title: Integrated cerebral protection: combined antegrade and retrograde cerebral perfusion during deep hypothermic circulatory arrest.
abstract: OBJECTIVE
  Aortic arch surgery requires temporary interruption of cerebral perfusion. Hypothermic circulatory arrest (HCA) is an established method of central nervous system protection for limited periods of absent cerebral blood flow. Adjuncts to increase the safe duration of circulatory arrest include either retrograde cerebral perfusion (RCP) or antegrade cerebral perfusion (ACP), with most complex aortic operations now performed using HCA with ACP. We reasoned that optimal cerebral protection might be achieved with a combination of ACP and RCP (integrated brain protection) and present an early clinical experience that supports this approach.
  
  
  METHODS
  The integrated brain protection strategy included sequential overlapping periods of RCP, ACP, and RCP during HCA. Moderate systemic hypothermia (25°C) was used. Patient data were gathered through retrospective chart review.
  
  
  RESULTS
  Between 2008 and 2009, six consecutive patients underwent ascending aortic graft replacement for acute type A dissection using HCA and integrated brain protection. The mean minimum systemic temperature was 22.9 ± 1.8°C, the mean total HCA time was 34 ± 5 minutes, and the mean duration of ACP and RCP was 22 ± 6 and 7 ± 5 minutes, respectively. Patients were awake and followed commands 10.1 ± 3.4 (range, 5-13) hours after operation, and there was no evidence of temporary neurologic dysfunction. There was no operative mortality.
  
  
  CONCLUSIONS
  Integrated brain protection using both RCP and ACP during HCA is a promising approach for the safe performance of complex aortic surgery and is worthy of evaluation in larger clinical series.
authors.affiliation: Division of Cardiac Surgery, University of Maryland Medical Center, Baltimore, MD 21201, USA. jgammie@smail.umaryland.edu
authors.forename: James S
authors.initials: JS
authors.lastname: Gammie
authors.forename: Britney
authors.initials: B
authors.lastname: Landree
authors.forename: Bartley P
authors.initials: BP
authors.lastname: Griffith