Unilateral versus bilateral antegrade selective cerebral perfusion technique in aortic surgery: A systematic review and meta-analysis_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

 WANG Xiaowen ¹ , CHEN Dan ¹ , JIANG Zhaolei ² , LI Linjun ^1,3 , LI Qiang ¹ ,  JIANG Yingjiu ¹ , WU Qingchen ¹

1. Department of Cardiothoracic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, P.R.China;
2. Department of Cardiothoracic Surgery, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, 200092, P.R.China;
3. Department of Cardiothoracic Surgery ICU, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, P.R.China;

Corresponding?author：

JIANG Yingjiu, Email: jiangyinjiu@yeah.net

Keywords：

Cerebral perfusion; cerebral protection; aortic surgery; aortic dissection; systematic review/meta-analysis

DOI：

10.7507/1007-4848.201906029

Video：

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Objective To investigate the clinical efficacy of unilateral antegrade selective cerebral perfusion (UASCP) compared to bilateral antegrade selective cerebral perfusion (BASCP) in aortic surgery.Methods PubMed, EBSCO, Web of Science, Cochrane Library, CBM, CNKI, Wanfang Database were searched from establishment of each database to January 2019 to identify clinical studies on prognosis of UASCP versus BASCP in aortic surgery patients. The quality of randomized controlled trials was assessed by Cochrane risk assessement tool. The quality of non-randomized controlled trials was assessed by the Newcastle-Ottawa Scale ( NOS). Meta-analyses were presented in terms of odds ratio (OR) with 95% confidence interval (CI) by using RevMan 5.3 software.Results Sixteen eligible studies including 3 randomized controlled trials, 2 propensity matching score studies, and 11 retrospective case control studies including4 490 patients were identified. The 3 randomized controlled trials were with high bias risk. The NOS score of the other 13 studies was more than 6 stars. Pooled analysis showed no significant difference between the UASCP and BASCP groups in terms of permanent neurological dysfunction (PND) (OR=0.93, 95%CI 0.74 to 1.18, P=0.57), temporary neurological dysfunction (TND) (OR=1.26, 95%CI 0.94 to 1.69, P=0.12), acute kidney injury rate (OR=1.11, 95%CI 0.79 to 1.55, P=0.55), 30-day mortality (OR=0.94, 95%CI 0.67 to 1.32, P=0.72), length of ICU stay (OR=–0.64, 95%CI –1.66 to 0.37, P=0.22) and hospital stay (OR=–0.35, 95%CI –2.38 to 1.68, P=0.74).Conclusion This meta-analysis shows that UASCP and BASCP administration do not result in different mortality and neurologic morbidity rates. However, more studies with good methodologic quality and large sample are still needed to make further assessment.

Citation： WANG Xiaowen, CHEN Dan, JIANG Zhaolei, LI Linjun, LI Qiang, JIANG Yingjiu, WU Qingchen. Unilateral versus bilateral antegrade selective cerebral perfusion technique in aortic surgery: A systematic review and meta-analysis. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2020, 27(4): 457-464. doi: 10.7507/1007-4848.201906029 Copy

