Research progress of antegrade cerebral perfusion and retrograde cerebral perfusion in aortic arch surgery_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

MA Hao , XIAO Zhenghua ,  GUO Yingqiang

Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu, 610041, P.R.China;

Corresponding author：

GUO Yingqiang, Email: drguoy@hotmail.com

Keywords：

Antegrade cerebral perfusion; retrograde cerebral perfusion; aortic arch surgery; cerebral protection

DOI：

10.7507/1007-4848.201607060

Video：

Export PDF Favorites Scan Get Citation

Abstract Full text Figures/Tables Video References Cited by

Antegrade cerebral perfusion (ACP) and retrograde cerebral perfusion (RCP) are the two major types of brain protection during aortic arch surgery. Which one is better has still been debated. By summarizing and analyzing the research progress of the comparative research of antegrade cerebral perfusion and retrograde cerebral perfusion in aortic arch surgery, we have found that there was no significant difference between ACP and RCP in terms of temporary nerve dysfunction (TND), permanent nerve dysfunction (PND), stroke, early mortality, morbidity, long-time survival, and a composite outcome of hospital death, bleeding, prolonged ventilation, need for dialysis, infection and stroke. But RCP resulted in a high incidence of prolonged mean ICU-stay and hospital-stay, longer mean extubation time as well as higher cost. And the surgeon is given more time to reconstruct the vessels of the arch since mean operative time is longer in the ACP. So we think that antegrade cerebral perfusion might be preferred as the brain protection method for complicated aortic arch procedures. If a surgeon confirms that the surgery is not very sophisticated and can be completed in a short time, it is better to choose RCP because of no catheter or cannula in the surgical field to impede the surgeon. The article aims at providing a reference to cardiac surgeries when choosing cerebral protection strategy in aortic arch surgery.

Citation： MA Hao, XIAO Zhenghua, GUO Yingqiang. Research progress of antegrade cerebral perfusion and retrograde cerebral perfusion in aortic arch surgery. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2017, 24(6): 469-474. doi: 10.7507/1007-4848.201607060 Copy

