Safety of prolonged bilateral antegrade cerebral perfusion in aortic arch surgery with moderate hypothermia.

Objectives: This study investigates the impact of bilateral antegrade cerebral perfusion time on outcomes in aortic arch surgery.

Methods: In total, 961 patients underwent either hemi arch (n = 385) or total arch replacement (n = 576) with bilateral antegrade cerebral perfusion and moderate hypothermia management between 2006 and 2020 across 2 aortic centers. Antegrade cerebral perfusion time was categorized into 4 groups (≤30 min: n = 169, 30-60min: n = 298, 60-90min: n = 261, >90min: n = 233). Inverse probability treatment weighting yielded a well-balanced cohort among the 4 groups except for the cannulation site. Adjusted cubic spline and multivariable logistic analysis were performed, controlling for surgical procedure, cannulation site and cardiopulmonary bypass time, to identify the relationship between antegrade cerebral perfusion time and major in-hospital complications including mortality, stroke, acute renal failure, and prolonged ventilation.

Results: There remained a significant difference in surgical procedures and cardiopulmonary bypass time in the matched cohort. The incidences of mortality and stroke did not show significant trend (P = 0.052 and P = 0.717 respectively). Cubic spline curves showed that odds ratios did not increase linearly for any complications with increasing antegrade cerebral perfusion time. Furthermore, antegrade cerebral perfusion time, even exceeding 90 min, was not associated with complication rates (mortality: odds ratio = 1.459 [0.368-6.049], p = 0.595; stroke: 0.310 [0.058-1.635], p = 0.166; renal failure: 1.744 [0.521-6.094], p = 0.374; prolonged ventilation: 1.502 [0.535-4.286], p = 0.442), whereas cardiopulmonary bypass time was associated with mortality and prolonged ventilation.

Conclusions: Even when antegrade cerebral perfusion time exceeded 90 min, it was not associated with major in-hospital complications, questioning its validity as a marker for surgical insult.