Optimal Cerebral Protection Strategies in Aortic Surgery

Abstract

Cerebral protection strategies in aortic surgery have undergone significant evolution over the years, but its tenets remain rooted in maintenance of hypothermia and cerebral perfusion to limit adverse neurologic outcomes. While deep hypothermic circulatory arrest alone remains a viable approach in many instances, the need for prolonged duration of circulatory arrest and increasing case complexity have driven the utilization of adjunctive cerebral perfusion strategies. In this review, we present the most recent studies published on this topic over the last few years investigating the efficacy of deep hypothermic circulatory arrest, retrograde cerebral perfusion, and unilateral and bilateral antegrade cerebral perfusion, as well as the emerging trend toward mild and moderate HCA temperatures. We highlight the ongoing controversies in the field that underscore the need for large-scale randomized trials using well-defined neurologic endpoints to optimize evidence-based practice in cerebral protection.

Keywords: Antegrade and retrograde cerebral perfusion; Cerebral protection; Deep hypothermic circulatory arrest; Moderate hypothermic circulatory arrest.

Figure 1.

Kaplan-Meier survival analysis comparing elective, first-time nondissection cases (n =424) with a reference population. Rug marks represent censored patients; dotted lines represent confidence bands. The survival of this group of DHCA patients was not significantly different from the age- and sex-matched population. (Adapted with permission Damberg et al.)

Figure 2.

Kaplan-Meier survival estimates (top) for all-comers undergoing DHCA + RCP and (bottom) broken down by groups based on duration of DHCA. (Adapted with permission Lau et al.)

Figure 3.

Kaplan-Meier survival curve for all-comers undergoing aortic arch surgery using ACP and MHCA (≥28°C). The number of patients at risk is indicated. (Adapted with permission Ahmad et al.)

Figure 4.

Thirty-day mortality and incidence of PND in the u-ACP (n = 82) and b-ACP (n = 121) groups among patients presenting with type A aortic dissection undergoing total arch replacement with selective ACP and MHCA. (Adapted with permission Tong et al.)