1.	Aoyagi S, Akashi H, Kubota Y, et al. Surgical treatment of aneurysms of the aortic arch using a simplified selective cerebral perfusion technique. Thorac Cardiovasc Surg, 1994, 42(5): 279-284.
2.	Olsson C, Thelin S. Antegrade cerebral perfusion with a simplified technique: unilateral versus bilateral perfusion. Ann Thorac Surg, 2006, 81(3): 868-874.
3.	Inamura S, Furuya H, Yagi K, et al. Recent surgical outcomes of acute type-A aortic dissection. Tokai J Exp Clin Med, 2006, 31(3): 109-112.
4.	Kr?henbühl ES, Clément M, Reineke D, et al. Antegrade cerebral protection in thoracic aortic surgery: lessons from the past decade. Eur J Cardiothorac Surg, 2010, 38(1): 46-51.
5.	Krüger T, Weigang E, Hoffmann I, et al. 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(4): 434-443.
6.	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(5): 1502-1508.
7.	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(6): 1917-1920.
8.	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.e1.
9.	Zierer A, Risteski P, El-Sayed Ahmad A, et al. 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(4): 1212-1218.
10.	Preventza O, Simpson KH, Cooley DA, et al. Unilateral versus bilateral cerebral perfusion for acute type a aortic dissection. Ann Thorac Surg, 2015, 99(1): 80-87.
11.	El-Sayed Ahmad A, Papadopoulos N, Risteski P, et al. The standardized concept of moderate-to-mild (≥28℃) systemic hypothermia during selective antegrade cerebral perfusion for? All-comers in aortic arch surgery: single-center experience in 587 consecutive patients over a 15-year period. Ann Thorac Surg, 2017, 104(1): 49-55.
12.	孫立忠, 田良鑫, 程衛平, 等. 單側與雙側順行性腦灌注的前瞻性隨機對照研究. 中華胸心血管外科雜志, 2005, 21(3): 154-156.
13.	王志維, 胡小平, 吳紅兵, 等. 單、雙側順行腦灌注在主動脈病變深低溫停循環手術中的效果比較. 中華胸心血管外科雜志, 2010, 26(1): 20-22.
14.	董國華, 許飚, 景華, 等. 單側與雙側選擇性順行腦灌注對 DeBakeyⅠ型主動脈夾層分離雜交手術患者神經功能的影響-前瞻性隨機對照研究. 國際腦血管病雜志, 2011, 19(12): 890-895.
15.	趙小寧, 喬晨暉, 羅鴻, 等. 選擇性單側與雙側腦灌注在急性 Stanford A 型夾層矯治術中的應用效果對比分析. 河南醫學研究, 2014, 23(12): 63-65.
16.	鄧宏平. 單、雙側腦灌注技術在主動脈外科手術中腦保護效果的比較. 武漢大學學報(醫學版), 2016, 37(1): 127-130.
17.	Krahenbühl, Eva S, Immer FF, Stalder M, et al. Temporary neurological dysfunction after surgery of the thoracic aorta: a predictor of poor outcome and impaired quality of life. Eur J Cardiothorac Surg, 2008, 33(6): 1025-1029.
18.	Zierer A, El-Sayed Ahmad A, Papadopoulos N, et al. Selective antegrade cerebral perfusion and mild (28℃-30℃) systemic hypothermic circulatory arrest for aortic arch replacement: Results from 1002 patients. J Thorac Cardiovasc Surg, 2012, 144(5): 1042-1050.
19.	Urbanski PP, Raad M, Lenos A, et al. Open aortic arch replacement in the era of endovascular techniques. Eur J Cardiothorac Surg, 2013, 44(3): 431-437.
20.	Lindsay H, Srinivas C, Djaiani G. Neuroprotection during aortic surgery. Best Pract Res Clin Anaesthesiol, 2016, 30(3): 283-303.
21.	Di Mauro M, Iaco AL, Di Lorenzo C, et al. Cold reperfusion before rewarming reduces neurological events after deep hypothermic circulatory arrest. Eur J Cardiothorac Surg, 2013, 43(1): 168-173.
22.	Yan TD, Tian DH, LeMaire SA, et al. The ARCH Projects: design and rationale (IAASSG 001). Eur J Cardiothorac Surg, 2014, 45(1): 10-16.
23.	Estrera AL, Miller CC, Lee TY, et al. Ascending and transverse aortic arch repair: The impact of retrograde cerebral perfusion. Circulation, 2008, 118(14_suppl_1): S160-S166.
24.	Eusanio MD, Pantaleo A, Petridis FD, et al. Impact of different cannulation strategies on in-hospital outcomes of aortic arch surgery: A propensity-score analysis. Ann Thorac Surg, 2013, 96(5): 1656-1663.
25.	Tang GHL, Kai M, Malekan R, et al. Trifurcated graft replacement of the aortic arch: State of the art. J Thorac Cardiovasc Surg, 2015, 149(2): S55-S58.
26.	Conzelmann LO, Hoffmann I, Blettner M, et al. Analysis of risk factors for neurological dysfunction in patients with acute aortic dissection type A: data from the German Registry for Acute Aortic Dissection Type A (GERAADA). Eur J Cardiothorac Surg, 2011, 44(2): 557-565.
27.	劉紅, 常謙, 張海濤, 等. 急性 Stanford A 型主動脈夾層術后腦神經系統并發癥的危險因素. 中華胸心血管外科雜志, 2014, 30(6): 342-345.
28.	Merkkola P, Tulla H, Ronkainen A, et al. Incomplete circle of willis and right axillary artery perfusion. Ann Thorac Surg, 2006, 82(1): 74-79.
29.	Papantchev V, Stoinova V, Aleksandrov A, et al. The role of Willis circle variations during unilateral selective cerebral perfusion: a study of 500 circles. Eur J Cardiothorac Surg, 2013, 44(4): 743-753.
30.	Manninen H, M?kinen K, Vanninen R, et al. How often does an incomplete circle of Willis predispose to cerebral ischemia during closure of carotid artery? Postmortem and clinical imaging studies. Acta Neurochirurgica, 2009, 151(9): 1099-1105.
31.	陳述花, 于鐵鏈, 張云亭, 等. 正常國人 Willis 環形態的 MRA 研究. 臨床放射學雜志, 2003, 22(9): 732-736.
32.	Harrer M, Waldenberger FR, Weiss G, et al. Aortic arch surgery using bilateral antegrade selective cerebral perfusion in combination with near-infrared spectroscopy. Eur J Cardiothorac Surg, 2010, 38(5): 561-567.
33.	Misfeld M, Mohr FW, Etz CD. Best strategy for cerebral protection in arch surgery - antegrade selective cerebral perfusion and adequate hypothermia. Ann Cardiothorac Surg, 2013, 2(3): 331-338.
34.	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(3): 402-408.
35.	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(5): 891-897.

