title: How to Perfuse: Concepts of Cerebral Protection during Arch Replacement.
abstract: Arch surgery remains undoubtedly among the most technically and strategically challenging endeavors in cardiovascular surgery. Surgical interventions of thoracic aneurysms involving the aortic arch require complete circulatory arrest in deep hypothermia (DHCA) or elaborate cerebral perfusion strategies with varying degrees of hypothermia to achieve satisfactory protection of the brain from ischemic insults, that is, unilateral/bilateral antegrade cerebral perfusion (ACP) and retrograde cerebral perfusion (RCP). Despite sophisticated and increasingly individualized surgical approaches for complex aortic pathologies, there remains a lack of consensus regarding the optimal method of cerebral protection and circulatory management during the time of arch exclusion. Many recent studies argue in favor of ACP with various degrees of hypothermic arrest during arch reconstruction and its advantages have been widely demonstrated. In fact ACP with more moderate degrees of hypothermia represents a paradigm shift in the cardiac surgery community and is widely adopted as an emergent strategy; however, many centers continue to report good results using other perfusion strategies. Amidst this important discussion we review currently available surgical strategies of cerebral protection management and compare the results of recent European multicenter and single-center data.
authors.affiliation: Division of Cardiovascular Surgery, University of Pennsylvania Medical Center, Philadelphia, PA 19104, USA ; Department of Cardiac Surgery, Vienna General Hospital, Medical University of Vienna, 1090 Vienna, Austria.
authors.forename: Andreas
authors.initials: A
authors.lastname: Habertheuer
authors.affiliation: Department of Cardiac Surgery, Vienna General Hospital, Medical University of Vienna, 1090 Vienna, Austria.
authors.forename: Dominik
authors.initials: D
authors.lastname: Wiedemann
authors.affiliation: Department of Cardiac Surgery, Vienna General Hospital, Medical University of Vienna, 1090 Vienna, Austria.
authors.forename: Alfred
authors.initials: A
authors.lastname: Kocher
authors.affiliation: Department of Cardiac Surgery, Vienna General Hospital, Medical University of Vienna, 1090 Vienna, Austria.
authors.forename: Guenther
authors.initials: G
authors.lastname: Laufer
authors.affiliation: Division of Cardiovascular Surgery, University of Pennsylvania Medical Center, Philadelphia, PA 19104, USA.
authors.forename: Prashanth
authors.initials: P
authors.lastname: Vallabhajosyula
mesh_terms: D001011:Aorta / Q000503:physiopathology / Q000601:surgery; D001013:Aorta, Thoracic / Q000503:physiopathology / Q000601:surgery*; D017545:Aortic Aneurysm, Thoracic / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D002560:Cerebrovascular Circulation / Q000502:physiology; D050792:Circulatory Arrest, Deep Hypothermia Induced / Q000379:methods*; D017052:Hospital Mortality; D006801:Humans; D010477:Perfusion / Q000379:methods*; D012307:Risk Factors; D016896:Treatment Outcome