Summary

A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was whether unilateral antegrade cerebral perfusion is equivalent to bilateral cerebral plegia for cerebral protection during aortic arch surgery. Altogether 233 papers were found using the reported search, of which 17 presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. These papers documented antegrade selective cerebral perfusion in a total of 3548 patients: bilateral cerebral perfusion in 2949 patients and unilateral perfusion in 599 patients. Both methods of cerebral perfusion resulted in neurological injury rates of <5%, but the period of antegrade cerebral perfusion allowed by bilateral perfusion was significantly higher. While unilateral perfusion allowed around 30–50 min, bilateral perfusion allowed 86 to over 164 min of ASCP with an acceptably low CVA rate. Therefore, we conclude that while both methods are acceptable, once the ASCP time is expected to rise over 40–50 min, bilateral cerebral perfusion is the technique that is best documented to be safe.

1. Introduction

A best evidence topic was constructed according to a structured protocol. This is fully described in the ICVTS [1].

2. Three-part question

In [patients undergoing aortic arch surgery] does [unilateral or bilateral cerebral perfusion] result in superior [survival and better neurologic outcome].

3. Clinical scenario

You are about to operate on a 32-year-old man who has presented as an emergency with a high type A aortic dissection with the tear involving the innominate artery. Several people comment on the fact that he is very tall and thin with long fingers and a high arched palate, and you conclude that it is very likely that he has Marfans. Therefore, you decide to perform a total arch replacement with an elephant trunk into the descending aorta. This is inevitably going to be a long procedure and you are anxious as to whether unilateral cerebral perfusion will be adequate for this young gentleman.

4. Search strategy

Medline 1990 to April 2008 using PubMed interface (aortic surgery) and (#1) antegrade cerebral perfusion.

5. Search outcome

Using the reported search, 233 papers were identified from which 17 papers provided the best evidence to answer the question. These are summarized in Tables 1 and 2 .

Table 1

Papers documenting a comparison between unilateral and bilateral cerebral perfusion

Author, date, and Patient group Outcomes Key results Comments 
country     
Study type     
(level of evidence)     
Dossche et al., (1999), 106 patients underwent aortic surgery 30-day mortality 9 patients (8.5%) Bilateral ASCP has a 
Ann Thorac Surg, 61 patients underwent aortic arch replacement   favorable impact on 
The Netherlands [2] in the period (1989–1997) Postoperative transient CVA 4 patients (3.8%) hospital outcome 
 37 patients had unilateral cerebral perfusion    
Retrospective study 69 patients had bilateral cerebral perfusion Postoperative permanent 6 patients (5.4%) Hospital mortality is 
(level 2b)  CVA  strongly influenced by 
 Mean age 64±11.5 years   postoperative 
    neurologic 
 25 °C nasopharyngeal temperature   dysfunction 
 Mean ASCP time 50.5±20.3 min    
    Unilateral perfusion is 
    dependent upon a 
    competent circle of 
    Willis 
     
    As a complete pre- 
    operative is not 
    always possible, the 
    unilateral ASCP 
    technique could not 
    be used routinally 
     
Immer et al., (2008), 567 patients underwent aortic arch surgery 30-day mortality  Mean follow-up of 
Ann Thorac Surg, 387 without cerebral protection, only HCA HCA 58 patients (15%) 2.4±1.2 years is 
Switzerland [3] 91 with bilateral ASCP Bilateral ASCP 9 patients (9.9%) available only for QoL 
 89 with unilateral cerebral perfusion from Unilateral ACP 6 patients (6.7%) evaluation 
Retrospective right axillary artery  P<0.05  
cohort study    Cerebral perfusion 
(level 2b) Bilateral ASCP flow 150–250 ml/min at Postoperative transient CVA  time not reported 
 12 °C HCA 59 patients (15.%)  
  Bilateral ASCP 10 patients (11%)  
 Unilateral cerebral perfusion flow Unilateral ACP 10 patients (11%)  
 1000–1500 ml/min at 12 °C    
  Postoperative permanent CVA   
  HCA 25 patients (6.5%)  
  Bilateral ASCP 9 patients (9.8%)  
  Unilateral ACP 1 patient (1.1%)  
   P<0.05  
     