1. Aoyagi S, Akashi H, Kubota Y, et al. Surgical treatment of aneurysms of the aortic arch using a simplified selective cerebral perfusion technique. Thorac Cardiovasc Surg, 1994, 42(5): 279-284.
2. Olsson C, Thelin S. Antegrade cerebral perfusion with a simplified technique: unilateral versus bilateral perfusion. Ann Thorac Surg, 2006, 81(3): 868-874.
3. Inamura S, Furuya H, Yagi K, et al. Recent surgical outcomes of acute type-A aortic dissection. Tokai J Exp Clin Med, 2006, 31(3): 109-112.
4. Kr?henbühl ES, Clément M, Reineke D, et al. Antegrade cerebral protection in thoracic aortic surgery: lessons from the past decade. Eur J Cardiothorac Surg, 2010, 38(1): 46-51.
5. Krüger T, Weigang E, Hoffmann I, et al. 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(4): 434-443.
6. 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(5): 1502-1508.
7. 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(6): 1917-1920.
8. 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.e1.
9. Zierer A, Risteski P, El-Sayed Ahmad A, et al. 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(4): 1212-1218.
10. Preventza O, Simpson KH, Cooley DA, et al. Unilateral versus bilateral cerebral perfusion for acute type a aortic dissection. Ann Thorac Surg, 2015, 99(1): 80-87.
11. El-Sayed Ahmad A, Papadopoulos N, Risteski P, et al. The standardized concept of moderate-to-mild (≥28℃) systemic hypothermia during selective antegrade cerebral perfusion for? All-comers in aortic arch surgery: single-center experience in 587 consecutive patients over a 15-year period. Ann Thorac Surg, 2017, 104(1): 49-55.
12. 孫立忠, 田良鑫, 程衛平, 等. 單側與雙側順行性腦灌注的前瞻性隨機對照研究. 中華胸心血管外科雜志, 2005, 21(3): 154-156.
13. 王志維, 胡小平, 吳紅兵, 等. 單、雙側順行腦灌注在主動脈病變深低溫停循環手術中的效果比較. 中華胸心血管外科雜志, 2010, 26(1): 20-22.
14. 董國華, 許飚, 景華, 等. 單側與雙側選擇性順行腦灌注對 DeBakeyⅠ型主動脈夾層分離雜交手術患者神經功能的影響-前瞻性隨機對照研究. 國際腦血管病雜志, 2011, 19(12): 890-895.
15. 趙小寧, 喬晨暉, 羅鴻, 等. 選擇性單側與雙側腦灌注在急性 Stanford A 型夾層矯治術中的應用效果對比分析. 河南醫學研究, 2014, 23(12): 63-65.
16. 鄧宏平. 單、雙側腦灌注技術在主動脈外科手術中腦保護效果的比較. 武漢大學學報(醫學版), 2016, 37(1): 127-130.
17. Krahenbühl, Eva S, Immer FF, Stalder M, et al. Temporary neurological dysfunction after surgery of the thoracic aorta: a predictor of poor outcome and impaired quality of life. Eur J Cardiothorac Surg, 2008, 33(6): 1025-1029.
18. Zierer A, El-Sayed Ahmad A, Papadopoulos N, et al. Selective antegrade cerebral perfusion and mild (28℃-30℃) systemic hypothermic circulatory arrest for aortic arch replacement: Results from 1002 patients. J Thorac Cardiovasc Surg, 2012, 144(5): 1042-1050.
19. Urbanski PP, Raad M, Lenos A, et al. Open aortic arch replacement in the era of endovascular techniques. Eur J Cardiothorac Surg, 2013, 44(3): 431-437.
20. Lindsay H, Srinivas C, Djaiani G. Neuroprotection during aortic surgery. Best Pract Res Clin Anaesthesiol, 2016, 30(3): 283-303.
