Safety and efficacy of retrograde cerebral perfusion as an adjunct for cerebral protection during surgery on the aortic arch

Objective: The best adjunct for cerebral protection during aortic arch reconstruction remains controversial. Retrograde cerebral perfusion (RCP) as an adjunct to profound hypothermic circulatory arrest (PHCA) extends the tolerable period of brain ischemia by flushing emboli and air from the cerebral circulation while maintaining hypothermia. We examined our experience with RCP to determine its efficacy in patients undergoing complex arch reconstruction. Methods: We retrospectively evaluated 879 patients undergoing arch reconstruction using RCP from July 1997 to March 2013. Perioperative risk factors were analyzed as predictors of neurologic injury and mortality. Survival for the type of arch reconstruction and for the interval of PHCA was calculated. Results: Of the 879 patients, 671 underwent hemiarch and 208 total arch replacement. The mean age was 65 +/- 13.3 years, and 61.6% were men. The total arch patients had longer mean periods of PHCA (39 vs 21 minutes, P < .001) and RCP (37 vs 19 minutes, P < .001). However, the incidence of transient neurologic dysfunction (3.0% vs 2.4%, P < .813) and permanent neurologic dysfunction (1.3% vs 1.9%, P < .519) was similar for both techniques. Mortality was greater in the hemiarch group (4.8% vs 0.5%, P < .003). Patients requiring >40 minutes of PHCA had outcomes similar to those requiring less. The 1-, 5-, and 10- year survival was similar, regardless of the procedure performed or interval of PHCA. Conclusions: RCP is a safe and effective adjunct for cerebral protection during arch surgery. Patients requiring more extensive arch reconstruction are not at greater risk of permanent neurologic dysfunction or perioperative mortality.