Olsson and Thelin, (2006), 65 patients underwent aortic arch surgery 30-day mortality 7 patients (11%) In propensity score 
Ann Thorac Surg, with right axillary artery direct cannulation   analysis, stroke 
Sweden [4] and bilateral ASCP Postoperative transient CVA 9 patients (14%) remained more 
 17 patients with unilateral cerebral perfusion  6 patients with common after 
Prospective study period (2001–2004)  unilateral ASCP unilateral ASCP (5 of 
(level 2b)   3 patients with 17 vs. 0 of 17, 
 Median age 59 years (57–62)  bilateral ASCP P=0.045). In a 
    multivariable model 
 ASCP flow 8–10 ml/kg/min at 18–22 °C Postoperative permanent CVA 3 patients (4.6%) unilateral ASCP was 
 nasopharyngeal temperature   the only variable 
 Mean ASCP time 33±4 min   independently related 
 ASCP time >45 min in 26% of patients   to stroke 
Author, date, and Patient group Outcomes Key results Comments 
country     
Study type     
(level of evidence)     
Dossche et al., (1999), 106 patients underwent aortic surgery 30-day mortality 9 patients (8.5%) Bilateral ASCP has a 
Ann Thorac Surg, 61 patients underwent aortic arch replacement   favorable impact on 
The Netherlands [2] in the period (1989–1997) Postoperative transient CVA 4 patients (3.8%) hospital outcome 
 37 patients had unilateral cerebral perfusion    
Retrospective study 69 patients had bilateral cerebral perfusion Postoperative permanent 6 patients (5.4%) Hospital mortality is 
(level 2b)  CVA  strongly influenced by 
 Mean age 64±11.5 years   postoperative 
    neurologic 
 25 °C nasopharyngeal temperature   dysfunction 
 Mean ASCP time 50.5±20.3 min    
    Unilateral perfusion is 
    dependent upon a 
    competent circle of 
    Willis 
     
    As a complete pre- 
    operative is not 
    always possible, the 
    unilateral ASCP 
    technique could not 
    be used routinally 
     
Immer et al., (2008), 567 patients underwent aortic arch surgery 30-day mortality  Mean follow-up of 
Ann Thorac Surg, 387 without cerebral protection, only HCA HCA 58 patients (15%) 2.4±1.2 years is 
Switzerland [3] 91 with bilateral ASCP Bilateral ASCP 9 patients (9.9%) available only for QoL 
 89 with unilateral cerebral perfusion from Unilateral ACP 6 patients (6.7%) evaluation 
Retrospective right axillary artery  P<0.05  
cohort study    Cerebral perfusion 
(level 2b) Bilateral ASCP flow 150–250 ml/min at Postoperative transient CVA  time not reported 
 12 °C HCA 59 patients (15.%)  
  Bilateral ASCP 10 patients (11%)  
 Unilateral cerebral perfusion flow Unilateral ACP 10 patients (11%)  
 1000–1500 ml/min at 12 °C    
  Postoperative permanent CVA   
  HCA 25 patients (6.5%)  
  Bilateral ASCP 9 patients (9.8%)  
  Unilateral ACP 1 patient (1.1%)  
   P<0.05  
     
Olsson and Thelin, (2006), 65 patients underwent aortic arch surgery 30-day mortality 7 patients (11%) In propensity score 
Ann Thorac Surg, with right axillary artery direct cannulation   analysis, stroke 
Sweden [4] and bilateral ASCP Postoperative transient CVA 9 patients (14%) remained more 
 17 patients with unilateral cerebral perfusion  6 patients with common after 
Prospective study period (2001–2004)  unilateral ASCP unilateral ASCP (5 of 
(level 2b)   3 patients with 17 vs. 0 of 17, 
 Median age 59 years (57–62)  bilateral ASCP P=0.045). In a 
    multivariable model 
 ASCP flow 8–10 ml/kg/min at 18–22 °C Postoperative permanent CVA 3 patients (4.6%) unilateral ASCP was 
 nasopharyngeal temperature   the only variable 
 Mean ASCP time 33±4 min   independently related 
 ASCP time >45 min in 26% of patients   to stroke 

CVA, cerebral vascular accident; ASCP, antegrade selective cerebral perfusion.

Table 2

Papers documenting either unilateral or bilateral cerebral perfusion alone

Author, date, and Patient group Outcomes Key results Comments 
country     
Study type     
(level of evidence)     
Tasdemir et al., 104 patients underwent aortic arch 30-day mortality 8 patients (7.6%) Low ASCP time 
(2002), Ann Thorac reconstruction with right upper brachial    
Surg, Turkey [6] artery perfusion for cerebral protection FU mortality 12 patients (11.5%) 50 patients underwent total 
 12 acute aortic dissection   aortic arch replacement 
Retrospective 31 total arch replacement Postoperative CVA 2 patients (1.9%)  
study (level 2b) period (1996–2001)    
     
 Mean age 52±12 years    
     
 Unilateral ASCP 8–10 ml/kg/min at    
 26 °C rectal temperature    
 Mean ASCP time 39±22 min    
     