21. Di Mauro M, Iaco AL, Di Lorenzo C, et al. Cold reperfusion before rewarming reduces neurological events after deep hypothermic circulatory arrest. Eur J Cardiothorac Surg, 2013, 43(1): 168-173.
22. Yan TD, Tian DH, LeMaire SA, et al. The ARCH Projects: design and rationale (IAASSG 001). Eur J Cardiothorac Surg, 2014, 45(1): 10-16.
23. Estrera AL, Miller CC, Lee TY, et al. Ascending and transverse aortic arch repair: The impact of retrograde cerebral perfusion. Circulation, 2008, 118(14_suppl_1): S160-S166.
24. Eusanio MD, Pantaleo A, Petridis FD, et al. Impact of different cannulation strategies on in-hospital outcomes of aortic arch surgery: A propensity-score analysis. Ann Thorac Surg, 2013, 96(5): 1656-1663.
25. Tang GHL, Kai M, Malekan R, et al. Trifurcated graft replacement of the aortic arch: State of the art. J Thorac Cardiovasc Surg, 2015, 149(2): S55-S58.
26. Conzelmann LO, Hoffmann I, Blettner M, et al. Analysis of risk factors for neurological dysfunction in patients with acute aortic dissection type A: data from the German Registry for Acute Aortic Dissection Type A (GERAADA). Eur J Cardiothorac Surg, 2011, 44(2): 557-565.
27. 劉紅, 常謙, 張海濤, 等. 急性 Stanford A 型主動脈夾層術后腦神經系統并發癥的危險因素. 中華胸心血管外科雜志, 2014, 30(6): 342-345.
28. Merkkola P, Tulla H, Ronkainen A, et al. Incomplete circle of willis and right axillary artery perfusion. Ann Thorac Surg, 2006, 82(1): 74-79.
29. Papantchev V, Stoinova V, Aleksandrov A, et al. The role of Willis circle variations during unilateral selective cerebral perfusion: a study of 500 circles. Eur J Cardiothorac Surg, 2013, 44(4): 743-753.
30. Manninen H, M?kinen K, Vanninen R, et al. How often does an incomplete circle of Willis predispose to cerebral ischemia during closure of carotid artery? Postmortem and clinical imaging studies. Acta Neurochirurgica, 2009, 151(9): 1099-1105.
31. 陳述花, 于鐵鏈, 張云亭, 等. 正常國人 Willis 環形態的 MRA 研究. 臨床放射學雜志, 2003, 22(9): 732-736.
32. Harrer M, Waldenberger FR, Weiss G, et al. Aortic arch surgery using bilateral antegrade selective cerebral perfusion in combination with near-infrared spectroscopy. Eur J Cardiothorac Surg, 2010, 38(5): 561-567.
33. Misfeld M, Mohr FW, Etz CD. Best strategy for cerebral protection in arch surgery - antegrade selective cerebral perfusion and adequate hypothermia. Ann Cardiothorac Surg, 2013, 2(3): 331-338.
34. 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(3): 402-408.
35. 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(5): 891-897.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Unilateral versus bilateral antegrade selective cerebral perfusion technique in aortic surgery: A systematic review and meta-analysis

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