Antegrade Versus Retrograde Cerebral Perfusion in Aortic Surgery: Systematic Review and Meta-Analysis of 19365 Patients
DOI:
https://doi.org/10.17140/SROJ-7-128Keywords:
Antegrade, Retrograde, Cerebral protection, Aorta and great vessels, Minimally invasive cardiac surgeryAbstract
Background
Since the risk of neurological injury and mortality can be mitigated with the appropriate choice of established brain protection strategies, we performed a meta-analysis of studies reporting cerebral perfusion strategy outcomes. Our focus was on surgeries that can be performed through a minimally-invasive approach, to support the decision-making process of adopting surgeons.
Methods
We searched the Excerpta Medica dataBASE (EMBASE), Medical literature analysis and retrieval system online (MEDLINE), and Cochrane databases, as well as ClinicalTrials.gov, Google Scholar, and the reference lists of relevant articles for studies reporting early mortality and/or stroke outcomes of both retrograde cerebral perfusion (RCP) and antegrade cerebral perfusion (ACP) strategies. The principal summary measures were odds ratio (OR) with 95% confidence interval (CI) and p values (statistically significant when <0.05). The pooled ORs were combined across studies that met the eligibility criteria.
Results
We identified and included seventeen eligible studies with a total of 19,365 patients undergoing ascending aorta and arch surgery from 2008-2019 by means of ACP (a total of 10,473 patients) or RCP (a total of 8,892 patients). Random effect model analyses found no increase in mortality (OR=1.03, 95%CI:0.80-1.32) or stroke (OR=1.04, 95%CI:0.81-1.32) associated RCP when compared to ACP (p>0.05).
Conclusion
In ascending aorta and arch surgery, requiring cerebral protection, ACP and RCP have similar rates of early mortality and stroke. While optimal application of cerebral protection strategies is both patient and surgeon specific, surgeons can comfortably adopt RCP in minimally invasive cases after accounting for factors that determine the outcomes of aortic surgery adequately.
References
Alnajar A, Aleong E, Azhar MZ, Azarrafiy R, Lamelas J. Review of cerebral perfusion strategies for aortic surgery with application for minimally invasive approaches. J Card Surg. 2020; 35: 1-6. doi: 10.1111/jocs.15061
Stroup DF, Berlin JA, Morton SC, et al. Meta-analysis of obser-vational studies in epidemiology: A proposal for reporting. JAMA. 2000; 283: 2008-2012. doi: 10.1001/jama.283.15.2008
Hozo SP, Djulbegovic B, Hozo I. Estimating the mean and var-iance from the median, range, and the size of a sample. BMC Med Res Methodol. 2005; 5: 13. doi: 10.1186/1471-2288-5-13
Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ. 2003; 327: 557-560. doi: 10.1136/bmj.327.7414.557
Begg CB, Mazumdar M. Operating characteristics of a rank cor-relation test for publication bias. Biometrics. 1994; 50: 1088-1101.
Egger M, Davey Smith G, Schneider M, Minder C. Bias in me-ta-analysis detected by a simple, graphical test. BMJ. 1997; 315: 629-634. doi: 10.1136/bmj.315.7109.629
Abdelgawad A and Arafat H. Moderate versus deep hypother-mic circulatory arrest for ascending aorta and aortic arch surger-ies using open distal anastomosis technique. Journal of the Egyptian Society of Cardio-Thoracic Surgery. 2017; 25: 323-330. doi: 10.1016/j. jescts.2017.11.006
Apaydin AZ, Islamoglu F, Askar FZ, et al. Immediate clinical outcome after prolonged periods of brain protection: Retrospec-tive comparison of hypothermic circulatory arrest, retrograde, and antegrade perfusion. Journal of Cardiac Surgery. 2009; 24: 486-489. doi: 10.1111/j.1540-8191.2008.00772.x
Arnaoutakis GJ, Vallabhajosyula P, Bavaria JE, et al. The im-pact of deep versus moderate hypothermia on postoperative kid-ney function after elective aortic hemiarch repair. Ann Thorac Surg. 2016; 102: 1313-1321. doi: 10.1016/j.athoracsur.2016.04.007