 Follow-up 2.2±1 year    
     
Karadeniz et al., 15 consecutive patients underwent surgical Postoperative CVA A normal circle of Willis 
(2005), Ann Thorac reconstruction of aortic arch with antegrade   should not carry 
Surg, Turkey [7] selective cerebral perfusion through the   hypoperfusion risk during 
 right brachial artery   unilateral ASCP 
Prospective cohort period January–June 2002    
study (level 2b)    TCD ultrasonography or 
 Mean age 53±3.3 years   NIRS are necessary to 
 12 men   monitoring the adequacy of 
    cerebral perfusion 
 Right brachial artery direct cannulation    
 transcranial Doppler monitoring unilateral   Low number of patients 
 ASCP 8–10 ml/kg/min at 26 °C rectal    
 temperature ASCP time 29±5.8   Detailed report of cerebral 
    monitoring 
 Right brachial artery group was    
 compared with aortic cannulation group    
 (20 patients)    
     
Ku;alcuker et al., (2005), 131 patients underwent aortic arch 30-day mortality 12 patients (6.6%) A total arch replacement 
Eur J Cardiothorac reconstruction with right upper brachial   was performed only in 
Surg, Turkey [8] artery perfusion for cerebral protection FU mortality 19 patients (10.5%) 50 patients, less 
 period (1996–2004)   complex procedures 
Retrospective study Ascending and/or partial arch replacement Postoperative 1 patient (0.6%) allow a shorter time of 
(level 2b) was performed in 90 patients transient CVA  cerebral perfusion 
 Ascending and total arch replacement    
 in 91 patients Postoperative 3 patients (1.8%)  
 24 patients with acute aortic dissection permanent CVA   
     
 Mean age 58±12 years    
 132 male    
     
 Unilateral ASCP 8–10 ml/kg/min at    
 26 °C rectal temperature    
 ASCP time 36±27 min    
 Follow-up 3.7±1.5 year    
     
Panos et al., (2006), 25 consecutive patients (17 men), with 30-day mortality 1 patient (4%) Limited number of 
Eur J Cardiothorac type A aortic dissection, underwent   patients 
Surg, Switzerland [9] surgery for replacement of the ascending FU mortality 2 patients (8%)  
 aorta extended on the hemi-arch or   Only 8 patients had total 
Retrospective arch in the period (2001–2005) Postoperative CVA 1 patient (4%) arch replacement 
study (level 2b)     
 Right axillary artery direct cannulation    
     
 Mean age 62.6±14.8 years    
     
 Unilateral ASCP 12 ml/kg/min 25 °C    
 rectal temperature    
 Mean ASCP time 39.7 min (24–55 min)    
     
 Follow-up mean 19 months (4–30 months)    
     
     
Budde et al., (2006), 61 patients underwent proximal aortic 30-day mortality  Limited number of 
Ann Thorac Surg, surgery with axillary cannulation for arterial  Elective 3 patients (7.2%) patients 
USA [10] perfusion with side graft interposition  Emergent 2 patients (10%)  
    Retrospective study 
Retrospective 41 elective cases Postoperative   
cohort study 20 emergent cases transient CVA  Different protocol with 
(level 2b) Comparison between group  Elective 2 patients (4.8%) higher ASCP flow 
   Emergent 2 patients (10%)  
 Mean age 57±2.4 years   Limited number of total 
  Postoperative  arch replacement 
 Unilateral ASCP 16 ml/kg/min at 23 °C permanent CVA   
 bladder temperature  Elective  
 Mean ASCP time (elective 27±2.7 min;  Emergent 1 patient (5%)  
 emergent 25±2.6 min)    
     
Bakhtiary et al., 120 patients underwent aortic surgery 30-day mortality 6 patients (5%) Limited number of total 
(2008), Ann Thorac for acute aortic dissection (2000–2006)   arch replacement with 
Surg, Germany [11] 12 patients underwent total arch Postoperative 3 patients (2.5%) lower mean ASCP time 
 replacement transient CVA   
Retrospective     
study (level 2b) Right axillary artery direct cannulation Postoperative 5 patients (4.2%)  
  permanent CVA   
 Mean age 68±12 years    
  Survival 6 years 104 patients (87%)  
 Unilateral ASCP 1320±160 ml/min, with (Kaplan–Meier)   
 perfusion pressure at 75 mmHg and at 30 °C    
 Mean ASCP time 25±12 min    
     
