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(Circulation. 2008;118:S160-S166.)
© 2008 American Heart Association, Inc.

Surgery for Aortic Diseases

Ascending and Transverse Aortic Arch Repair

The Impact of Retrograde Cerebral Perfusion

Anthony L. Estrera, MD; Charles C. Miller, III, PhD; Taek-Yeon Lee, MD; Pallav Shah, MD; Hazim J. Safi, MD

From the Department of Cardiothoracic and Vascular Surgery, The University of Texas at Houston Medical School, Memorial Hermann Heart and Vascular Institute, Houston, Texas.

Correspondence to Anthony L. Estrera, MD, Department of Cardiothoracic and Vascular Surgery, The University of Texas Houston Medical School, 6410 Fannin, Suite 425, Houston, TX 77030. E-mail anthony.l.estrera{at}uth.tmc.edu

Background— The benefit of retrograde cerebral perfusion (RCP) with profound hypothermic circulatory arrest has been subject to much debate. We examined our experience with ascending and transverse arch repairs to determine the impact of retrograde cerebral perfusion on stroke and mortality.

Methods and Results— Between August 1991 and June 2007, we performed 1107 repairs of the ascending and transverse aortic arch. RCP was used in 82% of cases (907 of 1107). Sixty-two percent were men (682 of 1107); median age was 64 years (range, 16 to 93 years). Perioperative variables were evaluated using univariate and multivariable analysis for mortality and stroke. Thiry-day mortality was 10.4% (115 of 1107). Stroke occurred in 2.8% (31 of 1107) of patients. Univariate risk factors for mortality were increasing age (P<0.0001), history of coronary artery disease (P=0.02), previous coronary artery bypass (P=0.02), emergency status (P<0.0001), acute dissection (P=0.02), rupture (P=0.0001), preoperative glomerular filtration rate, bypass time (P<0.0001), crossclamp time (P<0.007), RCP time (P<0.0001), and packed red blood cell transfusions (P=0.0001). Univariate risk factors for stroke included emergency status (P<0.02), cerebrovascular disease (P<0.02), and crossclamp time (P<0.04). Independent risk factors for mortality were glomerular filtration rate <90 mL/min (P=0.0004), emergency status (P=0.006), rupture (P=0.004), cardiopulmonary bypass time >120 minutes (P<0.04), and packed red blood cell transfusions (P=0.0002). Risk factors for stroke were emergency status (P<0.009) and hypertension (P<0.05). RCP was protective against mortality and stroke.

Conclusions— The use of RCP with profound hypothermic circulatory arrest was associated with a reduction in mortality and stroke. The use of RCP remains warranted during repairs of the ascending and transverse aortic arch.

Key Words: aortic arch • cerebral protection • circulatory arrest • perfusion • surgery