Meta-analysis: Bilateral and Unilateral Cerebral Perfusion in Type A Dissection

Abstract

Background This meta-analysis compared the outcomes of bilateral cerebral perfusion (BCP) and unilateral cerebral perfusion (UCP) in aortic surgery for acute type A aortic dissection.

Methods A systematic literature search identified 12 studies involving 4,547 patients. Pooled odds ratios (OR) with 95% confidence intervals (CI) were calculated to analyze perioperative characteristics, short-term mortality rates, and postoperative neurological complications.

Results No significant differences were found between the BCP and UCP groups in terms of cardiopulmonary bypass time, aortic cross clamp time, lowest body temperature, and lower body circulatory arrest time. Short-term mortality rates (OR [95% CI] = 0.87 [0.64–1.19], p = 0.40) and permanent neurological deficits (OR [95% CI] = 1.01 [0.69–1.47], p = 0.96) were comparable between the groups. However, subgroup analysis of studies exclusively involving total arch replacement showed a lower short-term mortality rate (OR [95% CI] = 0.42 [0.28–0.63], p < 0.01) and permanent neurological deficits (OR [95% CI] = 0.53 [0.30–0.92], p = 0.03) in the BCP group. The BCP group also had a lower rate of temporary neurological deficits (OR [95% CI] = 0.70 [0.53–0.93], p = 0.01), particularly in studies exclusively involving total arch replacement (OR [95% CI] = 0.58 [0.40–0.85], p < 0.01).

Conclusion This meta-analysis suggests that BCP and UCP yield comparable outcomes. However, BCP may be associated with lower short-term mortality rates and reduced incidence of neurological complications, particularly in cases requiring total arch replacement. BCP should be considered as a preferred cerebral perfusion in specific patient populations.