Kazui et al., (2002), 330 patients underwent surgery for aortic 30-day mortality 37 patients (11.2%) All patients underwent 
Ann Thorac Surg, arch disease   aortic arch surgery 
Japan [12]  30-day mortality 4 patients (3.2%)  
 89 patients (27%) acute aortic dissection (1997–2001)  Long-term follow-up 
Retrospective     
study (level 2b) Mean age 62.9±12.7 years Postoperative 4.2% ASCP time is not an 
 220 (67%) male transient CVA  independent risk factor 
  period (1986–2001)   for mortality and 
  Postoperative 2.4% postoperative CVA at 
 Bilateral ASCP 10 ml/kg/min at 22 °C permanent CVA  the logistic regression 
 rectal temperature   analysis 
 Mean ASCP time 86.2±28.5 min Survival 5 years 80.4±2.3%  
     
 Follow-up 10 years Survival 10 years 75.7±2.8%  
     
Di Eusanio et al., 588 patients underwent operations on the 30-day mortality 51 patients (8.7%) No follow-up data available 
(2003), Ann Thorac thoracic aorta using antegrade selective    
Surg, Italy, cerebral perfusion and moderate Postoperative 31/552 patients (5.6%) Large series of total arch 
The Netherlands hypothermia at St Antonius Hospital transient CVA  replacement 
Japan [13] (Nieuwegein, The Netherlands), at Sant    
 Orsola Hospital (Bologna, Italy), and at Postoperative 22/574 patients (3.8%)  
Retrospective Hamamatsu University (Hamamatsu, permanent CVA   
multicenter study Japan)    
(level 2b)     
 152 patients (25.9%) acute aortic dissection    
 352 patients (60%) underwent total arch    
 replacement in the period (1995–2002)    
     
 Mean age 63.7±11.8 years    
 334 male (56.8%)    
     
 Bilateral ASCP 10 ml/kg/min at 22–    
 26 °C nasopharyngeal temperature    
 Mean ASCP time 67.3±37.3 min    
     
Numata et al., (2003), 120 patients underwent total arch 30-day mortality 4 patients (3.3%) Total arch replacement 
Eur J Cardiothorac Surg, replacement with right axillary artery   requires longer time of ASCP, 
Japan [14] direct cannulation and left common carotid Postoperative 7 patients (5.8%) however ASCP time >150 min 
 artery cannulation transient CVA  is not a risk factor for 
Retrospective period (1998–2002)   in-hospital mortality 
study (level 2b)  Postoperative 1 patient (0.8%)  
 20 patients (16.7%) emergency surgery permanent CVA  No follow-up data reported 
     
 99 male    
 Mean age 69±10 years    
     
 ASCP 500 ml/min at 22 °C nasopharyngeal    
 temperature    
 Mean ASCP time 164±41 min    
     
Ueda et al., (2003), 103 patients underwent total arch 30-day mortality 7 patients (7%) All patients had total arch 
Ann Thorac Surg, replacement through a median sternotomy   replacement 
Japan [15] using a branched arch graft with selective Postoperative 7 patients (7%)  
 cerebral perfusion transient CVA  Mid-term follow-up data 
Retrospective period (1993–2001)   reported 
study (level 2b) 35 patients with acute aortic dissection Postoperative 9 patients (9%)  
  permament CVA   
 77 male    
 Mean age 65±11 years Survival 5 years 67%  
  (Kaplan–Meier)   
 Bilateral ASCP 10 ml/kg/min at 23 °C    
 of rectal temperature    
 Mean ASCP time 145±36 min    
     
 Median follow-up 34 months    
     
Pacini et al., (2007), 305 patients underwent hemiarch and 30-day mortality 40 patients (13.1%) Authors did not find 
Eur J Cardiothorac total aortic arch replacement for chronic   differences between 
Surg, Italy [16] aortic aneurysm and acute and chronic Postoperative 25 patients (8.2%) group A and group B for 
 aortic dissection using antegrade selective transient CVA  CVA and mortality 
Retrospective cerebral perfusion with hypothermic    
study (level 2b) circulatory arrest (HCA) as method Postoperative 8 patients (2.6%) Bilateral ASCP and moderate 
 of cerebral protection permanent CVA  hypothermia are safe and 
 period (1996–2005)   sufficient tools for brain 
    protection also in acute 
 105 patients with acute aortic dissection   aortic dissection 
     
 189 group A moderate hypothermia   No follow-up data reported 
 (>25 °C)    
 116 group B deep hypothermia <25 °C    
     
 Bilateral ASCP 10 ml/kg/min    
 Mean ASCP time group A: 63±38 min;    
 group B: 59±36 min    
     
