title: Antegrade versus retrograde cerebral perfusion for hemiarch replacement with deep hypothermic circulatory arrest: does it matter? A propensity-matched analysis.
abstract: OBJECTIVE
  The choice of cerebral perfusion strategy for aortic arch surgery has been debated, and the superiority of antegrade (ACP) or retrograde (RCP) cerebral perfusion has not been shown. We examined the early and late outcomes for ACP versus RCP in proximal (hemi-) arch replacement using deep hypothermic circulatory arrest (DHCA).
  
  
  METHODS
  A retrospective analysis of a prospectively maintained database was performed for all patients undergoing elective and nonelective hemiarch replacement at a single referral institution from June 2005 to February 2013. Total arch cases were excluded to limit the analysis to shorter DHCA times and a more uniform patient population for whom clinical equipoise regarding ACP versus RCP exists. A total of 440 procedures were identified, with 360 (82%) using ACP and 80 (18%) using RCP. The endpoints included 30-day/in-hospital and late outcomes. A propensity score with 1:1 matching of 40 pre- and intraoperative variables was used to adjust for differences between the 2 groups.
  
  
  RESULTS
  All 80 RCP patients were propensity matched to a cohort of 80 similar ACP patients. The pre- and intraoperative characteristics were not significantly different between the 2 groups after matching. No differences were found in 30-day/in-hospital mortality or morbidity outcomes. The only significant difference between the 2 groups was a shorter mean operative time in the RCP cohort (P = .01). No significant differences were noted in late survival (P = .90).
  
  
  CONCLUSIONS
  In proximal arch operations using DHCA, equivalent early and late outcomes can be achieved with RCP and ACP, although the mean operative time is significantly less with RCP, likely owing to avoidance of axillary cannulation. Questions remain regarding comparative outcomes with straight DHCA and lesser degrees of hypothermia.
authors.affiliation: Duke Center for Aortic Disease, Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC.
authors.forename: Asvin M
authors.initials: AM
authors.lastname: Ganapathi
authors.affiliation: Duke Center for Aortic Disease, Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC.
authors.forename: Jennifer M
authors.initials: JM
authors.lastname: Hanna
authors.affiliation: Duke Center for Aortic Disease, Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC.
authors.forename: Matthew A
authors.initials: MA
authors.lastname: Schechter
authors.affiliation: Duke Center for Aortic Disease, Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC.
authors.forename: Brian R
authors.initials: BR
authors.lastname: Englum
authors.affiliation: Duke Center for Aortic Disease, Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC.
authors.forename: Anthony W
authors.initials: AW
authors.lastname: Castleberry
authors.affiliation: Duke Center for Aortic Disease, Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC.
authors.forename: Jeffrey G
authors.initials: JG
authors.lastname: Gaca
authors.affiliation: Duke Center for Aortic Disease, Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC. Electronic address: gchad.hughes@duke.edu.
authors.forename: G Chad
authors.initials: GC
authors.lastname: Hughes
mesh_terms: D000328:Adult; D000368:Aged; D000784:Aortic Dissection / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D001013:Aorta, Thoracic / Q000503:physiopathology / Q000601:surgery*; D017545:Aortic Aneurysm, Thoracic / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D001019:Aortic Rupture / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000401:mortality; D002560:Cerebrovascular Circulation; D016009:Chi-Square Distribution; D050792:Circulatory Arrest, Deep Hypothermia Induced / Q000009:adverse effects / Q000401:mortality; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D010477:Perfusion / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D057216:Propensity Score; D012042:Registries; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome