Bilateral or Unilateral Antegrade Cerebral Perfusion During Surgery For Acute Type A Dissection
Bilateral or Unilateral Antegrade Cerebral Perfusion During Surgery For Acute Type A Dissection
Bilateral or Unilateral Antegrade Cerebral Perfusion During Surgery For Acute Type A Dissection
ADULT
Bilateral or unilateral antegrade cerebral perfusion during
surgery for acute type A dissection
Philipp Angleitner, MD,a Marie-Elisabeth Stelzmueller, MD,a Stephane Mahr, MD,a
Alexandra Kaider, MSc,b Guenther Laufer, MD,a and Marek Ehrlich, MDa
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. 100
80
100
80
Survival (%)
Survival (%)
60 60
40 40
Methods: Patients who underwent surgery for type A dissection with the applica- 20
0 Logrank P = .02
20
0 Logrank P = .91
0 1 2 3 4 5 6 7 8 0 1 2 3 4 5 6 7 8
tion of antegrade cerebral perfusion between 2009 and 2017 at the Division of 1
2
27
16
22
6
18
5
Survival time (years)
15
5
13
5
10
4
9
3
6
2
3
1
1
2
64
77
44
60
33
52
Survival time (years)
24
45
21
37
16
29
14
23
9
8
5
1
Cardiac Surgery, Medical University of Vienna were analyzed retrospectively 1: Bilateral ACP 2: Unilateral ACP 1: Bilateral ACP 2: Unilateral ACP
(bilateral antegrade cerebral perfusion: n ¼ 91, 49.5%; unilateral antegrade cere- ACP durations ≥ 50 min ACP durations < 50 min
bral perfusion: n ¼ 93, 50.5%). The primary outcome variable was overall sur- b-ACP and superior overall survival in patients with
vival. Subgroup analyses were performed in patients requiring antegrade ACP durations of 50 minutes or more.
cerebral perfusion durations of 50 minutes or more and less than 50 minutes. Sec-
ondary outcome variables were 30-day mortality, adverse outcome, permanent Central Message
and temporary neurologic deficits, renal replacement therapy, prolonged ventila- b-ACP and u-ACP are associated with compa-
tion, intensive care unit stay, and hospital stay. rable outcomes after surgery for acute TAD.
b-ACP might be preferentially applied in pa-
Results: Multivariable Cox proportional hazards analysis demonstrated no signif- tients with longer ACP durations.
icant association of bilateral antegrade cerebral perfusion with overall survival
(hazard ratio, 0.63; 95% confidence interval, 0.34-1.14, P ¼ .126). Propensity Perspective
score modeling using the method of inverse probability of treatment weighting In the present analysis, b-ACP and u-ACP are
confirmed this result (hazard ratio, 0.73; 95% confidence interval, 0.33-1.60, associated with similar outcomes after surgery
P ¼ .428). Bilateral antegrade cerebral perfusion was associated with significantly for acute TAD. Subgroup analyses suggest
improved overall survival in patients requiring antegrade cerebral perfusion dura- that b-ACP is associated with superior overall
survival in patients requiring ACP durations
tions of 50 minutes or more (P ¼ .017). The bilateral antegrade cerebral perfusion of 50 minutes or more. An adequately powered
and unilateral antegrade cerebral perfusion groups showed comparable rates of randomized controlled trial is required to vali-
secondary outcome variables. date these results.
Conclusions: In the present study, bilateral antegrade cerebral perfusion and uni-
lateral antegrade cerebral perfusion are associated with comparable outcomes af- See Commentaries on pages 2168,
ter surgery for type A dissection. Subgroup analyses suggest that bilateral 2170, and 2171.
antegrade cerebral perfusion is associated with superior overall survival in pa-
tients requiring antegrade cerebral perfusion durations of 50 minutes or more.