Kazui et al., (2007), 472 patients underwent aortic arch 30-day mortality 44 patients (9.3%) Cannulation of innominate 
Ann Thorac Surg, replacement with the aid of antegrade   or right axillary artery and 
Japan [17] cerebral perfusion Postoperative 4.7% 1986–1996 cannulation under direct 
 126 patients (27%) were treated for transient CVA 4.9% 1997–2006 vision of left common carotid 
Retrospective acute dissection   artery allow a safe cerebral 
study (level 2b) period (1986 – 2006) Postoperative 3.2% 1986–1996 protection 
  permanent CVA 3.8% 1997–2006  
 Mean age 64±13 years   ASCP duration has no 
 65% male   significant correlation 
    with in-hospital mortality and 
 Bilateral carotid perfusion 10 ml/kg/min at   neurologic outcome 
 25 °C rectal temperature    
 Mean ASCP time 88.2±32.2 min    
     
Sasaki et al., (2007), 305 patients underwent total aortic arch 30-day mortality 6 patients (1.9%) Large series of total arch 
Ann Thorac Surg, replacement   replacement 
Japan [18] 34 patients with aortic dissection Postoperative 20 patients (6.6%)  
 238 men transient CVA  Mid-term follow-up 
Retrospective period (2000–2005)    
study (level 2b)  Postoperative 5 patients (1.6%)  
 Median age 73 years (52–87) permanent CVA   
     
 Right axillary artery cannulation Survival at follow- 94.6±1.5%  
 Bilateral carotid perfusion 10 ml/kg/min up (Kaplan–Meier)   
 at 20–28 °C (from 2003 higher    
 temperature of patients' cooling)    
     
 Mean ASCP time 150.1±39.0 min    
     
 Follow-up 3 years    
     
Khaladj et al., (2008), 501 patients underwent aortic surgery 30-day mortality 58 patients (11.6%) Large series of aortic 
J Thorac Cardiovasc 103 patients with acute aortic dissection   arch surgery 
Surg, Germany 320 men Postoperative 67 patients (13.4%)  
[19] period (1999–2006) transient CVA  Higher incidence of 
    CVA 
Retrospective Median age 64 years (20–86) Postoperative 48 patients (9.6%)  
study (level 2b)  permanent CVA   
 Bilateral carotid perfusion 10 ml/kg/min    
 Mean ASCP time 23±18 min    
Author, date, and Patient group Outcomes Key results Comments 
country     
Study type     
(level of evidence)     
Tasdemir et al., 104 patients underwent aortic arch 30-day mortality 8 patients (7.6%) Low ASCP time 
(2002), Ann Thorac reconstruction with right upper brachial    
Surg, Turkey [6] artery perfusion for cerebral protection FU mortality 12 patients (11.5%) 50 patients underwent total 
 12 acute aortic dissection   aortic arch replacement 
Retrospective 31 total arch replacement Postoperative CVA 2 patients (1.9%)  
study (level 2b) period (1996–2001)    
     
 Mean age 52±12 years    
     
 Unilateral ASCP 8–10 ml/kg/min at    
 26 °C rectal temperature    
 Mean ASCP time 39±22 min    
     
 Follow-up 2.2±1 year    
     
Karadeniz et al., 15 consecutive patients underwent surgical Postoperative CVA A normal circle of Willis 
(2005), Ann Thorac reconstruction of aortic arch with antegrade   should not carry 
Surg, Turkey [7] selective cerebral perfusion through the   hypoperfusion risk during 
 right brachial artery   unilateral ASCP 
Prospective cohort period January–June 2002    
study (level 2b)    TCD ultrasonography or 
 Mean age 53±3.3 years   NIRS are necessary to 
 12 men   monitoring the adequacy of 
    cerebral perfusion 
 Right brachial artery direct cannulation    
 transcranial Doppler monitoring unilateral   Low number of patients 
 ASCP 8–10 ml/kg/min at 26 °C rectal    
 temperature ASCP time 29±5.8   Detailed report of cerebral 
    monitoring 
 Right brachial artery group was    
 compared with aortic cannulation group    
 (20 patients)    
     
Ku;alcuker et al., (2005), 131 patients underwent aortic arch 30-day mortality 12 patients (6.6%) A total arch replacement 
Eur J Cardiothorac reconstruction with right upper brachial   was performed only in 
Surg, Turkey [8] artery perfusion for cerebral protection FU mortality 19 patients (10.5%) 50 patients, less 
 period (1996–2004)   complex procedures 
Retrospective study Ascending and/or partial arch replacement Postoperative 1 patient (0.6%) allow a shorter time of 
(level 2b) was performed in 90 patients transient CVA  cerebral perfusion 
 Ascending and total arch replacement    
 in 91 patients Postoperative 3 patients (1.8%)  
 24 patients with acute aortic dissection permanent CVA   
     
 Mean age 58±12 years    
 132 male    
     
 Unilateral ASCP 8–10 ml/kg/min at    
 26 °C rectal temperature    
 ASCP time 36±27 min    
 Follow-up 3.7±1.5 year    
     
