Unilateral versus bilateral antegrade cerebral perfusion during aortic arch surgery: an updated meta-analysis of...

Despite advances in cerebral protection strategies, aortic arch surgery remains associated with significant neurological risk. Unilateral antegrade cerebral perfusion (uACP) and bilateral ACP (bACP) are widely used during moderate hypothermic circulatory arrest, but the optimal strategy remains controversial.

A comprehensive literature search was performed to identify RCT and comparative studies comparing uACP and bACP in patients undergoing aortic arch surgery. Studies were pooled using the random-effects model to perform a pairwise meta-analysis. Primary outcomes were 30-day mortality, permanent neurological deficit (PND), and transient neurological deficit (TND). Secondary outcomes included paraplegia, transfusion, acute kidney injury, tracheostomy, and long-term mortality.

A total of 20 studies with 5,647 patients were included. There was no significant difference between uACP and bACP in 30-day mortality (RR 1.16, p = 0.26) or PND (RR 1.10, p = 0.57). However, uACP was associated with a significantly higher risk of 30-day TND (RR 1.32, p = 0.006). No significant difference was observed for any other explored outcomes. Meta-regression revealed no significant correlation between duration of circulatory arrest or ACP on primary outcomes.

Compared to bACP, uACP during aortic arch surgery is associated with increased transient neurologic deficits but similar rates of mortality and PND. Selection of cerebral perfusion strategy should be individualized to patient anatomy, operative context, and anticipated circulatory arrest duration, recognizing that some subgroups may derive greater benefit from bACP.