What is the best strategy for brain protection in patients undergoing aortic arch surgery? A single center experience of 636 patients.

Abstract

BACKGROUND:

Cerebral protection during aortic arch surgery can be performed using various surgical strategies. We retrospectively analyzed our results of different brain protection modalities during aortic arch surgery.

METHODS:

Between January 2003 and November 2009, 636 consecutive patients underwent aortic arch replacement surgery using unilateral antegrade cerebral perfusion (UACP [n=123]), bilateral antegrade cerebral perfusion (BACP [n=242]), retrograde cerebral perfusion (RCP [n=51]), or deep hypothermia and circulatory arrest (DHCA [n=220]). Mean age of patients was 62±14 years, 64% were male, 15% were reoperations, and 37% were performed for acute type A dissections. Mean follow-up was 4.9±0.1 years and was 97% complete.

RESULTS:

Circulatory arrest time was 22±17 minutes UACP, 23±21 minutes BACP, 18±12 minutes RCP, and 15±13 minutes DHCA; p<0.001). Early mortality was 11% (n=72) and was not different between the surgical groups. Stroke rate was 9% for ACP patients (n=33) versus 15% (n=39) for patients who did not receive ACP (p=0.035). Independent predictors of stroke were type A aortic dissection (odds ratio [OR], 1.9; 95% confidence interval [CI], 1.3 to 3.2; p<0.001), age (OR, 1.04; 95% CI, 1.01 to 1.06; p=0.001), duration of circulatory arrest (OR, 1.01, 95% CI, 1.002 to 1.03; p=0.02), and total aortic arch replacement (OR, 2.7; 95% CI, 1.3 to 5.7; p=0.005). Five year survival was 68%±4% and was not significantly different between groups.

CONCLUSIONS:

Antegrade cerebral perfusion is associated with significantly less neurologic complications than RCP and DHCA, despite longer circulatory arrest times. Medium-term survival is worse for patients with postoperative permanent neurologic deficit and preoperative type A aortic dissection.

• Authors: Martin Misfeld, Sergey Leontyev, Michael A Borger, Olivier Gindensperger, Sven Lehmann, Jean-Francois Legare, Friedrich W Mohr
• Journal: The Annals of thoracic surgery (Ann Thorac Surg) Vol. 93 Issue 5 Pg. 1502-8 (May 2012) ISSN: 1552-6259 [Electronic] Netherlands
• PMID: 22480393 (Publication Type: Comparative Study, Journal Article)
• Copyright: Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Topics

• Age Factors
• Aged
• Angiography (methods)
• Aorta, Thoracic (physiopathology, surgery)
• Aortic Aneurysm, Thoracic (diagnostic imaging, mortality, surgery)
• Blood Vessel Prosthesis Implantation (adverse effects, methods)
• Brain Ischemia (etiology, prevention & control)
• Cardiopulmonary Bypass (methods, mortality)
• Cerebrovascular Circulation (physiology)
• Chi-Square Distribution
• Circulatory Arrest, Deep Hypothermia Induced (adverse effects, methods)
• Cohort Studies
• Databases, Factual
• Female
• Follow-Up Studies
• Hospital Mortality (trends)
• Humans
• Intraoperative Complications (prevention & control)
• Kaplan-Meier Estimate
• Male
• Middle Aged
• Odds Ratio
• Perfusion (methods)
• Postoperative Complications (prevention & control)
• Predictive Value of Tests
• Proportional Hazards Models
• Retrospective Studies
• Risk Assessment
• Sex Factors
• Survival Analysis
• Treatment Outcome