Panos et al., (2006), 25 consecutive patients (17 men), with 30-day mortality 1 patient (4%) Limited number of 
Eur J Cardiothorac type A aortic dissection, underwent   patients 
Surg, Switzerland [9] surgery for replacement of the ascending FU mortality 2 patients (8%)  
 aorta extended on the hemi-arch or   Only 8 patients had total 
Retrospective arch in the period (2001–2005) Postoperative CVA 1 patient (4%) arch replacement 
study (level 2b)     
 Right axillary artery direct cannulation    
     
 Mean age 62.6±14.8 years    
     
 Unilateral ASCP 12 ml/kg/min 25 °C    
 rectal temperature    
 Mean ASCP time 39.7 min (24–55 min)    
     
 Follow-up mean 19 months (4–30 months)    
     
     
Budde et al., (2006), 61 patients underwent proximal aortic 30-day mortality  Limited number of 
Ann Thorac Surg, surgery with axillary cannulation for arterial  Elective 3 patients (7.2%) patients 
USA [10] perfusion with side graft interposition  Emergent 2 patients (10%)  
    Retrospective study 
Retrospective 41 elective cases Postoperative   
cohort study 20 emergent cases transient CVA  Different protocol with 
(level 2b) Comparison between group  Elective 2 patients (4.8%) higher ASCP flow 
   Emergent 2 patients (10%)  
 Mean age 57±2.4 years   Limited number of total 
  Postoperative  arch replacement 
 Unilateral ASCP 16 ml/kg/min at 23 °C permanent CVA   
 bladder temperature  Elective  
 Mean ASCP time (elective 27±2.7 min;  Emergent 1 patient (5%)  
 emergent 25±2.6 min)    
     
Bakhtiary et al., 120 patients underwent aortic surgery 30-day mortality 6 patients (5%) Limited number of total 
(2008), Ann Thorac for acute aortic dissection (2000–2006)   arch replacement with 
Surg, Germany [11] 12 patients underwent total arch Postoperative 3 patients (2.5%) lower mean ASCP time 
 replacement transient CVA   
Retrospective     
study (level 2b) Right axillary artery direct cannulation Postoperative 5 patients (4.2%)  
  permanent CVA   
 Mean age 68±12 years    
  Survival 6 years 104 patients (87%)  
 Unilateral ASCP 1320±160 ml/min, with (Kaplan–Meier)   
 perfusion pressure at 75 mmHg and at 30 °C    
 Mean ASCP time 25±12 min    
     
Kazui et al., (2002), 330 patients underwent surgery for aortic 30-day mortality 37 patients (11.2%) All patients underwent 
Ann Thorac Surg, arch disease   aortic arch surgery 
Japan [12]  30-day mortality 4 patients (3.2%)  
 89 patients (27%) acute aortic dissection (1997–2001)  Long-term follow-up 
Retrospective     
study (level 2b) Mean age 62.9±12.7 years Postoperative 4.2% ASCP time is not an 
 220 (67%) male transient CVA  independent risk factor 
  period (1986–2001)   for mortality and 
  Postoperative 2.4% postoperative CVA at 
 Bilateral ASCP 10 ml/kg/min at 22 °C permanent CVA  the logistic regression 
 rectal temperature   analysis 
 Mean ASCP time 86.2±28.5 min Survival 5 years 80.4±2.3%  
     
 Follow-up 10 years Survival 10 years 75.7±2.8%  
     
Di Eusanio et al., 588 patients underwent operations on the 30-day mortality 51 patients (8.7%) No follow-up data available 
(2003), Ann Thorac thoracic aorta using antegrade selective    
Surg, Italy, cerebral perfusion and moderate Postoperative 31/552 patients (5.6%) Large series of total arch 
The Netherlands hypothermia at St Antonius Hospital transient CVA  replacement 
Japan [13] (Nieuwegein, The Netherlands), at Sant    
 Orsola Hospital (Bologna, Italy), and at Postoperative 22/574 patients (3.8%)  
Retrospective Hamamatsu University (Hamamatsu, permanent CVA   
multicenter study Japan)    
(level 2b)     
 152 patients (25.9%) acute aortic dissection    
 352 patients (60%) underwent total arch    
 replacement in the period (1995–2002)    
     
 Mean age 63.7±11.8 years    
 334 male (56.8%)    
     
 Bilateral ASCP 10 ml/kg/min at 22–    
 26 °C nasopharyngeal temperature    
 Mean ASCP time 67.3±37.3 min    
     