1.	De Bakey ME, Crawford ES, Cooley DA, et al. Successful resection of fusiform aneurysm of aortic arch with replacement by homograft. Surg Gynecol Obstet, 1957, 105(6): 657-664.
2.	Griepp RB, Stinson EB, Hollingsworth JF, et al. Prosthetic replacement of the aortic arch. J Thorac Cardiovasc Surg, 1975, 70(6): 1051-1063.
3.	Svensson LG, Crawford ES, Hess KR, et al. Deep hypothermia with circulatory arrest. Determinants of stroke and early mortality in 656 patients. J Thorac Cardiovasc Surg, 1993, 106(1): 19-28.
4.	Borst HG, Schaudig A, Rudolph W. Arteriovenous fistula of the aortic arch: repair during deep hypothermia and circulatory arrest. J Thorac Cardiovasc Surg, 1964, 48: 443-447.
5.	Ergin MA, Galla JD, Lansman SL, et al. Hypothermic circulatory arrest in operations on the thoracic aorta. Determinants of operative mortality andneurologic outcome. J Thorac Cardiovasc Surg, 1994, 107(3): 788-797.
6.	Ueda Y, Miki S, Kusuhara K, et al. Surgical treatment of aneurysm or dissection involving the ascending aorta and aortic arch, utilizing circulatory arrest and retrograde cerebral perfusion. J Cardiovasc Surg (Torino), 1990, 31(5): 553-558.
7.	Coselli JS, LeMaire SA. Experience with retrograde cerebral perfusion during proximal aortic surgery in 290 patients. J Card Surg, 1997, 12(2 Suppl): 322-325.
8.	Okita Y, Takamoto S, Ando M, et al. Mortality and cerebral outcome in patients who underwent aortic arch operations using deep hypothermic circulatory arrest with retrograde cerebral perfusion: no relation of early death, stroke, and delirium to the duration of circulatory arrest. J Thorac Cardiovasc Surg, 1998, 115(1): 129-138.
9.	Kawata M, Takamoto S, Kitahori K, et al. Intermittent pressure augmentation during retrograde cerebral perfusion under moderate hypothermia provides adequate neuroprotection: An experimental study. J Thorac Cardiovasc Surg, 2006, 132(1): 80-88.
10.	Safi H, Letsou G, Iliopoulos D, et al. Impact of retrograde cerebral perfusion on ascending aortic and arch aneurysm repair. Ann Thorac Surg, 1997, 63(6): 1601-1607.
11.	Deeb G, Jenkins E, Bolling S, et al. Retrograde cerebral perfusion during hypothermic circulatory arrest reduces neurologic morbidity. J Thorac Cardiovasc Surg, 1995, 109(2): 259-268.
12.	Usui A, Abe T, Murase M. Early clinical results of retrograde cerebral perfusion for aortic arch operations in Japan. Ann Thorac Surg, 1996, 62(1): 94-103.
13.	Okita Y, Takamoto S, Ando M, et al. Mortality and cerebral outcome in patients who underwent aortic arch operations using deep hypothermic circulatory arrest with retrograde cerebral perfusion: No relation of early death, stroke, and delirium to the duration of circulatory arrest. J Thorac Cardiovasc Surg, 1998, 115(1): 129-138.
14.	Coselli J. Retrograde cerebral perfusion is an effective means of neural support during deep hypothermic circulatory arrest. Ann Thorac Surg, 1997, 64(3): 908-912.
15.	Okita Y, Minatoya K, Tagusari O, et al. Prospective comparative study of brain protection in total aortic arch replacement: deep hypothermic circulatory arrest with retrograde cerebral perfusion or selective antegrade cerebral perfusion. Ann Thorac Surg, 2001, 72(1): 72-79.
16.	Hagl C, Ergin MA, Galla JD, et al. Neurologic outcome after ascending aorta aortic arch operations: effect of brain protection technique in high-risk patients. J Thorac Cardiovasc Surg, 2001, 121(6): 1107-1121.
17.	Frist WH, Baldwin JC, Starnes VA, et al. A reconsideration of cerebral perfusion in aortic arch replacement. Ann Thorac Surg, 1986, 42(3): 273-281.
18.	Bachet J, Guilmet D, Goudot B, et al. Antegrade cerebral perfusion with cold blood: a 13-year experience. Ann Thorac Surg, 1999, 67(6): 1874-1878.
19.	Kazui T, Inoue N, Yamada O, et al. Selective cerebral perfusion during operation for aneurysms of the aortic arch: a reassessment. Ann Thorac Surg, 1992, 53(1): 109-114.
20.	Di Eusanio M, Schepens MA, Morshuis WJ, et al. Antegrade selective cerebral perfusion during operations on the thoracic aorta: factors influencing survival and neurologic outcome in 413 patients. J Thorac Cardiovasc Surg, 2002, 124(6): 1080-1086.
21.	王茜, 龙村. 顺行性脑灌注与逆行性脑灌注. 中国体外循环杂志, 2011, 9(1): 48-52.
22.	Girardi LN, Shavladze N, Sedrakyan A, et al. Safety and efficacy of retrograde cerebral perfusion as an adjunct for cerebral protection during surgery on the aortic arch. J Thorac Cardiovasc Surg, 2014, 148(6): 2927-2933.
