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

Abstract

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. 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. 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. 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.