An adequately powered prospective randomized controlled trial is required to
validate these results. (J Thorac Cardiovasc Surg 2020;159:2159-67)
The Journal of Thoracic and Cardiovascular Surgery c Volume 159, Number 6 2159
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TABLE 1. Preoperative baseline characteristics
All patients Bilateral ACP Unilateral ACP
Variables n ¼ 184 (100%) n ¼ 91 (49.5%) n ¼ 93 (50.5%) P value
Age (y) 61.0 14 61.0 13.8 60.9 14.3 .961*
Female (%) 55 (29.9) 24 (26.4) 31 (33.3) .303y
BMI (kg/m2) 26.8 4.8 26.8 4.5 26.7 5.1 .831*
Hypertension (%) 155 (84.2) 78 (85.7) 77 (82.8) .587y
Diabetes mellitus (%) 10 (5.4) 6 (6.6) 4 (4.3) .534z
Atrial fibrillation (%) 26 (14.1) 16 (17.6) 10 (10.8) .184y
COPD (%) 15 (8.2) 3 (3.3) 12 (12.9) .017y
CAD (%) 36 (19.6) 15 (16.5) 21 (22.6) .297y
PAD (%) 18 (9.8) 9 (9.9) 9 (9.7) .961y
CVD (%) 12 (6.5) 8 (8.8) 4 (4.3) .218y
History of stroke (%) 15 (8.2) 8 (8.8) 7 (7.5) .754y
Creatinine (mg/dL) 1.1 (0.8-1.3) 1.1 (0.9-1.4) 1.1 (0.8-1.3) .239*
Marfan syndrome (%) 4 (2.2) 0 (0) 4 (4.3) .121z
Previous sternotomy (%) 7 (3.8) 4 (4.4) 3 (3.2) .719z
DeBakey type I (%) 129 (70.1) 65 (71.4) 64 (68.8) .699y
Malperfusion (%)
Coronary 33 (17.9) 15 (16.5) 18 (19.4) .612y
Cerebral 36 (19.6) 15 (16.5) 21 (22.6) .297y
Spinal 1 (0.5) 1 (1.1) 0 (0) NT
Mesenteric 12 (6.5) 5 (5.5) 7 (7.5) .577y
Renal 52 (28.3) 26 (28.6) 26 (28.0) .926y
Peripheral 35 (19.0) 17 (18.7) 18 (19.4) .907y
Hemodynamic instability (%) 45 (24.5) 20 (22) 25 (26.9) .439y
Lactate (mmol/L) 1.5 (1.1-2.6) 1.7 (1.1-2.7) 1.5 (1-2.4) .925*
Iatrogenic dissection (%) 18 (9.8) 8 (8.8) 10 (10.8) .654y
Complication of cardiac surgery 9 (4.9) 4 (4.4) 5 (5.4) NT
Complication of coronary angiography 6 (3.3) 2 (2.2) 4 (4.3) NT
Complication of TEVAR 3 (1.6) 2 (2.2) 1 (1.1) NT
Surgery within 6 h (%) 111 (60.3) 48 (52.8) 63 (67.7) .038y
Surgery within 48 h (%) 172 (93.5) 85 (93.4) 87 (93.6) .969y
Bold indicates statistical significance (P<.05). ACP, Antegrade cerebral perfusion; BMI, body mass index; COPD, chronic obstructive pulmonary disease; CAD, coronary artery
disease; PAD, peripheral arterial disease; CVD, cerebrovascular disease; NT, not tested; TEVAR, thoracic endovascular aortic repair. *t test. yChi-square test. zFisher exact test.
follow-up was 51.9 months. Survival probabilities were estimated by the These subgroup analyses were motivated by a statistically significant inter-
Kaplan–Meier method, and the log-rank test was used to compare survival action between the effects of b-ACP and ACP duration on overall survival
curves. Univariate and multivariable Cox proportional hazards models (P ¼ .039) as evaluated in the multivariable Cox proportional hazards
were applied to analyze the effect of b-ACP on overall survival during model. The cutoff of ‘‘50 minutes’’ was chosen in accordance with the re-
the follow-up period. Covariates for the multivariable model were chosen sults of 2 meta-analyses showing improved outcomes after the application
with regard to clinical experience and published evidence.17 To confirm the of b-ACP in patients requiring ACP durations ‘‘longer than 40 to 50 mi-
findings of the multivariable Cox proportional hazards analysis, propensity nutes’’ and ‘‘longer ACP durations.’’18,19
score modeling was performed using the method of inverse probability of Secondary outcome variables were defined as 30-day mortality, adverse
treatment weighting. Baseline characteristics assumed to influence the de- outcome (in-hospital mortality or PND), PND (ischemic or hemorrhagic
cision for applying b-ACP or the patient’s outcome were included in the lesion documented by cranial computed tomography, or irreversible
propensity score model, namely, aortic team, surgical year, surgery within coma), temporary neurologic deficit (TND) (full recovery before hospital
6 hours, mesenteric malperfusion, hemodynamic instability, age, female discharge), renal replacement therapy (RRT) during the postoperative hos-
sex, chronic obstructive pulmonary disease, and creatinine (log2- pital stay, prolonged ventilation (ventilation >48 hours or death during
transformed). 48 hours after surgery), prolonged intensive care unit (ICU) stay
Univariate and multivariable subgroup analyses were performed to (>7 days), and prolonged hospital stay (>30 days). Chi-square tests were
analyze the impact of b-ACP on overall survival in patients requiring used to compare the rates of secondary outcome variables between the b-
ACP durations of 50 minutes or more or less than 50 minutes, respectively. ACP and u-ACP groups.