23.	Comas GM, Leshnower BG, Halkos ME, et al. Acute Type A dissection: impact of antegrade cerebral perfusion under moderate hypothermia. Ann Thorac Surg, 2013, 96(6): 2135-2141.
24.	Ganapathi MD, Hanna JM, Schechter MA, et al. Antegrade versus retrograde cerebral perfusion for hemiarch replacement with deep hypothermic circulatory arrest:Does it matter? A propensity-matched analysis. J Thorac Cardiovasc Surg, 2014, 148(6): 2896-2902.
25.	Apostolakis E, Koletsis EN, Dedeilias P, et al. Antegrade versus retrograde cerebral perfusion in relation to postoperative complications following aortic arch surgery for acute aortic dissection Type A. J Card Surg, 2008, 23(5): 480-487.
26.	Sabik JF, Nemeh H, Lytle BW, et al. Cannulation of the axillary artery with a side graft reduces morbidity. Ann Thorac Surg, 2004, 77(4): 1315-1320.
27.	姬尚义, 杨建安, 陈长春, 等. 无名动脉插管与主动脉弓部手术中的脑保护. 中华胸心外科血管杂志, 2006, 22(6): 424-425.
28.	Okita Y, Miyata H, Motomura N, et al. A study of brain protection 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(2 Suppl): S65-S73.
29.	Hagl C, Khaladj N, Peterss S, et al. Hypothermic circulatory arrest with and without cold selective antegrade cerebral perfusion: impact on neurological recovery and tissue metabolism in an acute porcine model. Eur J Cardiothorac Surg, 2004, 26(1): 73-80.
30.	Elmistekawy EM, Rubens FD. Deep hypothermic circulatory arrest: alternative strategies for cerebral perfusion. A review article. Perfusion, 2011, 26(Suppl 1): 27-34.
31.	Künzli A, Zingg PO, Zünd G, et al. Does retrograde cerebral perfusion via superior vena cava cannulation protect the brain? Eur J Cardiothorac Surg, 2006, 30(6): 906-909.
32.	Duebener L, Hagino I, Schmitt K, et al. Direct visualization of minimal cerebral capillary flow during retrograde cerebral perfusion: An intravital fluorescence microcopy study in pigs. Ann Thorac Surg, 2003, 75(4): 1288-1293.
33.	Katz M, Khazin V, Steinmetz A, et al. Distribution of cerebral flow using retrograde versus antegrade cerebral perfusion. Ann Thorac Surg, 1999, 67(4): 1065-1069.
34.	Filgureiras C, Winsborrow B, Ye J, et al. A 31P-Magnetic resonance study of antegrade and retrograde cerebral perfusion during aortic arch surgery in pigs. J Thorac Cardiovasc Surg, 1995, 110(1): 55-62.
35.	Oohara K, Usui A, Murase M, et al. Regional cerebral tissue blood flow measured by the coloured microsphere method during retrograde cerebral perfusion. J Thorac Cardiovasc Surg, 1995, 109(4): 772-779.
36.	Ehrlich MP, Hagl C, McCullough JN, et al. Retrograde cerebral perfusion provides negligible flow through brain capillaries in the pig. J Thorac Cardiovasc Surg, 2001, 122(2): 331-338.
37.	高勇, 邹小明, 王武军, 等. 深低温停循环中不同脑灌注方式脑保护的实验研究. 南方大学学报, 2006, 26(5): 644-647.
38.	Perreas K, Samanidis G, Dimitriou S, et al. Outcomes after ascending aorta and proximal aortic arch repair using deep hypothermic circulatory arrest with retrograde cerebral perfusion: analysis of 207 patients. Interact Cardiovasc Thorac Surg, 2012, 15(3): 456-461.
39.	Tian DH, Wan B, Bannon PG, et al. A meta-analysis of deep hypothermic circulatory arrest alone versus with adjunctive selective antegrade cerebral perfusion. Ann Cardiothorac Surg, 2013, 2(3): 261-270.
40.	Milewski RK, Pacini D, Moser GW, et al. Retrograde and antegrade cerebral perfusion: results in short elective arch reconstructive times. Ann Thorac Surg, 2010, 89(5): 1448-1457.
41.	Usui A, Miyata H, Ueda Y, et al. Risk-adjusted and case-matched comparative study between antegrade and retrograde cerebral perfusion during aortic arch surgery: based on the Japan Adult Cardiovascular Surgery Database. Gen Thorac Cardiovasc Surg, 2012, 60(3): 132-139.
42.	Wiedemann D, Kocher A, Dorfmeister M, et al. Effect of cerebral protection strategy on outcome of patients with Stanford type A aortic dissection. J Thorac Cardiovasc Surg, 2013, 146(3): 647-655.
43.	Guo SS, Sun YH, Ji BY, et al. Similar cerebral protective effectiveness of antegrade and retrograde cerebral perfusion during deep hypothermic circulatory arrest in aortic surgery: a meta-analysis of 7023 patients. Artif Organs, 2015, 39(4): 300-308.
44.	Perreas K, Samanidis G, Thanopoulos A, et al. Antegrade or retrograde cerebral perfusion in ascending aorta and hemiarch surgery? a propensity-matched analysis. Ann Thorac Surg, 2016, 101(1): 146-152.
45.	Erbel R, Aboyans V, Boileau C, et al. 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases. Kardiol Pol, 2014, 72(12): 1169-1252.

