Effect of cerebral protection strategy on outcome of patients with Stanford type A aortic dissection

Abstract

Objective: The aim of the present study was to assess the efficacy and mid- to long-term results of different cerebral protection techniques in the treatment of acute type A aortic dissection.

Methods: Between April 1987 and January 2011, 329 patients (220 male patients; median age, 60 years; range, 16-87) with type A aortic dissection underwent replacement of the ascending aorta or aortic arch with an open distal anastomosis. Either hypothermic circulatory arrest alone at 18 °C (n = 116; 35%) or combined with retrograde cerebral perfusion (n = 122; 37%) or antegrade cerebral perfusion at 25 °C (n = 91; 28%) was used.

Results: The median circulatory arrest time was 30 minutes (range, 12-92). The overall 30-day mortality was 19% (62 of 329). The 30-day mortality stratified by group was 26% (30 patients) in the hypothermic circulatory arrest group, 16% in the retrograde cerebral perfusion group (20 patients), and 13% (12 patients) in the antegrade cerebral perfusion group (P = .047). Permanent neurologic dysfunction occurred in 53 patients (16%), with statistically significant differences among the 3 groups (23% for hypothermic circulatory arrest, 12% for retrograde cerebral perfusion, and 12% for antegrade cerebral perfusion; P = .033). Univariate analysis showed a significant effect of the brain protection strategy on 30-day mortality and neurologic outcome. Multivariate analysis revealed preoperative hemodynamic instability, preoperative resuscitation, age, and operative year as independent predictors of 30-day mortality. Regarding permanent neurologic dysfunction, the multivariate analysis could not identify any independent predictors. Kaplan-Meier analyses revealed statistically significant differences among the 3 groups with a 1-, 3-, and 5-year survival rate of 84%, 79%, and 77% with antegrade cerebral perfusion, 75%, 72%, and 66% with retrograde cerebral perfusion, and 66%, 62%, and 60% with hypothermic circulatory arrest alone.

Conclusions: Patients in the antegrade cerebral perfusion group had the best short- and long-term survival rates. However, during the study period, several significant improvements in the treatment of patients with type A aortic dissection were achieved; therefore, independent predictors of mortality and permanent neurologic dysfunction were difficult to identify.

Keywords: 26; 26.1; 26.1.2; 26.1.3; ACP; CPB; HCA; PND; RCP; antegrade cerebral perfusion; bACP; bilateral ACP; cardiopulmonary bypass; hypothermic circulatory arrest; permanent neurologic deficit; retrograde cerebral perfusion; uACP; unilateral ACP.