The Journal of Thoracic and Cardiovascular Surgery c Volume 159, Number 6 2161
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In addition, characteristics of cerebral lesions in patients with PND were regard to the extent of replacement, although the rate of to-
analyzed descriptively. Moreover, causes of death were descriptively tal arch replacement was numerically higher in the b-ACP
analyzed in patients with ACP durations of 50 minutes or more. All ana-
lyses were performed using SAS software version 9.4 (SAS Institute Inc,
group (Table 2). As expected, the b-ACP group was charac-
Cary, NC). terized by significantly longer median durations of CPB,
crossclamping, HCA, and ACP. Also, DHCA was more
frequently used in the b-ACP group (28.6% vs 12.9%)
RESULTS
(Table 2).
During the study period, 184 patients underwent surgery
for TAD with the use of ACP. b-ACP was applied in 91 pa-
tients (49.5%), and u-ACP was applied in 93 patients Primary Outcome: Overall Survival
(50.5%). Fourteen patients (7.6%) were initially perfused Kaplan–Meier survival curves of the b-ACP and u-ACP
using u-ACP but immediately switched to b-ACP after a groups are visualized in Figure 2 (log-rank test, P ¼ .40).
unilateral decrease in oxygen saturation occurred. These pa- The univariate hazard ratio (HR) for b-ACP was 0.79
tients were assigned to the b-ACP group for all statistical (95% confidence interval [CI], 0.45-1.38, P ¼ .40). The
analyses. multivariable Cox proportional hazards model demon-
Preoperative baseline characteristics of the b-ACP and strated that the application of b-ACP was not associated
u-ACP groups are shown in Table 1. The mean age of the with overall survival (HR, 0.63; 95% CI, 0.34-1.14;
study cohort was 61.0 14 years. The majority of patients P ¼ .126) (Table 3). Covariates used in this model were
had a DeBakey type I dissection (n ¼ 129, 70.1%). In pa- age, mesenteric malperfusion, duration of CPB, duration
tients undergoing surgery within 6 hours after first medical of ACP, and use of DHCA.
contact, u-ACP was more commonly applied (Table 1). To confirm these results, propensity score modeling was
Intraoperative baseline characteristics are shown in Table performed, showing an HR for b-ACP of 0.73 (95% CI,
2. The aortic team was operating on 31.5% of patients. 0.33-1.60; P ¼ .428) adjusted for the same covariates as
b-ACP was more frequently applied by these surgeons, in the multivariable Cox proportional hazards model.
although the difference did not reach statistical significance.
However, a significant trend toward generally increased use Subgroup Analyses
of b-ACP was evident in more recent years. No differences Subgroup analyses were performed because of a statisti-
were found between the b-ACP and u-ACP groups with cally significant interaction between the effects of b-ACP
ADULT
Bilateral ACP versus Unilateral ACP
100 100
80 80
Survival (%)
Survival (%)
60 60
40 40
20 20
0 1 2 3 4 5 6 7 8 0 1 2 3 4 5 6 7 8
Survival time (years) Survival time (years)
1 27 22 18 15 13 10 9 6 3 1 64 44 33 24 21 16 14 9 5
2 16 6 5 5 5 4 3 2 1 2 77 60 52 45 37 29 23 8 1
FIGURE 1. b-ACP and superior overall survival in patients with ACP durations of 50 minutes or more. ACP, Antegrade cerebral perfusion.
and ACP duration on overall survival (P ¼ .039) as evalu- The subgroup of patients with ACP durations less than
ated in the multivariable Cox proportional hazards model. 50 minutes consisted of 141 patients (b-ACP: n ¼ 64,
The subgroup of patients requiring ACP durations of 50 mi- 45.4%; u-ACP: n ¼ 77, 54.6%). Figure 2, B shows similar
nutes or more consisted of 43 patients (b-ACP: n ¼ 27, survival curves of patients receiving b-ACP and u-ACP
62.8%; u-ACP: n ¼ 16, 37.2%). Kaplan–Meier survival (log-rank test, P ¼ .91). Multivariable Cox proportional
curves in Figure 3, A show the significantly improved over- hazards analysis demonstrated no association of b-ACP
all survival of patients receiving b-ACP in comparison with with overall survival in this subgroup (HR, 0.84; 95% CI,
u-ACP in this subgroup (log-rank test, P ¼ .02). Multivari- 0.43-1.66; P ¼ .620) (Table 4).