Keywords

cerebral perfusion - acute type A aortic dissection - meta-analysis

Publikationsverlauf

Eingereicht: 20. Juli 2023

Angenommen: 27. Dezember 2023

Artikel online veröffentlicht:
30. Januar 2024

• References

• 1 Daily PO, Trueblood HW, Stinson EB, Wuerflein RD, Shumway NE. Management of acute aortic dissections. Ann Thorac Surg 1970; 10 (03) 237-247
• 2 Zhu Y, Lingala B, Baiocchi M. et al. Type A aortic dissection-experience over 5 decades: JACC historical breakthroughs in perspective. J Am Coll Cardiol 2020; 76 (14) 1703-1713
• 3 Pape LA, Awais M, Woznicki EM. et al. Presentation, diagnosis, and outcomes of acute aortic dissection: 17-year trends from the international registry of acute aortic dissection. J Am Coll Cardiol 2015; 66 (04) 350-358
• 4 Abramowitz Y, Jilaihawi H, Chakravarty T, Mack MJ, Makkar RR. Mitral annulus calcification. J Am Coll Cardiol 2015; 66 (17) 1934-1941
• 5 Benedetto U, Dimagli A, Cooper G. et al; UK Aortic Surgery. Neuroprotective strategies in acute aortic dissection: an analysis of the UK National Adult Cardiac Surgical Audit. Eur J Cardiothorac Surg 2021; 60 (06) 1437-1444
• 6 Krüger T, Weigang E, Hoffmann I, Blettner M, Aebert H. GERAADA Investigators. Cerebral protection during surgery for acute aortic dissection type A: results of the German Registry for Acute Aortic Dissection Type A (GERAADA). Circulation 2011; 124 (04) 434-443
• 7 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 (01) 19-28 , discussion 28–31
• 8 Misfeld M, Leontyev S, Borger MA. et al. What is the best strategy for brain protection in patients undergoing aortic arch surgery? A single center experience of 636 patients. Ann Thorac Surg 2012; 93 (05) 1502-1508
• 9 Halkos ME, Kerendi F, Myung R, Kilgo P, Puskas JD, Chen EP. Selective antegrade cerebral perfusion via right axillary artery cannulation reduces morbidity and mortality after proximal aortic surgery. J Thorac Cardiovasc Surg 2009; 138 (05) 1081-1089
• 10 Samanidis G, Kanakis M, Khoury M. et al. Antegrade and retrograde cerebral perfusion during acute type A aortic dissection repair in 290 patients. Heart Lung Circ 2021; 30 (07) 1075-1083
• 11 Malvindi PG, Scrascia G, Vitale N. Is unilateral antegrade cerebral perfusion equivalent to bilateral cerebral perfusion for patients undergoing aortic arch surgery?. Interact Cardiovasc Thorac Surg 2008; 7 (05) 891-897
• 12 Samanidis G, Katselis C, Contrafouris C. et al. Predictors of outcomes after correction of acute type A aortic dissection under moderate hypothermic circulatory arrest and antegrade cerebral perfusion. Rev Bras Cir Cardiovasc 2018; 33 (02) 143-150
• 13 Jiang Q, Huang K, Wang D, Xia J, Yu T, Hu S. A comparison of bilateral and unilateral cerebral perfusion for total arch replacement surgery for non-Marfan, type A aortic dissection. Perfusion 2023;
• 14 Liu Z, Wang C, Zhang X, Wu S, Fang C, Pang X. Effect of different types of cerebral perfusion for acute type A aortic dissection undergoing aortic arch procedure, unilateral versus bilateral. BMC Surg 2020; 20 (01) 286
• 15 Tong G, Zhang B, Zhou X. et al. Bilateral versus unilateral antegrade cerebral perfusion in total arch replacement for type A aortic dissection. J Thorac Cardiovasc Surg 2017; 154 (03) 767-775
• 16 Page MJ, McKenzie JE, Bossuyt PM. et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021; 372 (71) n71
• 17 Kim SY, Park JE, Lee YJ. et al. Testing a tool for assessing the risk of bias for nonrandomized studies showed moderate reliability and promising validity. J Clin Epidemiol 2013; 66 (04) 408-414
• 18 Piperata A, Watanabe M, Pernot M. et al. Unilateral versus bilateral cerebral perfusion during aortic surgery for acute type A aortic dissection: a multicentre study. Eur J Cardiothorac Surg 2022; 61 (04) 828-835
• 19 Montagner M, Kofler M, Pitts L. et al. Matched comparison of 3 cerebral perfusion strategies in open zone-0 anastomosis for acute type A aortic dissection. Eur J Cardiothorac Surg 2022; 62 (05) ezac214
• 20 Dong SB, Xiong JX, Zhang K. et al. Different hypothermic and cerebral perfusion strategies in extended arch replacement for acute type a aortic dissection: a retrospective comparative study. J Cardiothorac Surg 2020; 15 (01) 236
• 21 Norton EL, Wu X, Kim KM, Patel HJ, Deeb GM, Yang B. Unilateral is comparable to bilateral antegrade cerebral perfusion in acute type A aortic dissection repair. J Thorac Cardiovasc Surg 2020; 160 (03) 617-625.e5
• 22 Angleitner P, Stelzmueller ME, Mahr S, Kaider A, Laufer G, Ehrlich M. Bilateral or unilateral antegrade cerebral perfusion during surgery for acute type A dissection. J Thorac Cardiovasc Surg 2020; 159 (06) 2159-2167.e2
• 23 Preventza O, Simpson KH, Cooley DA. et al. Unilateral versus bilateral cerebral perfusion for acute type A aortic dissection. Ann Thorac Surg 2015; 99 (01) 80-87
• 24 Lu S, Sun X, Hong T. et al. Bilateral versus unilateral antegrade cerebral perfusion in arch reconstruction for aortic dissection. Ann Thorac Surg 2012; 93 (06) 1917-1920
• 25 Tasoudis PT, Varvoglis DN, Vitkos E, Ikonomidis JS, Athanasiou T. Unilateral versus bilateral anterograde cerebral perfusion in acute type A aortic dissection repair: a systematic review and meta-analysis. Perfusion 2023; 38 (05) 931-938
• 26 Angeloni E, Melina G, Refice SK. et al. Unilateral versus bilateral antegrade cerebral protection during aortic surgery: an updated meta-analysis. Ann Thorac Surg 2015; 99 (06) 2024-2031
• 27 Angeloni E, Benedetto U, Takkenberg JJ. et al. Unilateral versus bilateral antegrade cerebral protection during circulatory arrest in aortic surgery: a meta-analysis of 5100 patients. J Thorac Cardiovasc Surg 2014; 147 (01) 60-67
• 28 Merkkola P, Tulla H, Ronkainen A. et al. Incomplete circle of Willis and right axillary artery perfusion. Ann Thorac Surg 2006; 82 (01) 74-79
• 29 Urbanski PP, Lenos A, Blume JC. et al. Does anatomical completeness of the circle of Willis correlate with sufficient cross-perfusion during unilateral cerebral perfusion?. Eur J Cardiothorac Surg 2008; 33 (03) 402-408
• 30 Zierer A, Risteski P, El-Sayed Ahmad A, Moritz A, Diegeler A, Urbanski PP. The impact of unilateral versus bilateral antegrade cerebral perfusion on surgical outcomes after aortic arch replacement: a propensity-matched analysis. J Thorac Cardiovasc Surg 2014; 147 (04) 1212-1217 , discussion 1217–1218