Commentary: Antegrade cerebral perfusion versus retrograde cerebral perfusion: If only it was that easy

Central MessageThe interplay of temperature, cerebral perfusion, and circulatory arrest time remains critically important to neurologic outcomes, with differences in both benefits risks across them.See Article page XXX. The them. See Cerebral protection the crux aortic surgery involving arch and, not surprisingly, cerebral-protection strategies have been topic passionate debate intense research from onset deep hypothermia. Multiple approaches developed achieve goal preservation, but past 15 years seen a strong emphasis antegrade perfusion (ACP) for protection. Despite this trend, retrograde (RCP) use has only persisted also experienced resurgence over last 5 years. This suggests that, despite individual biases, there are likely roles antegrade, retrograde, as well potentially mixed field progresses. In issue Journal, Brown colleagues1Brown J.A. Navid F. Serna-Gallegos D. Aranda-Michel E. Wang Y. Bianco V. et al.Long-term outcomes hemiarch replacement hypothermic perfusion.J Thorac Cardiovasc Surg. August 3, 2021; ([Epub ahead print])Abstract Full Text PDF Scopus (2) Google Scholar Pittsburgh present an impressive single-institution series evaluating strategy at 20°C during proximal dissection aneurysmal disease. overall stroke rate 4.6% cohort (2.6% aneurysm, 6.8% dissection), low perioperative mortality 5-year survival above 80% admirable. Importantly, study demonstrates importance expediency arrest, increased rates (9.0% vs 2.0%) (13.5% 3.1%) when duration crosses 23-minute threshold. These results encouraging validate isolated RCP 20°C. authors allude complexity astutely highlight 3 major variables involved what can be called triangle protection; nadir approach, (Figure 1). these is respect each providing risks. Many surgeons would argue that associated prolonged bypass complicate coagulation, preferring warmer temperatures. Other embolic washout RCP, it may sufficient long times so ACP should considered any possibility ischemia, such more complicated or unpredictable repair. Outside single surgeon Yale who does well, most surgeons, Society Thoracic Surgeons database, agree straight avoided whenever possible. literature become riddled single-centered successes specific combinations sporadic way, which makes development firm guidelines difficult. Every must decide combination work best them their patients commit perfecting technique group here. this, we complacent resistant “thinking outside triangle.” Emerging approaches, followed by temperatures, promising eventually prove worlds. Only time, well-designed studies, will tell. Long-term perfusionThe Journal Cardiovascular SurgeryPreviewThis sought report secondarily, operative approach type underlying Full-Text