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Bilateral or unilateral antegrade cerebral perfusion during surgery for acute type A dissection
Philipp Angleitner1, Marie-Elisabeth Stelzmueller1, Stéphane Mahr1
1Division of Cardiac Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria.
Insights
Bilateral antegrade cerebral perfusion shows comparable overall survival to unilateral antegrade cerebral perfusion in acute type A dissection surgery. However, bilateral perfusion may improve survival in patients needing longer durations of cerebral protection.
Area of Science:
- Cardiovascular Surgery
- Thoracic Surgery
- Neurosurgery
Background:
- Acute type A aortic dissection is a life-threatening condition requiring surgical intervention.
- Antegrade cerebral perfusion (ACP) is crucial for protecting the brain during aortic arch surgery.
- The optimal strategy for ACP (bilateral vs. unilateral) remains debated.
Purpose of the Study:
- To compare outcomes of bilateral antegrade cerebral perfusion (BACP) versus unilateral antegrade cerebral perfusion (UACP) in acute type A dissection surgery.
- To identify patient subgroups that may benefit from BACP.
- To evaluate the impact of ACP strategy on overall survival and secondary outcomes.
Main Methods:
- Retrospective analysis of 91 patients receiving BACP and 93 patients receiving UACP for type A dissection (2009-2017).
- Primary outcome: overall survival.
- Subgroup analyses based on ACP duration (≥50 minutes vs. <50 minutes); secondary outcomes included mortality, neurologic deficits, and organ support.
Main Results:
- No significant difference in overall survival between BACP and UACP groups overall.
- BACP was associated with significantly improved overall survival in patients requiring ≥50 minutes of ACP (P=0.017).
- Secondary outcomes were comparable between the BACP and UACP groups.
Conclusions:
- Bilateral and unilateral antegrade cerebral perfusion demonstrate comparable outcomes in acute type A dissection surgery.
- Bilateral ACP may offer superior survival benefits for patients requiring prolonged cerebral protection (≥50 minutes).
- Further prospective randomized trials are needed to confirm these findings.
Objective:
The study objective was to investigate outcomes associated with the application of bilateral or unilateral antegrade cerebral perfusion during surgery for acute type A dissection.
Methods:
Patients who underwent surgery for type A dissection with the application of antegrade cerebral perfusion between 2009 and 2017 at the Division of Cardiac Surgery, Medical University of Vienna were analyzed retrospectively (bilateral antegrade cerebral perfusion: n = 91, 49.5%; unilateral antegrade cerebral perfusion: n = 93, 50.5%). The primary outcome variable was overall survival. Subgroup analyses were performed in patients requiring antegrade cerebral perfusion durations of 50 minutes or more and less than 50 minutes. Secondary outcome variables were 30-day mortality, adverse outcome, permanent and temporary neurologic deficits, renal replacement therapy, prolonged ventilation, intensive care unit stay, and hospital stay.
Results:
Multivariable Cox proportional hazards analysis demonstrated no significant association of bilateral antegrade cerebral perfusion with overall survival (hazard ratio, 0.63; 95% confidence interval, 0.34-1.14, P = .126). Propensity score modeling using the method of inverse probability of treatment weighting confirmed this result (hazard ratio, 0.73; 95% confidence interval, 0.33-1.60, P = .428). Bilateral antegrade cerebral perfusion was associated with significantly improved overall survival in patients requiring antegrade cerebral perfusion durations of 50 minutes or more (P = .017). The bilateral antegrade cerebral perfusion and unilateral antegrade cerebral perfusion groups showed comparable rates of secondary outcome variables.
Conclusions:
In the present study, bilateral antegrade cerebral perfusion and unilateral antegrade cerebral perfusion are associated with comparable outcomes after surgery for type A dissection. Subgroup analyses suggest that bilateral antegrade cerebral perfusion is associated with superior overall survival in patients requiring antegrade cerebral perfusion durations of 50 minutes or more. An adequately powered prospective randomized controlled trial is required to validate these results.
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