1. De Bakey ME, Crawford ES, Cooley DA, et al. Successful resection of fusiform aneurysm of aortic arch with replacement by homograft. Surg Gynecol Obstet, 1957, 105(6): 657-664.
2. Griepp RB, Stinson EB, Hollingsworth JF, et al. Prosthetic replacement of the aortic arch. J Thorac Cardiovasc Surg, 1975, 70(6): 1051-1063.
3. Svensson LG, Crawford ES, Hess KR, et al. Deep hypothermia with circulatory arrest. Determinants of stroke and early mortality in 656 patients. J Thorac Cardiovasc Surg, 1993, 106(1): 19-28.
4. Borst HG, Schaudig A, Rudolph W. Arteriovenous fistula of the aortic arch: repair during deep hypothermia and circulatory arrest. J Thorac Cardiovasc Surg, 1964, 48: 443-447.
5. Ergin MA, Galla JD, Lansman SL, et al. Hypothermic circulatory arrest in operations on the thoracic aorta. Determinants of operative mortality andneurologic outcome. J Thorac Cardiovasc Surg, 1994, 107(3): 788-797.
6. Ueda Y, Miki S, Kusuhara K, et al. Surgical treatment of aneurysm or dissection involving the ascending aorta and aortic arch, utilizing circulatory arrest and retrograde cerebral perfusion. J Cardiovasc Surg (Torino), 1990, 31(5): 553-558.
7. Coselli JS, LeMaire SA. Experience with retrograde cerebral perfusion during proximal aortic surgery in 290 patients. J Card Surg, 1997, 12(2 Suppl): 322-325.
8. Okita Y, Takamoto S, Ando M, et al. Mortality and cerebral outcome in patients who underwent aortic arch operations using deep hypothermic circulatory arrest with retrograde cerebral perfusion: no relation of early death, stroke, and delirium to the duration of circulatory arrest. J Thorac Cardiovasc Surg, 1998, 115(1): 129-138.
9. Kawata M, Takamoto S, Kitahori K, et al. Intermittent pressure augmentation during retrograde cerebral perfusion under moderate hypothermia provides adequate neuroprotection: An experimental study. J Thorac Cardiovasc Surg, 2006, 132(1): 80-88.
10. Safi H, Letsou G, Iliopoulos D, et al. Impact of retrograde cerebral perfusion on ascending aortic and arch aneurysm repair. Ann Thorac Surg, 1997, 63(6): 1601-1607.
11. Deeb G, Jenkins E, Bolling S, et al. Retrograde cerebral perfusion during hypothermic circulatory arrest reduces neurologic morbidity. J Thorac Cardiovasc Surg, 1995, 109(2): 259-268.
12. Usui A, Abe T, Murase M. Early clinical results of retrograde cerebral perfusion for aortic arch operations in Japan. Ann Thorac Surg, 1996, 62(1): 94-103.
13. Okita Y, Takamoto S, Ando M, et al. Mortality and cerebral outcome in patients who underwent aortic arch operations using deep hypothermic circulatory arrest with retrograde cerebral perfusion: No relation of early death, stroke, and delirium to the duration of circulatory arrest. J Thorac Cardiovasc Surg, 1998, 115(1): 129-138.
14. Coselli J. Retrograde cerebral perfusion is an effective means of neural support during deep hypothermic circulatory arrest. Ann Thorac Surg, 1997, 64(3): 908-912.
