 10 Using multivariable logistic regression, we found that independent predictors of operative mortality were hemodynamic instability and CPB time, not type of cerebral protection used. 10 The strongest negative effect of DHCA originates from increased CPB times and subsequent length of operation in comparison with MH.…”

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confidence: 99%

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Repair of Acute Type-A Aortic Dissection in the Present Era: Outcomes and Controversies

Moeller

Nores

Stamou

2019

Aorta

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Acute Type-A aortic dissection (AAAD) remains a surgical emergency with a relatively high operative mortality despite advances in medical and surgical management over the past three decades. In spite of the severity of disease, there is a paucity of studies reviewing key controversies surrounding AAAD repair and management. A systematic literature search was performed using Cochrane review and PubMed bibliography review. Abstracts were first reviewed for general pertinence and then articles were reviewed in full. Literature review indicates that use of moderate hypothermia and antegrade cerebral perfusion is a safe alternative to deep hypothermia. In hemodynamically stable patients, axillary cannulation may be substituted for femoral cannulation. With regard to the technical aspects of repair, preserving the aortic root whenever possible and performing the distal anastomosis with the open distal technique rather than with the clamp on is the preferred approach. In patients with a patent false lumen, close monitoring is indicated. As demonstrated by the literature, significant improvement of early and late mortality over the past years has occurred in patients presenting with AAAD. Repair of acute Type-A aortic dissection remains a challenge with high operative mortality; however, improvement of surgical techniques and management have resulted in improvement of early and late clinical outcomes.

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“…Acute type A aortic dissection (ATAAD) is a life-threatening vascular emergency, mandating immediate surgical repair 1 . While developments in surgical, anaesthetic, and perfusion techniques have resulted in improved clinical outcomes, complex aortic arch procedures with hypothermic circulatory arrest (HCA), selective cerebral perfusion (SCP) and individual arterial cannulation modalities are still associated with a relatively high incidence of postoperative neurological complications and mortality 2 – 4 .…”

Section: Introductionmentioning

confidence: 99%

Identification of CTA-Based Predictive Findings for Temporary and Permanent Neurological Dysfunction after Repair in Acute Type A Aortic Dissection

Zhao

Wen

Duan

et al. 2018

Sci Rep

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The aim of this study was to determine CT risk findings predictive of temporary neurological dysfunction (TND) and permanent neurological dysfunction (PND) after surgical repair for acute type A aortic dissection (ATAAD). A total of 255 patients (41 ± 16 years, 79% male) with ATAAD underwent aortic CT angiography (CTA) and surgical repair consecutively from January 2013 to June 2016. The CTA findings of the 255 patients for the thoracic aorta and carotid artery were analysed to identify risk factors predictive of TND and PND. Thirty-eight patients (15%) suffered TND, and 18 (7%) exhibited PND. Common carotid artery (CCA) dissection (OR = 4.63), lower enhancement of unilateral ICA (OR = 3.02) and aortic arch tears (OR = 2.83) were predictors of postoperative TND, while PND was best predicted by retrograde ascending aorta (aAO) dissection (OR = 5.62) and aortic arch tears (OR = 6.74). In CCA dissection, the extent of the entire CCA and proximal ICA (P = 0.014), a low-enhancement false lumen with re-entry (P = 0.000) and a severely narrowed true lumen without re-entry (P = 0.005) significantly increased the risk of postoperative TND. In patients with ATAAD, specific CT findings allow the individual risk of postoperative TND and PND to be identified and may guide subsequent surgical management.

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Comparison between antegrade and retrograde cerebral perfusion or profound hypothermia as brain protection strategies during repair of type A aortic dissection

Cited by 23 publications

References 22 publications

Simple retrograde cerebral perfusion is as good as complex antegrade cerebral perfusion for hemiarch replacement

Simple retrograde cerebral perfusion is as good as complex antegrade cerebral perfusion for hemiarch replacement

Repair of Acute Type-A Aortic Dissection in the Present Era: Outcomes and Controversies

Identification of CTA-Based Predictive Findings for Temporary and Permanent Neurological Dysfunction after Repair in Acute Type A Aortic Dissection

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