Numata et al., (2003), 120 patients underwent total arch 30-day mortality 4 patients (3.3%) Total arch replacement 
Eur J Cardiothorac Surg, replacement with right axillary artery   requires longer time of ASCP, 
Japan [14] direct cannulation and left common carotid Postoperative 7 patients (5.8%) however ASCP time >150 min 
 artery cannulation transient CVA  is not a risk factor for 
Retrospective period (1998–2002)   in-hospital mortality 
study (level 2b)  Postoperative 1 patient (0.8%)  
 20 patients (16.7%) emergency surgery permanent CVA  No follow-up data reported 
     
 99 male    
 Mean age 69±10 years    
     
 ASCP 500 ml/min at 22 °C nasopharyngeal    
 temperature    
 Mean ASCP time 164±41 min    
     
Ueda et al., (2003), 103 patients underwent total arch 30-day mortality 7 patients (7%) All patients had total arch 
Ann Thorac Surg, replacement through a median sternotomy   replacement 
Japan [15] using a branched arch graft with selective Postoperative 7 patients (7%)  
 cerebral perfusion transient CVA  Mid-term follow-up data 
Retrospective period (1993–2001)   reported 
study (level 2b) 35 patients with acute aortic dissection Postoperative 9 patients (9%)  
  permament CVA   
 77 male    
 Mean age 65±11 years Survival 5 years 67%  
  (Kaplan–Meier)   
 Bilateral ASCP 10 ml/kg/min at 23 °C    
 of rectal temperature    
 Mean ASCP time 145±36 min    
     
 Median follow-up 34 months    
     
Pacini et al., (2007), 305 patients underwent hemiarch and 30-day mortality 40 patients (13.1%) Authors did not find 
Eur J Cardiothorac total aortic arch replacement for chronic   differences between 
Surg, Italy [16] aortic aneurysm and acute and chronic Postoperative 25 patients (8.2%) group A and group B for 
 aortic dissection using antegrade selective transient CVA  CVA and mortality 
Retrospective cerebral perfusion with hypothermic    
study (level 2b) circulatory arrest (HCA) as method Postoperative 8 patients (2.6%) Bilateral ASCP and moderate 
 of cerebral protection permanent CVA  hypothermia are safe and 
 period (1996–2005)   sufficient tools for brain 
    protection also in acute 
 105 patients with acute aortic dissection   aortic dissection 
     
 189 group A moderate hypothermia   No follow-up data reported 
 (>25 °C)    
 116 group B deep hypothermia <25 °C    
     
 Bilateral ASCP 10 ml/kg/min    
 Mean ASCP time group A: 63±38 min;    
 group B: 59±36 min    
     
Kazui et al., (2007), 472 patients underwent aortic arch 30-day mortality 44 patients (9.3%) Cannulation of innominate 
Ann Thorac Surg, replacement with the aid of antegrade   or right axillary artery and 
Japan [17] cerebral perfusion Postoperative 4.7% 1986–1996 cannulation under direct 
 126 patients (27%) were treated for transient CVA 4.9% 1997–2006 vision of left common carotid 
Retrospective acute dissection   artery allow a safe cerebral 
study (level 2b) period (1986 – 2006) Postoperative 3.2% 1986–1996 protection 
  permanent CVA 3.8% 1997–2006  
 Mean age 64±13 years   ASCP duration has no 
 65% male   significant correlation 
    with in-hospital mortality and 
 Bilateral carotid perfusion 10 ml/kg/min at   neurologic outcome 
 25 °C rectal temperature    
 Mean ASCP time 88.2±32.2 min    
     
Sasaki et al., (2007), 305 patients underwent total aortic arch 30-day mortality 6 patients (1.9%) Large series of total arch 
Ann Thorac Surg, replacement   replacement 
Japan [18] 34 patients with aortic dissection Postoperative 20 patients (6.6%)  
 238 men transient CVA  Mid-term follow-up 
Retrospective period (2000–2005)    
study (level 2b)  Postoperative 5 patients (1.6%)  
 Median age 73 years (52–87) permanent CVA   
     
 Right axillary artery cannulation Survival at follow- 94.6±1.5%  
 Bilateral carotid perfusion 10 ml/kg/min up (Kaplan–Meier)   
 at 20–28 °C (from 2003 higher    
 temperature of patients' cooling)    
     
 Mean ASCP time 150.1±39.0 min    
     
 Follow-up 3 years    
     
Khaladj et al., (2008), 501 patients underwent aortic surgery 30-day mortality 58 patients (11.6%) Large series of aortic 
J Thorac Cardiovasc 103 patients with acute aortic dissection   arch surgery 
Surg, Germany 320 men Postoperative 67 patients (13.4%)  
[19] period (1999–2006) transient CVA  Higher incidence of 
    CVA 
Retrospective Median age 64 years (20–86) Postoperative 48 patients (9.6%)  
study (level 2b)  permanent CVA   
 Bilateral carotid perfusion 10 ml/kg/min    
 Mean ASCP time 23±18 min    

CVA, cerebral vascular accident; ASCP, antegrade selective cerebral perfusion.