able Cox proportional hazards analysis confirmed that
b-ACP was associated with significantly improved overall Secondary Outcome Variables
survival in patients requiring ACP durations of 50 minutes Comparison of the b-ACP and u-ACP groups demon-
or more (HR, 0.26; 95% CI, 0.09-0.79; P ¼ .017) (Table strated similar rates of 30-day mortality (b-ACP: 12.1%,
4). Duration of CPB was used as a covariate for this u-ACP: 16.1%, P ¼ .431), adverse outcome (26.4% vs
analysis. 30.1%, P ¼ .574), PND (18.7% vs 19.4%, P ¼ .753),
The Journal of Thoracic and Cardiovascular Surgery c Volume 159, Number 6 2163
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60
hypoxic brain injury) than in the u-ACP group (33.3% vs
75%) (Table E3).
40
20 DISCUSSION
In the present study, the application of b-ACP was not
0 associated with overall survival after surgery for TAD.
Moreover, the b-ACP and u-ACP groups showed similar
0 1 2 3 4 5 6 7 8
rates of 30-day mortality, adverse outcome, PND, TND,
Survival Time (Years)
RRT, prolonged ventilation, ICU stay, and hospital stay.
Numbers at risk:
Several retrospective studies have yielded comparable re-
1 91 66 51 39 34 26 23 15 8
sults.3,20-23
2 93 66 57 50 42 33 26 10 2
Subgroup analyses demonstrated that b-ACP was associ-
1: Bilateral ACP 2: Unilateral ACP ated with significantly improved overall survival in patients
FIGURE 2. Primary outcome: overall survival (Kaplan–Meier survival requiring ACP durations of 50 minutes or more (Table 4,
curves, log-rank test). Kaplan–Meier survival curves show that overall sur- Figure 3, A). Comparative analysis of causes of death in
vival is similar (log-rank P ¼ .40) in patients receiving b-ACP (n ¼ 91) or this subgroup suggested that in patients receiving b-ACP,
u-ACP (n ¼ 93) during surgery for acute TAD. ACP, Antegrade cerebral death was less frequently caused by major neurologic
perfusion. events than in the u-ACP group (Table E3). These findings
are in line with the results of 2 meta-analyses showing that
TND (7.7% vs 9.7%, P ¼ .226), RRT (23.1% vs 22.6%, the application of b-ACP is associated with improved out-
P ¼ .996), prolonged ventilation (47.3% vs 52.7%, comes in patients with prolonged ACP durations during
P ¼ .461), prolonged ICU stay (57.1% vs 61.3%, aortic arch surgery. Malvindi and colleagues18 analyzed
P ¼ .567), and prolonged hospital stay (40.7% vs 44.1%, 17 studies including a total of 2949 patients receiving
P ¼ .638) (Table E1). b-ACP and 599 patients receiving u-ACP. The authors
concluded that b-ACP was associated with improved sur-
Characteristics of Cerebral Lesions in Patients With vival and lower rates of cerebrovascular events in patients
Permanent Neurologic Deficit with ACP durations over 40 to 50 minutes.18 Angeloni
Ischemic stroke was the most common type of lesion and colleagues19 reviewed 32 studies including 3723 pa-
characterized as PND (Table E2). Some patients had com- tients receiving b-ACP and 3065 patients receiving
bined lesions (eg, ischemic stroke and hypoxic brain u-ACP. Meta-regression analysis demonstrated that pro-
injury). The rate of right-sided lesions was higher in patients longed HCA times were associated with increased mortality
receiving b-ACP, whereas the rate of left-sided lesions was in patients receiving u-ACP, but not in patients receiving
higher in patients receiving u-ACP. Overall, most lesions b-ACP.19
occurred bilaterally (Table E2). The pathophysiologic basis for this association remains
to be elucidated. In the majority of patients operated with
TABLE 3. Primary outcome: Overall survival (multivariable Cox
the application of u-ACP via the right axillary artery, bi-
proportional hazards model)
hemispheric cerebral blood supply is provided by the circle
Hazard ratio of Willis.24 Clinical data even suggest that bi-hemispheric
Variables (95% CI) P value perfusion is preserved independently of an anatomically
Bilateral ACP 0.63 (0.34-1.14) .126 complete circle of Willis, likely via collateral vessels.25
Age (y) 1.02 (1.00-1.04) .085 The adequacy of cerebral perfusion and metabolism during
Mesenteric malperfusion 6.24 (2.89-13.47) <.001 ACP is influenced by flow rate, pH, hematocrit, and temper-
Duration of CPB (min, log2-transformed) 3.69 (2.15-6.33) <.001 ature.26 The cerebroprotective effects of hypothermia have
Duration of ACP (min, log2-transformed) 0.77 (0.52-1.14) .189
long been used during aortic surgery.27 On the one hand, hy-
pothermic ACP decreases cerebral oxygen extraction as a
DHCA 1.07 (0.55-2.08) .854
measure of metabolism.28 On the other hand, hypothermia
Bold indicates statistical significance (P <.05). CI, Confidence interval; ACP, ante-
grade cerebral perfusion; CPB, cardiopulmonary bypass; DHCA, deep hypothermic significantly reduces cerebral blood flow during ACP, as
circulatory arrest. shown in animal studies by Strauch and colleagues.29 The
ADULT
100 100
80 80
Survival (%)
