Variation in techniques of selective antegrade cerebral perfusion in neonates undergoing aortic arch reconstruction - a comprehensive review.

Background: Despite the widespread adoption of selective antegrade cerebral perfusion (SACP) for neonatal aortic arch reconstruction, significant variability in techniques persists across institutions, reflecting limited supporting data and lack of consensus on best practices. This review aims to comprehensively characterize the utilization of SACP in the extant literature and highlight variation in practice to guide future research and standardization of care.

Methods: A comprehensive search was conducted using Embase, Medline/OVID, and NCBI/PubMed databases to identify studies published from 1999-2024 that contained the following terms: ('neonatal' OR 'neonate' OR 'newborn') AND ('aortic arch' OR 'Norwood' OR 'stage one') AND ('circulatory arrest' OR 'cerebral perfusion'). Studies were included if they were human studies, with ≥10 patients, and with description of SACP flow rates and at least one other parameter.

Results: Based on the specified search terms, following removal of duplicate studies, 845 manuscripts were reviewed. Utilizing the described inclusion criteria, a total of 57 studies were identified and assessed. All studies were published between 2000-2023, and the overall median sample size was 47 patients (interquartile range 24-70). Across these studies, targeted flow rate ranged from 10 to 100 mL/kg/minute, targeted temperature ranged from 18ºC to 34ºC, and there was significant variation in monitoring strategy and response to monitoring.

Conclusions: There persists significant variability in SACP technique in neonatal patients, including flow rate, temperature, and monitoring strategies. Given the critical neurodevelopmental risks associated with this patient population, it is essential to rigorously evaluate and optimize SACP practices in neonates undergoing aortic arch reconstruction.