Review of cerebral perfusion strategies for aortic surgery with application for minimally invasive approaches

Abstract

Aortic arch and hemiarch surgery necessitate the temporary interruption of blood perfusion to the brain. Despite its complexity, hemiarch and ascending aortic surgery can be performed via a minimally invasive approach. Due to the higher risk of neurological injury during a circulatory arrest, several techniques were developed to further protect the brain during this surgery. We searched the Embase, Medline, and Cochrane databases and identified articles reporting outcomes of antegrade and retrograde cerebral perfusion strategies. Herein, we outline surgical approaches, intra-operative technical considerations, and clinical outcomes of hemiarch and ascending aortic surgery. Hemiarch and ascending aortic surgery is associated with a higher risk of mortality and morbidity. Attention to the optimal approach and cerebral protection strategy has been shown to significantly affect outcomes and mitigate risk.

Minimally invasive approach: is this the future of aortic surgery?

“…MS, however, allows for easy and safe conversion to full sternotomy in case of unexpected complications or unpredicted technical problems. In patients undergoing arch replacement, both antegrade selective cerebral perfusion (ASCP) or retrograde cerebral perfusion (RCP) methods can be used [9]. The advantages and drawbacks of such perfusion techniques were extensively reported in conventional aortic interventions and could be reasonably translated to MS approach [9].…”

“…In patients undergoing arch replacement, both antegrade selective cerebral perfusion (ASCP) or retrograde cerebral perfusion (RCP) methods can be used [9]. The advantages and drawbacks of such perfusion techniques were extensively reported in conventional aortic interventions and could be reasonably translated to MS approach [9]. Additionally, in patients undergoing mini arch surgery, RCP may provide improved exposure of the arch vessels, although there is constant flooding of venous blood return into the operative field, whereas ASCP yields a dry field with catheters potentially reducing visibility.…”

“…In patients undergoing hemiarch replacement, cerebral protection can be exclusively performed via deep hypothermic circulatory arrest and RCP [9]. The latter is obtained by means of a venous cannula placed into the superior vena cava through a port site positioned several interspaces below the MT.…”

Commentary: Does facilitating left subclavian artery revascularization matter during zone 2 thoracic endovascular aortic repair?

“…4 Although FET and repair of aortic arch aneurysm with dissection were successfully performed in this study using antegrade perfusion, a retrograde perfusion strategy may improve arch vessel exposure and decrease the overall technical difficulty without negatively impacting outcomes. 5,6 The authors completed FET procedures with excellent outcomes in different scenarios without operative mortality or neurologic complications. Long-term results will ultimately demonstrate the viability as well as disadvantages of this Facilitating left subclavian artery anastomosis during aortic arch surgery will reduce the overall technical difficulty and may decrease the risk of neurologic injury.…”