6. Comment

Dossche et al. [2] reported their experience with thoracic aortic surgery in 106 patients: 37 patients had unilateral and 69 patients bilateral antegrade selective cerebral perfusion (ASCP). They observed an incidence of postoperative transient and permanent cerebral vascular accident (CVA) in 3.8% and 5.4% of patients, respectively. Unfortunately, no information was provided as to which technique of cerebral perfusion resulted in reduced cerebral ischemic events, although the authors concluded that patients undergoing bilateral cerebral perfusion had a reduced rate of in-hospital complications.

Immer et al. [3] compared the hospital and neurologic outcome of 567 patients who underwent aortic arch surgery with different protocols of cerebral protection: 387 patients had deep hypothermic circulatory arrest (DHCA) alone, 91 patients DHCA associated to bilateral antegrade cerebral perfusion, 89 patients had DHCA and unilateral cerebral perfusion from the right axillary artery. The unilateral antegrade perfusion allowed better early survival and it is safer against postoperative permanent CVA (P<0.05). The authors concluded that reducing neck vessels manipulation and the insertion of intraluminal cannulae decreases the thromboembolic events and air embolism.

Olsson et al. [4] compared the hospital outcome and the incidence of postoperative CVA in a series of 65 patients with bilateral ASCP and 17 patients with unilateral ASCP for aortic surgery. The propensity score analysis showed a higher incidence of stroke after unilateral ASCP. Furthermore, the multivariable model showed unilateral ASCP was the only variable independently related to stroke. These clinical findings are supported by anatomic studies investigating variations and acquired diseases of the circle of Willis by MR angiography and post-mortem examination. Merkkolla et al. [5] studied the anatomy of the cerebral arteries of 87 deceased individuals by angiography and permanent silicone casts: 22% of the anterior communicating arteries and 46% of the left posterior communicating arteries were missing, these findings may cause insufficient contra-lateral perfusion. Several series of patients undergoing elective and emergency surgery with unilateral antegrade selective cerebral perfusion document an incidence of postoperative cerebral vascular accident ranging from 0.6% up to 10% [6–11], with transient CVA having a higher incidence than permanent CVA [8,10]. In all these experiences direct cannulation of epiaortic vessels was avoided, right axillary artery or upper brachial artery were cannulated for CPB establishment and the achievement of unilateral cerebral perfusion. Although all these studies report good results with unilateral antegrade cerebral perfusion, three of them are small series [7,9,10]. In the remaining two studies [6,8,11], short time of unilateral cerebral perfusion are reported with a mean time of cerebral plegia of 39±22 min in Tasdemir's experience, 36±27 min in Kucuker's one and 25±12 min in Bakhtiary report. Tasdemir's and Kucuker's series include only small numbers of patients presented with acute aortic dissection. In Bakhtiary's experience all the patients presented with a diagnosis of acute aortic dissection. All these three series include few cases of complex aortic arch procedures.

Kazui and coworkers used bilateral cerebral perfusion [12,17] in two large series of patients operated upon for total arch replacement (27% for acute aortic dissection). In all cases left common carotid artery was selectively cannulated, the right carotid perfusion was achieved by direct cannulation of the innominate artery or from the right axillary artery that was cannulated directly or by a side graft. The axillary approach was used to establish CPB also. The authors reported an incidence of postoperative transient CVA ranging from 4.2% to 4.9% and permanent CVA ranging from 2.4% to 3.8% over different time spans. Mean cerebral perfusion time was approximately 88±30 min higher than in the reported findings with unilateral perfusion [6,8]. Moreover, they found that length of time of bilateral cerebral perfusion had no significant correlation with hospital mortality and neurological outcome. Similar results were reported in other studies [13–16,18] with large series of complex surgical procedures that required a longer time of bilateral cerebral perfusion.

7. Clinical bottom line

We found 17 papers including 3548 patients undergoing aortic surgery using either unilateral or bilateral cerebral perfusion. These papers documented bilateral cerebral perfusion in 2949 patients and unilateral perfusion in 599 patients. Both methods of cerebral perfusion resulted in neurological injury rates of <5%, but the period of antegrade cerebral perfusion allowed by bilateral perfusion was significantly higher. While unilateral perfusion allowed around 30–50 min, bilateral perfusion allowed 86 to over 164 min of ASCP with an acceptably low CVA rate. Therefore, we conclude that while both methods are acceptable, once the ASCP time is expected to rise over 40–50 min, bilateral cerebral perfusion is the technique that is best documented to be safe.

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