Stroke After Aortic Arch Surgery with Short Circulatory Arrest Times: The Role of Cerebral Perfusion Strategies.

Document Type

Article

Publication Date

2025

Publication Title

The Journal of thoracic and cardiovascular surgery

Abstract

BACKGROUND: Neuroprotection during aortic arch surgery often involves hypothermia and the use of adjunctive cerebral perfusion. While antegrade cerebral perfusion (ACP) is favored for extended hypothermic circulatory arrest (HCA), debate continues regarding the optimal cerebral protection strategy during shorter circulatory arrest durations. This study evaluates the association between cerebral perfusion strategies and stroke risk among patients undergoing aortic arch surgery with HCA time < 30 minutes.

METHODS: Registry data from 1,079 patients across 42 centers who underwent elective aortic surgery with HCA between 2018 and 2024 were analyzed. Patients with aortic dissections, HCA durations >30 minutes or receiving both ACP and retrograde cerebral perfusion (RCP) were excluded. Cerebral perfusion strategies were categorized as no cerebral perfusion (NCP), RCP, or ACP. Preoperative, intraoperative, and postoperative variables were compared across cerebral perfusion strategies. Multivariable logistic regression was used to assess the association between perfusion strategy and postoperative stroke, adjusting for age, sex, race, prior stroke, chronic lung disease, lowest HCA temperature, cardiopulmonary bypass time, and duration of circulatory arrest.

RESULTS: ACP was the most common strategy (n=560, 51.9%), followed by RCP (n=264, 24.5%) and NCP (n=255, 23.6%). Baseline characteristics were similar across cerebral perfusion strategies, although chronic lung disease was more frequent among ACP patients. Median [IQR] HCA temperature was 19.4°C [18.0-24.4], 25.8°C [22.9-27.7], and 21.6°C [18.9-23.5] in the NCP, ACP, and RCP groups, respectively (p< 0.01). Median HCA time was 14 [10-20], 14 [9-20], and 16 [13-19] minutes; bypass time was 201 [158-250], 154 [115-207], and 172 [132-214] minutes, respectively (p< 0.01). Stroke rates were lowest among RCP patients, with an 86.5% reduction in adjusted odds of stroke compared to NCP (aOR 0.135, 95% CI: 0.023-0.783; p=0.03). There was a non-significant protective effect associated with ACP.

CONCLUSIONS: In this large, multicenter cohort of patients undergoing elective aortic arch surgery with short HCA times, RCP was associated with a significantly lower risk of postoperative stroke compared to no cerebral perfusion. Physician-led quality improvement collaboratives may serve as an effective mechanism for advance performance related to cerebral perfusion strategies and mitigation of stroke in the setting of elective aortic arch surgery with short circulatory arrest.

DOI

10.1016/j.jtcvs.2025.10.019

ISSN

1097-685X

PubMed ID

41115650

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