15. Okita Y, Minatoya K, Tagusari O, et al. Prospective comparative study of brain protection in total aortic arch replacement: deep hypothermic circulatory arrest with retrograde cerebral perfusion or selective antegrade cerebral perfusion. Ann Thorac Surg, 2001, 72(1): 72-79.
16. Hagl C, Ergin MA, Galla JD, et al. Neurologic outcome after ascending aorta aortic arch operations: effect of brain protection technique in high-risk patients. J Thorac Cardiovasc Surg, 2001, 121(6): 1107-1121.
17. Frist WH, Baldwin JC, Starnes VA, et al. A reconsideration of cerebral perfusion in aortic arch replacement. Ann Thorac Surg, 1986, 42(3): 273-281.
18. Bachet J, Guilmet D, Goudot B, et al. Antegrade cerebral perfusion with cold blood: a 13-year experience. Ann Thorac Surg, 1999, 67(6): 1874-1878.
19. Kazui T, Inoue N, Yamada O, et al. Selective cerebral perfusion during operation for aneurysms of the aortic arch: a reassessment. Ann Thorac Surg, 1992, 53(1): 109-114.
20. Di Eusanio M, Schepens MA, Morshuis WJ, et al. Antegrade selective cerebral perfusion during operations on the thoracic aorta: factors influencing survival and neurologic outcome in 413 patients. J Thorac Cardiovasc Surg, 2002, 124(6): 1080-1086.
21. 王茜, 龙村. 顺行性脑灌注与逆行性脑灌注. 中国体外循环杂志, 2011, 9(1): 48-52.
22. Girardi LN, Shavladze N, Sedrakyan A, et al. Safety and efficacy of retrograde cerebral perfusion as an adjunct for cerebral protection during surgery on the aortic arch. J Thorac Cardiovasc Surg, 2014, 148(6): 2927-2933.
23. Comas GM, Leshnower BG, Halkos ME, et al. Acute Type A dissection: impact of antegrade cerebral perfusion under moderate hypothermia. Ann Thorac Surg, 2013, 96(6): 2135-2141.
24. Ganapathi MD, Hanna JM, Schechter MA, et al. Antegrade versus retrograde cerebral perfusion for hemiarch replacement with deep hypothermic circulatory arrest:Does it matter? A propensity-matched analysis. J Thorac Cardiovasc Surg, 2014, 148(6): 2896-2902.
25. Apostolakis E, Koletsis EN, Dedeilias P, et al. Antegrade versus retrograde cerebral perfusion in relation to postoperative complications following aortic arch surgery for acute aortic dissection Type A. J Card Surg, 2008, 23(5): 480-487.
26. Sabik JF, Nemeh H, Lytle BW, et al. Cannulation of the axillary artery with a side graft reduces morbidity. Ann Thorac Surg, 2004, 77(4): 1315-1320.
27. 姬尚义, 杨建安, 陈长春, 等. 无名动脉插管与主动脉弓部手术中的脑保护. 中华胸心外科血管杂志, 2006, 22(6): 424-425.
28. Okita Y, Miyata H, Motomura N, et al. A study of brain protection 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(2 Suppl): S65-S73.
29. Hagl C, Khaladj N, Peterss S, et al. Hypothermic circulatory arrest with and without cold selective antegrade cerebral perfusion: impact on neurological recovery and tissue metabolism in an acute porcine model. Eur J Cardiothorac Surg, 2004, 26(1): 73-80.
30. Elmistekawy EM, Rubens FD. Deep hypothermic circulatory arrest: alternative strategies for cerebral perfusion. A review article. Perfusion, 2011, 26(Suppl 1): 27-34.
31. Künzli A, Zingg PO, Zünd G, et al. Does retrograde cerebral perfusion via superior vena cava cannulation protect the brain? Eur J Cardiothorac Surg, 2006, 30(6): 906-909.
