Pressure level required during prolonged cerebral perfusion time has no impact on neurological outcome: a propensity score analysis of 800 patients undergoing selective antegrade cerebral perfusion.

Abstract

Operating on the aortic arch is a surgical challenge involving various periods of circulatory arrest. Deep hypothermia is used to protect the brain. Selective antegrade cerebral perfusion (SACP) is employed to protect the brain and enable cerebral ischaemia time to be prolonged. However, there is no standardized SACP protocol. Our centre has performed flow- and pressure-controlled bilateral antegrade cerebral perfusion since 1999. The aim of this study was to investigate the potential relationship between perfusion pressure and neurological outcome, and to examine whether the selective application of higher cerebral perfusion pressure results in better neurological outcomes. Prospectively recorded data of 800 patients undergoing selective cerebral perfusion during aortic surgery were collected. Using stratification, patients were clustered into three subgroups according to the postoperative neurological complication severity to assess any differences in antegrade cerebral perfusion pressure or flow. Furthermore, using the cluster analysis, a total of 50 patients were selected for a high cerebral perfusion group and another 51 patients for a low cerebral perfusion group. A propensity score was used to 're-randomize' the two groups to evaluate comparability. Finally, statistical analyses of the postoperative neurological outcome were performed. Flow-managed, pressure-controlled cerebral perfusion provided sufficient cerebral tissue perfusion. We observed no association between antegrade cerebral perfusion conditions and the rate of neurological complications after stratifying all patients in the three subgroups. There was no difference in the rate of neurological complication between the groups with high (mean: 79.61 ± 14.97 mmHg) versus low (mean: 53.64 ± 12.09 mmHg) selective cerebral perfusion pressure, either. We hereby present SACP data as a real-time curve, based on a large patient cohort containing a total of 800 patients. Our perfusion strategy employing a lower selective cerebral perfusion pressure (∼50 vs ∼80 mmHg) is not associated with a higher rate of neurological complications during aortic surgery. This finding demonstrates that this perfusion strategy is a safe protocol in a clinical setting for a large cohort.