Di Mauro M, Iacò AL, Di Lorenzo C, et al. Cold reperfusion before rewarming reduces neurological events after deep hypo-thermic circulatory arrest. Eur J Cardiothorac Surg. 2013; 43: 168- 173. doi: 10.1093/ejcts/ezs281
Englum BR, He X, Gulack BC, et al. Hypothermia and cerebral protection strategies in aortic arch surgery: A comparative effec-tiveness analysis from the STS adult cardiac surgery database. Eur J Cardiothorac Surg. 2017; 52: 492-498. doi: 10.1093/ejcts/ezx133
Ganapathi AM, Hanna JM, Schechter MA, et al. Antegrade ver-sus retrograde cerebral perfusion for hemiarch replacement with deep hypothermic circulatory arrest: Does it matter? A propen-sity-matched analysis. Journal of Thoracic and Cardiovascular Surgery. 2014; 148: 2896-2902. doi: 10.1016/j.jtcvs.2014.04.014
Itagaki S, Chikwe J, Sun E, Chu D, Toyoda N, Egorova N. Impact of cerebral perfusion on outcomes of aortic surgery: STS adult cardiac database analysis. Ann Thorac Surg. 2020; 109(2): 428- 435. doi: 10.1016/j.athoracsur.2019.08.043
Leshnower BG, Rangaraju S, Allen JW, Stringer AY, Gleason TG, Chen EP. Deep hypothermia with retrograde cerebral perfu-sion versus moderate hypothermia with antegrade cerebral perfu-sion for arch surgery. Ann Thorac Surg. 2019; 107: 1104-1110. doi: 10 Lamelas J et al 10.1016/j.athoracsur.2018.10.008
Milewski RK, Pacini D, Moser GW, et al. Retrograde and ante-grade cerebral perfusion: results in short elective arch reconstruc-tive times. Ann Thorac Surg. 2010; 89: 1448-1457. doi: 10.1016/j. athoracsur.2010.01.056
Misfeld M, Leontyev S, Borger MA, et al. What is the best strategy for brain protection in patients undergoing aortic arch sur-gery? A single center experience of 636 patients. Ann Thorac Surg. 2012; 93: 1502-1508. doi: 10.1016/j.athoracsur.2012.01.106
Okada N, Oshima H, Narita Y, et al. Impact of surgical stroke on the early and late outcomes after thoracic aortic op-erations. Ann Thorac Surg. 2015; 99: 2017-2023. doi: 10.1016/j. athoracsur.2015.01.033
Okita Y, Miyata H, Motomura N, Takamoto S, Japan Cardio-vascular Surgery Database Organization. A study of brain protec-tion during total arch replacement comparing antegrade cerebral perfusion versus hypothermic circulatory arrest, with or without retrograde cerebral perfusion: Analysis based on the Japan adult cardiovascular surgery database. J Thorac Cardiovasc Surg. 2015; 149: S65-73. doi: 10.1016/j.jtcvs.2014.08.070
Perreas K, Samanidis G, Thanopoulos A, et al. Antegrade or retrograde cerebral perfusion in ascending aorta and hemiarch sur-gery? A propensity-matched analysis. Ann Thorac Surg. 2016; 101: 146-152. doi: 10.1016/j.athoracsur.2015.06.029
Sundt TM, 3rd, Orszulak TA, Cook DJ, Schaff HV. Improving results of open arch replacement. Ann Thorac Surg. 2008; 86: 787- 796; discussion 787-796. doi: 10.1016/j.athoracsur.2008.05.011
Svensson LG, Blackstone EH, Apperson-Hansen C, et al. Im-plications from neurologic assessment of brain protection for total arch replacement from a randomized trial. J Thorac Cardiovasc Surg. 2015; 150: 1140-1147.e1111. doi: 10.1016/j.jtcvs.2015.07.054
Usui A, Miyata H, Ueda Y, Motomura N, Takamoto S. Risk-ad-justed and case-matched comparative study between antegrade and retrograde cerebral perfusion during aortic arch surgery: Based on the Japan adult cardiovascular surgery database: The Japan cardio-vascular surgery database organization. General Thoracic and Cardio-vascular Surgery. 2012; 60: 132-139. doi: 10.1007/s11748-011-0857-2
Vallabhajosyula P, Jassar AS, Menon RS, et al. Moderate versus deep hypothermic circulatory arrest for elective aortic transverse hemiarch reconstruction. Ann Thorac Surg. 2015; 99: 1511-1517. doi: 10.1016/j.athoracsur.2014.12.067