60 60
Survival (%)
40 40
20 20
same authors have also demonstrated that cerebral blood net’’ by ensuring acceptable postoperative outcomes even
flow remains relatively constant for limited durations of if ACP durations of 50 minutes or more are required. This
ACP but is significantly decreased after 60 minutes of notion is supported by one study that exclusively focused
ACP.30 Against this background, our clinical findings sug- on patients receiving total arch replacement and showed a
gest that b-ACP might enable more physiologic bi- trend toward lower rates of 30-day mortality and PND in
hemispheric perfusion than u-ACP during prolonged the group receiving b-ACP.3 Although u-ACP might be
periods of HCA. applied safely when bi-hemispheric cerebral perfusion is
Surgery for TAD is characterized by considerable intrao- continuously monitored via NIRS, it needs to be remem-
perative risk of technical complications related to the aortic bered that further investigations into this technology are
arch (eg, intractable bleeding or progressive dissection in necessary to determine its sensitivity to detect cerebral
the area of the distal anastomosis). Thus, the surgeon needs ischemia.16,31 On the basis of these considerations, we
to be prepared for scenarios necessitating unexpected total share the opinion of Bachet,10 Takayama and Borger,11
arch replacement with substantial prolongation of HCA. and Spielvogel and colleagues26 that b-ACP should prefer-
In situations like these, b-ACP seems to provide a ‘‘safety entially be applied during surgery for TAD (Video 1).
Critics of the use of b-ACP have raised concerns
regarding unnecessary manipulation of supra-aortic vessels
TABLE 4. Subgroup analyses: Overall survival (multivariable Cox with potentially devastating consequences, including ca-
proportional hazards models) rotid dissection or embolization of particulate matter from
Hazard ratio P
the aortic arch. In fact, a trend toward a higher stroke rate
Variables (95% CI) value was shown in recipients of b-ACP in one retrospective anal-
ysis of 246 propensity score–matched patients undergoing
ACP durations 50 min
Bilateral ACP 0.26 (0.09-0.79) .017
elective aortic arch surgery (b-ACP: 6%, u-ACP: 2%,
Duration of CPB (min, log2-transformed) 4.55 (1.78-11.64) .002 P ¼ .06).32 In the present analysis, however, the rates of
ACP durations <50 min
bilateral cerebral lesions and unilateral left-sided lesions
Bilateral ACP 0.84 (0.43-1.66) .620 were higher in patients receiving u-ACP, whereas the rates
Duration of CPB (min, log2-transformed) 2.65 (1.42-4.94) .002 of unilateral right-sided lesions were higher in patients
Bold indicates statistical significance (P <.05). CI, Confidence interval; ACP, ante- receiving b-ACP (Table E2). These findings imply that the
grade cerebral perfusion; CPB, cardiopulmonary bypass. insertion of a perfusion cannula into the left common
The Journal of Thoracic and Cardiovascular Surgery c Volume 159, Number 6 2165
Adult: Aorta Angleitner et al
ADULT
Study Limitations
Several limitations need to be considered when interpret-
ing these findings. First, this study is likely subject to selec-
tion bias. Also, the increased use of b-ACP in more recent
VIDEO 1. Philipp Angleitner and Marek Ehrlich present the results and years might have biased the results. To adjust for these in-
implications of this study. Video available at: https://www.jtcvs.org/ fluences, a propensity score model was generated, including
article/S0022-5223(19)31353-4/fulltext. the variables ‘‘aortic team,’’ ‘‘surgery within 6 hours,’’ and
‘‘surgical year,’’ among others. This analysis confirmed the
results of the multivariable Cox proportional hazards anal-
carotid artery does not increase the risk of left-sided embo- ysis. Furthermore, this single-center analysis is limited by
lization and subsequent stroke. Clinical data have shown the relatively small sample size. As a consequence, this
that the presence of preoperative cerebral malperfusion is study might be underpowered to detect a potentially signif-
significantly associated with postoperative rates of PND.33 icant influence of b-ACP on postoperative outcomes. Unfor-
Moreover, substantial postoperative neurologic improve- tunately, the small number of patients requiring ACP
ment has been shown in patients presenting with preopera- durations of 50 minutes or more precluded more detailed
tive neurologic deficits.34,35 These findings suggest that subgroup analyses of secondary outcome variables, most
timely resolution of cerebral malperfusion by surgery importantly PND and TND. Moreover, continuous NIRS
might play a more important role in the prevention of monitoring data were not documented for the entire study
PND than the choice of ACP. In the present study, the b- cohort and thus could not be included for statistical
ACP and u-ACP groups had similar rates of preoperative analysis.
