An Extensive Review and Meta-analysis of 19365 Patients Comparing Antegrade and Retrograde Cerebral Perfusion in Aortic Surgery

Abstract

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) strat
egies. 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 com
pared 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.