Hu Z, Wang Z, Ren Z, et al. Similar cerebral protective effec-tiveness of antegrade and retrograde cerebral perfusion combined with deep hypothermia circulatory arrest in aortic arch surgery: a meta-analysis and systematic review of 5060 patients. J Thorac Cardiovasc Surg 2014; 148: 544-560. doi: 10.1016/j.jtcvs.2013.10.036 Systematic Review | Volume 7 | Number 1|
Guo S, Sun Y, Ji B, Liu J, Wang G, Zheng Z. Similar cerebral protective effectiveness of antegrade and retrograde cerebral per-fusion during deep hypothermic circulatory arrest in aortic sur-gery: A meta-analysis of 7023 patients. Artif Organs. 2015; 39: 300- 308. doi: 10.1111/aor.12376
Takagi H, Mitta S, Ando T. A contemporary meta-analysis of antegrade versus retrograde cerebral perfusion for thoracic aortic surgery. Thorac Cardiovasc Surg. 2019; 67: 351-362. doi: 10.1055/s-0038-1632389
Hameed I, Rahouma M, Khan FM, et al. Cerebral protection strategies in aortic arch surgery: A network meta-analysis. J Thorac Cardiovasc Surg. 2019; S0022-5223(19)30483-0. doi: 10.1016/j. jtcvs.2019.02.045
Lamelas J, Chen PC, Loor G, LaPietra A. Successful use of sternal-sparing minimally invasive surgery for proximal ascend-ing aortic pathology. Ann Thorac Surg. 2018; 106: 742-748. doi: 10.1016/j.athoracsur.2018.03.081
Baldwin ZK, Chuter TA, Hiramoto JS, Reilly LM, Schnei-der DB. Double-barrel technique for preservation of aortic arch branches during thoracic endovascular aortic repair. Ann Vasc Surg. 2008; 22: 703-709. doi: 10.1016/j.avsg.2008.06.002
Chuter TA, Schneider DB. Endovascular repair of the aor-tic arch. Perspect Vasc Surg Endovasc Ther. 2007; 19: 188-192. doi: 10.1177/1531003507304165
Moon MC, Morales JP, Greenberg RK. The aortic arch and as-cending aorta: Are they within the endovascular realm? Semin Vasc Surg. 2007; 20: 97-107. doi: 10.1053/j.semvascsurg.2007.04.007
Juvonen T, Weisz DJ, Wolfe D, et al. Can retrograde perfusion mitigate cerebral injury after particulate embolization? A study in a chronic porcine model. J Thorac Cardiovasc Surg. 1998; 115: 1142- 1159. doi: 10.1016/s0022-5223(98)70415-5 Submit your article to this journal | https://openventio.org/submit-manuscript/ Systematic Review | Volume 7 | Number 1| Lamelas J et al
Ueda Y. A reappraisal of retrograde cerebral perfusion. Ann Cardiothorac Surg. 2013; 2: 316-325. doi: 10.3978/j.issn.2225- 319X.2013.01.02
Midulla PS, Gandsas A, Sadeghi AM, et al. Comparison of retrograde cerebral perfusion to antegrade cerebral perfusion and hypothermic circulatory arrest in a chronic porcine model. J Card Surg. 1994; 9: 560-574; discussion 575. doi: 10.1111/j.1540- 8191.1994.tb00889.x
Anttila V, Kiviluoma K, Pokela M, et al. Cold retrograde cer-ebral perfusion improves cerebral protection during moderate hypothermic circulatory arrest: A long-term study in a porcine model. J Thorac Cardiovasc Surg. 1999; 118: 938-945. doi: 10.1016/ s0022-5223(99)70065-6
Safi HJ, Iliopoulos DC, Gopinath SP, et al. Retrograde cere-bral perfusion during profound hypothermia and circulatory arrest in pigs. Ann Thorac Surg. 1995; 59: 1107-1112. doi: 10.1016/0003- 4975(95)00122-2
Juvonen T, Zhang N, Wolfe D, et al. Retrograde cerebral perfu-sion enhances cerebral protection during prolonged hypothermic circulatory arrest: a study in a chronic porcine model. Ann Thorac Surg. 1998; 66: 38-50. doi: 10.1016/s0003-4975(98)00375-0
Liang MY, Tang ZX, Chen GX, et al. Is selective antegrade cer-ebral perfusion superior to retrograde cerebral perfusion for brain protection during deep hypothermic circulatory arrest? Metabol-ic evidence from microdialysis. Crit Care Med. 2014; 42: e319-328. doi: 10.1097/ccm.0000000000000220
Ye J, Yang L, Del Bigio MR, et al. Neuronal damage after hy-pothermic circulatory arrest and retrograde cerebral perfusion in the pig. Ann Thorac Surg. 1996; 61: 1316-1322. doi: 10.1016/0003- 4975(96)00076-8
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