cerebral malperfusion (corresponding to
hemodynamically significant dissection of supra-aortic ves-
sels), suggesting that surgeons did not consider the presence CONCLUSIONS
or absence of dissection in supra-aortic vessels when The present study demonstrates comparable overall sur-
deciding between the use of b-ACP or u-ACP (Table 1). vival and similar rates of secondary outcome variables in
Notably, the b-ACP and u-ACP groups showed differ- patients receiving b-ACP or u-ACP during surgery for
ences regarding several aspects of the surgical procedure. TAD. Subgroup analyses suggest that b-ACP is associated
b-ACP was more frequently applied by the aortic team, with significantly improved overall survival in patients
although the difference did not reach statistical significance requiring ACP durations of 50 minutes or more. On the ba-
(Table 2). However, a significant trend toward increased use sis of these findings, we believe that b-ACP should prefer-
of b-ACP during more recent years of the study period was entially be applied during surgery for TAD. Nevertheless,
demonstrated (Table 2). In the early 2000s, surgeons at our an adequately powered prospective randomized controlled
department used b-ACP almost exclusively in patients trial is required to validate these results.
showing a unilateral decrease in cerebral oxygen saturation
as assessed by NIRS. Currently, our departmental policy Conflict of Interest Statement
recommends the universal application of b-ACP in patients Laufer: Consultant and Proctor activity for Edwards/Intuity
operated for TAD in response to recent publications Valve. All other authors have nothing to disclose with re-
showing improved outcomes in patients receiving gard to commercial support.
b-ACP.18,19 The lower rate of b-ACP in patients operated
within 6 hours after first medical contact possibly The authors thank Marina Manduric for assistance with the sur-
indicates that u-ACP was preferentially applied in more gical database of the Division of Cardiac Surgery, Medical Univer-
urgent cases to decrease procedural complexity, although sity of Vienna.
this difference was not evident in the rates of
hemodynamic instability or axillary cannulation (Tables 1 References
and 2). The b-ACP and u-ACP groups were similar 1. Evangelista A, Isselbacher EM, Bossone E, Gleason TG, Di Eusanio M,
Sechtem U, et al. Insights from the International Registry of Acute Aortic Dissec-
regarding the extent of aortic replacement, although a tion: a 20-year experience of collaborative clinical research. Circulation. 2018;
numerically higher rate of patients receiving total arch 137:1846-60.
ADULT
2. Preventza O, Olive JK, Liao JL, Orozco-Sevilla V, Simpson K, Rodriguez MR, of the German Registry for Acute Aortic Dissection Type A (GERAADA). Cir-
et al. Acute type I aortic dissection with or without antegrade stent delivery: culation. 2011;124:434-43.
mid-term outcomes. J Thorac Cardiovasc Surg. 2019;158:1273-81. 21. Lu S, Sun X, Hong T, Yang S, Song K, Lai H, et al. Bilateral versus unilateral
3. Tong G, Zhang B, Zhou X, Tao Y, Yan T, Wang X, et al. Bilateral versus unilateral antegrade cerebral perfusion in arch reconstruction for aortic dissection. Ann
antegrade cerebral perfusion in total arch replacement for type A aortic dissec- Thorac Surg. 2012;93:1917-20.
tion. J Thorac Cardiovasc Surg. 2017;154:767-75. 22. Wiedemann D, Kocher A, Dorfmeister M, Vadehra A, Mahr S, Laufer G, et al.
