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Published on: May 19, 2021
Simple retrograde cerebral perfusion is as good as complex antegrade cerebral perfusion for hemiarch replacement
Akiko Tanaka1, Anthony L Estrera1
1Department of Cardiothoracic and Vascular Surgery, McGovern Medical School, The University of Texas Health Science Center, Houston and Memorial Hermann Hospital, Houston, TX, USA.
Insights
Deep hypothermic circulatory arrest protects the brain during aortic arch surgery. Antegrade cerebral perfusion (ACP) and retrograde cerebral perfusion (RCP) are techniques to reduce neurological issues, with RCP preferred for shorter procedures.
Area of Science:
- Cardiovascular Surgery
- Neurosurgery
- Thoracic Surgery
Background:
- Cerebral complications are a significant risk in aortic arch surgery, potentially leading to mortality.
- Deep hypothermic circulatory arrest (DHCA) was developed to mitigate brain ischemia, but safe durations were initially limited.
- Advancements in the 1990s introduced antegrade cerebral perfusion (ACP) and retrograde cerebral perfusion (RCP) techniques to improve cerebral protection during DHCA.
Purpose of the Study:
- To evaluate the necessity and efficacy of different cerebral protection strategies during aortic arch repair.
- To compare the outcomes of antegrade cerebral perfusion (ACP) versus retrograde cerebral perfusion (RCP) in various aortic arch reconstruction scenarios.
- To determine the optimal cerebral protection technique for procedures involving short circulatory arrest times, such as hemiarch replacement.
Main Methods:
- Review of existing literature comparing ACP and RCP techniques in aortic arch surgery.
- Analysis of retrospective studies investigating the incidence of postoperative neurological dysfunction and mortality.
- Discussion of the surgical field implications and potential benefits of RCP, such as atheromatous debris flushing.
Main Results:
- Both ACP and RCP have significantly decreased postoperative neurological dysfunction and mortality compared to DHCA alone.
- Retrospective studies suggest ACP may offer advantages over RCP in complex aortic arch reconstructions requiring prolonged circulatory arrest.
- Evidence supporting the superiority of complex ACP over simple RCP for short circulatory arrest times (e.g., hemiarch replacement) is limited.
Conclusions:
- Surgeons often favor ACP for complex aortic arch repairs like total or hybrid arch replacement.
- For shorter procedures such as hemiarch replacement, retrograde cerebral perfusion (RCP) with DHCA is a simple, effective technique with minimal surgical interference.
- RCP is the preferred adjunct to DHCA for hemiarch replacement at our institution due to its efficiency and potential to clear debris.
Abstract:
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.
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