32. Duebener L, Hagino I, Schmitt K, et al. Direct visualization of minimal cerebral capillary flow during retrograde cerebral perfusion: An intravital fluorescence microcopy study in pigs. Ann Thorac Surg, 2003, 75(4): 1288-1293.
33. Katz M, Khazin V, Steinmetz A, et al. Distribution of cerebral flow using retrograde versus antegrade cerebral perfusion. Ann Thorac Surg, 1999, 67(4): 1065-1069.
34. Filgureiras C, Winsborrow B, Ye J, et al. A 31P-Magnetic resonance study of antegrade and retrograde cerebral perfusion during aortic arch surgery in pigs. J Thorac Cardiovasc Surg, 1995, 110(1): 55-62.
35. Oohara K, Usui A, Murase M, et al. Regional cerebral tissue blood flow measured by the coloured microsphere method during retrograde cerebral perfusion. J Thorac Cardiovasc Surg, 1995, 109(4): 772-779.
36. Ehrlich MP, Hagl C, McCullough JN, et al. Retrograde cerebral perfusion provides negligible flow through brain capillaries in the pig. J Thorac Cardiovasc Surg, 2001, 122(2): 331-338.
37. 高勇, 邹小明, 王武军, 等. 深低温停循环中不同脑灌注方式脑保护的实验研究. 南方大学学报, 2006, 26(5): 644-647.
38. Perreas K, Samanidis G, Dimitriou S, et al. Outcomes after ascending aorta and proximal aortic arch repair using deep hypothermic circulatory arrest with retrograde cerebral perfusion: analysis of 207 patients. Interact Cardiovasc Thorac Surg, 2012, 15(3): 456-461.
39. Tian DH, Wan B, Bannon PG, et al. A meta-analysis of deep hypothermic circulatory arrest alone versus with adjunctive selective antegrade cerebral perfusion. Ann Cardiothorac Surg, 2013, 2(3): 261-270.
40. Milewski RK, Pacini D, Moser GW, et al. Retrograde and antegrade cerebral perfusion: results in short elective arch reconstructive times. Ann Thorac Surg, 2010, 89(5): 1448-1457.
41. Usui A, Miyata H, Ueda Y, et al. Risk-adjusted and case-matched comparative study between antegrade and retrograde cerebral perfusion during aortic arch surgery: based on the Japan Adult Cardiovascular Surgery Database. Gen Thorac Cardiovasc Surg, 2012, 60(3): 132-139.
42. Wiedemann D, Kocher A, Dorfmeister M, et al. Effect of cerebral protection strategy on outcome of patients with Stanford type A aortic dissection. J Thorac Cardiovasc Surg, 2013, 146(3): 647-655.
43. Guo SS, Sun YH, Ji BY, et al. Similar cerebral protective effectiveness of antegrade and retrograde cerebral perfusion during deep hypothermic circulatory arrest in aortic surgery: a meta-analysis of 7023 patients. Artif Organs, 2015, 39(4): 300-308.
44. Perreas K, Samanidis G, Thanopoulos A, et al. Antegrade or retrograde cerebral perfusion in ascending aorta and hemiarch surgery? a propensity-matched analysis. Ann Thorac Surg, 2016, 101(1): 146-152.
45. Erbel R, Aboyans V, Boileau C, et al. 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases. Kardiol Pol, 2014, 72(12): 1169-1252.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Research progress of antegrade cerebral perfusion and retrograde cerebral perfusion in aortic arch surgery

Abstract Full text Figures/Tables Video References Cited by

Previous Article

Next Article

Format

Content