4. Dumfarth J, Peterss S, Kofler M, Plaikner M, Ziganshin BA, Schachner T, et al. In Effect of cerebral protection strategy on outcome of patients with Stanford
DeBakey type I aortic dissection, bovine aortic arch is associated with arch tears type A aortic dissection. J Thorac Cardiovasc Surg. 2013;146:647-55.e1.
and stroke. Ann Thorac Surg. 2017;104:2001-8. 23. Preventza O, Simpson KH, Cooley DA, Cornwell L, Bakaeen FG, Omer S, et al.
5. Okita Y. Neuro-protection in open arch surgery. Ann Cardiothorac Surg. 2018;7: Unilateral versus bilateral cerebral perfusion for acute type A aortic dissection.
389-96. Ann Thorac Surg. 2015;99:80-7.
6. Ziganshin BA, Elefteriades JA. Deep hypothermic circulatory arrest. Ann Cardi- 24. Merkkola P, Tulla H, Ronkainen A, Soppi V, Oksala A, Koivisto T, et al. Incom-
othorac Surg. 2013;2:303-15. plete circle of Willis and right axillary artery perfusion. Ann Thorac Surg. 2006;
7. Englum BR, He X, Gulack BC, Ganapathi AM, Mathew JP, Brennan JM, et al. 82:74-9.
Hypothermia and cerebral protection strategies in aortic arch surgery: a compar- 25. Urbanski PP, Lenos A, Blume JC, Ziegler V, Griewing B, Schmitt R, et al. Does
ative effectiveness analysis from the STS Adult Cardiac Surgery Database. Eur J anatomical completeness of the circle of Willis correlate with sufficient cross-
Cardiothorac Surg. 2017;52:492-8. perfusion during unilateral cerebral perfusion? Eur J Cardiothorac Surg. 2008;
8. Ziganshin BA. Which method of cerebral protection do you prefer to use for 33:402-8.
aortic arch surgery? Aorta (Stamford). 2013;1:69-70. 26. Spielvogel D, Kai M, Tang GH, Malekan R, Lansman SL. Selective cerebral perfu-
9. De Paulis R, Czerny M, Weltert L, Bavaria J, Borger MA, Carrel TP, et al. Current sion: a review of the evidence. J Thorac Cardiovasc Surg. 2013;145:S59-62.
trends in cannulation and neuroprotection during surgery of the aortic arch in Eu- 27. Griepp RB. Cerebral protection during aortic arch surgery. J Thorac Cardiovasc
rope. Eur J Cardiothorac Surg. 2015;47:917-23. Surg. 2001;121:425-7.
10. Bachet J. I have only 1 brain but 2 hemispheres: please perfuse both adequately! J 28. Harrington DK, Walker AS, Kaukuntla H, Bracewell RM, Clutton-Brock TH,
Thorac Cardiovasc Surg. 2017;154:765-6. Faroqui M, et al. Selective antegrade cerebral perfusion attenuates brain meta-
11. Takayama H, Borger MA. Bilateral antegrade cerebral perfusion during aortic bolic deficit in aortic arch surgery: a prospective randomized trial. Circulation.
dissection surgery: if no harm, then why not? J Thorac Cardiovasc Surg. 2017; 2004;110:II231-6.
154:776-7. 29. Strauch JT, Spielvogel D, Lauten A, Zhang N, Rinke S, Weisz D, et al. Optimal
12. Yan TD, Bannon PG, Bavaria J, Coselli JS, Elefteriades JA, Griepp RB, et al. temperature for selective cerebral perfusion. J Thorac Cardiovasc Surg. 2005;
Consensus on hypothermia in aortic arch surgery. Ann Cardiothorac Surg. 130:74-82.
2013;2:163-8. 30. Strauch JT, Haldenwang PL, Mullem K, Schmalz M, Liakopoulos O, Christ H,
13. Chikwe J, Cavallaro P, Itagaki S, Seigerman M, Diluozzo G, Adams DH. Na- et al. Temperature dependence of cerebral blood flow for isolated regions of
tional outcomes in acute aortic dissection: influence of surgeon and institutional the brain during selective cerebral perfusion in pigs. Ann Thorac Surg. 2009;
volume on operative mortality. Ann Thorac Surg. 2013;95:1563-9. 88:1506-13.
14. Lenos A, Bougioukakis P, Irimie V, Zacher M, Diegeler A, Urbanski PP. Impact 31. Yu Y, Zhang K, Zhang L, Zong H, Meng L, Han R. Cerebral near-infrared spec-
of surgical experience on outcome in surgery of acute type A aortic dissection. troscopy (NIRS) for perioperative monitoring of brain oxygenation in children
Eur J Cardiothorac Surg. 2015;48:491-6. and adults. Cochrane Database Syst Rev. 2018;1:CD010947.
