Unilateral Antegrade Cerebral Perfusion And Retrograde Cerebral Perfusion In Acute Stanford Type A Aortic Dissection Comparison Of Brain Protection Effect

Objective To analyze and compare the brain protection effects after unilateral anterograde cerebral perfusion(ACP)via axillary artery and retrograde cerebral perfusion(RCP)via superior vena cava during deep hypothermic circulatory arrest(DHCA)in acute Stanford A type aortic dissection(ATAAD)surgery,so as to evaluate the brain protection effects of unilateral anterograde cerebral perfusion and retrograde cerebral perfusion,so as to formulate a better operation plan for patients and improve the prognosis and quality of life of patients.Methods A retrospective analysis of 127 cases of acute Stanford type A aortic dissection treated surgically in our Heart Large Vessel Disease Center from August 2019 to January 2021 was performed.After exclusion according to the exclusion criteria,a total of 109 cases remained,of which 41 cases received simultaneous unilateral anterograde cerebral perfusion(u-ACP)through the axillary artery for cerebral protection as DHCA group in ATAAD surgery.During the operation,68 cases of DHCA were also protected with RCPs passing through the superior vena cava as the RCP group.Preoperative symptomatic treatments including control of blood pressure,heart rate,analgesia,and absolute bed rest were given.All operations were performed by the same operator.There was no significant difference in anesthesia and cardiopulmonary bypass during the operation,except for the difference in brain perfusion mode during DHCA.Ventilators were regularly used to assist breathing in the early postoperative period.Vasoactive drugs were used to maintain stable circulation.Psychological care was given immediately after awakening,and appropriate analgesia was carried out according to the general situation of patients.Patients’ data were collected and compared between the two groups in terms of age,cardiopulmonary bypass(CPB)time,DHCA time,surgical incision,postoperative ICU stay time,hospital stay,and the presence of permanent neurological dysfunction(PND)or transient neurological dysfunction(TND),right upper limb numbness or motor dysfunction(no other manifestations),etc.SPSS 24.0was used for data entry and statistical analysis.Results A total of 109 patients were included in the study,including 41 cases in the ACP group and 68 cases in the RCP group.In terms of age distribution,there were 9patients(22%)over 60 years old in the ACP group and 34 patients(50%)over 60 years old in the RCP group.Ages 27–69 years in the ACP group and 28–90 years in the RCP group.There was a difference between the two groups(P < 0.05).The CPB time in the ACP group was 169–360 min,with an average of(239.71±40.77min).The CPB time in the RCP group was 141–323 min,with an average of(213.06±35.25min).The CPB time in the RCP group was 141–323 min,with an average of(213.06±35.25min).There was a difference in CPB time between the two groups(P < 0.05).In DHCA time,ACP group included 29 cases(70.7%)within 38 min and 12 cases(29.3%)exceed38min.52 cases(76.5%)in the RCP group within 38min(inclusive)were higher than16 cases(23.5%)exceed 38 min.There was no significant difference in DHCA time between the two groups(P > 0.05).In terms of surgical incision,axillary artery intubation was performed in all patients in the ACP group,and all patients in this group had more right subclavian incision than those in the RCP group.One case in ACP group developed numbness in the right upper limb after surgery(no other site manifestation).The ICU stay time after surgery in the ACP group was from 1 to 28 days,with an average of(7.22±5.89)days.The ICU stay time after surgery in the RCP group was from 2 to 33 days,with an average of(8.37±6.25)days.There was no significant difference between the two groups(P > 0.05).The hospitalization time of ACP group was 12 – 57 days,with an average of(27.24 ± 10.54)days.Two cases who were hospitalized for 57 days were all due to postoperative incision infection.The hospitalization time of RCP group was 12-46 days,with an average of(24.97±7.22)days.There was no significant difference in hospital stay between the two groups(P >0.05).In the ACP group,seven cases(17.1%)experienced varying degrees of delirium,cognitive dysfunction,irritability and anxiety after surgery,and all the symptoms disappeared after symptomatic treatment and before discharge.Two cases(4.9%)had hemiplegia after operation,and the cranial CT examination clearly indicated the existence of cerebral infarction.In the RCP group,11 cases(16.2%)experienced varying degrees of delirium and irritability and anxiety after surgery,and all the symptoms disappeared after symptomatic treatment and before discharge.Three cases(4.4%)experienced deep coma after operation.Head CT examination of two cases revealed massive cerebral infarction,and the other one refused to undergo head CT examination.There was no significant difference in the incidence of postoperative TND and PND between the two groups(P > 0.05).Conclusion 1.In acute Stanford A aortic dissection,retrograde cerebral perfusion via superior vena cava intubation or unilateral anterograde cerebral perfusion via axillary artery intubation while deep hypothermic circulatory arrest had no significant effect on the occurrence of permanent and transient neurological dysfunction after surgery.2.DHCA combined with RCP is a feasible cerebral protection method in acute Stanford type A aortic dissection surgery,and has similar cerebral protection effect with DHCA combined with u-ACP.3.Simultaneous RCP or ACP with DHCA in ATAAD surgery has little impact on postoperative ICU stay,hospital stay,and mortality.