15. Harrer M, Waldenberger FR, Weiss G, Folkmann S, Gorlitzer M, Moidl R, et al. 32. Zierer A, Risteski P, El-Sayed Ahmad A, Moritz A, Diegeler A, Urbanski PP. The
Aortic arch surgery using bilateral antegrade selective cerebral perfusion in impact of unilateral versus bilateral antegrade cerebral perfusion on surgical out-
combination with near-infrared spectroscopy. Eur J Cardiothorac Surg. 2010;38: comes after aortic arch replacement: a propensity-matched analysis. J Thorac
561-7. Cardiovasc Surg. 2014;147:1212-7; discussion 7-8.
16. Lewis C, Parulkar SD, Bebawy J, Sherwani S, Hogue CW. Cerebral neuromoni- 33. Kreibich M, Rylski B, Czerny M, Beyersdorf F, Itagaki R, Okamura H, et al.
toring during cardiac surgery: a critical appraisal with an emphasis on near- Impact of carotid artery involvement in type A aortic dissection. Circulation.
infrared spectroscopy. J Cardiothorac Vasc Anesth. 2018;32:2313-22. 2019;139:1977-8.
17. Heinze G, Dunkler D. Five myths about variable selection. Transpl Int. 2017;30: 34. Estrera AL, Garami Z, Miller CC, Porat EE, Achouh PE, Dhareshwar J, et al.
6-10. Acute type A aortic dissection complicated by stroke: can immediate repair be
18. Malvindi PG, Scrascia G, Vitale N. Is unilateral antegrade cerebral perfusion performed safely? J Thorac Cardiovasc Surg. 2006;132:1404-8.
equivalent to bilateral cerebral perfusion for patients undergoing aortic arch sur- 35. Di Eusanio M, Patel HJ, Nienaber CA, Montgomery DM, Korach A, Sundt TM,
gery? Interact Cardiovasc Thorac Surg. 2008;7:891-7. et al. Patients with type A acute aortic dissection presenting with major brain injury:
19. Angeloni E, Melina G, Refice SK, Roscitano A, Capuano F, Comito C, et al. Uni- should we operate on them? J Thorac Cardiovasc Surg. 2013;145:213-21.e1.
lateral versus bilateral antegrade cerebral protection during aortic surgery: an up-
dated meta-analysis. Ann Thorac Surg. 2015;99:2024-31.
20. Kruger T, Weigang E, Hoffmann I, Blettner M, Aebert H, GERAADA Investiga- Key Words: acute type A dissection, antegrade cerebral
tors. Cerebral protection during surgery for acute aortic dissection type A: results perfusion, aortic dissection
The Journal of Thoracic and Cardiovascular Surgery c Volume 159, Number 6 2167
Adult: Aorta Angleitner et al
ADULT
TABLE E2. Characteristics of cerebral lesions in patients with permanent neurologic deficit
All patients Bilateral ACP Unilateral ACP
Cerebral lesions N ¼ 35 (100%) n ¼ 17 (48.6%) n ¼ 18 (51.4%)
Lesion type
Ischemic stroke 30 (85.7) 16 (94.1) 14 (77.8)
Hemorrhagic stroke 3 (8.6) 2 (11.8) 1 (5.6)
Hypoxic brain injury 10 (28.6) 5 (29.4) 5 (27.8)
Lesion laterality
Unilateral right-sided lesions 11 (31.4) 10 (58.8) 1 (5.6)
Unilateral left-sided lesions 5 (14.3) 1 (5.9) 4 (22.2)
Bilateral lesions 16 (45.7) 6 (35.3) 10 (55.6)
ACP, Antegrade cerebral perfusion.
ADULT
TABLE E3. Causes of death in patients with antegrade cerebral perfusion durations 50 minutes or more
All patients Bilateral ACP Unilateral ACP
Patients n ¼ 14 (100%) n ¼ 6 (42.9%) n ¼ 8 (57.1%)
Ischemic stroke/hemorrhagic stroke/hypoxic brain injury 8 (57.1) 2 (33.3) 6 (75)
Multiorgan failure 4 (28.6) 2 (33.3) 2 (25)
Cardiogenic shock 2 (14.3) 2 (33.3) 0 (0)
ACP, Antegrade cerebral perfusion.
The Journal of Thoracic and Cardiovascular Surgery c Volume 159, Number 6 2167.e2