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Cerebral protection in acute type A aortic dissection surgery: a systematic review and meta-analysis - PubMed

  • ️Mon Jan 01 2024

Cerebral protection in acute type A aortic dissection surgery: a systematic review and meta-analysis

Mehran Rahimi et al. J Thorac Dis. 2024.

Abstract

Background: Acute type A aortic dissection (ATAAD) still challenges physicians and warrants emergent surgical management. Two main methods to reduce cerebrovascular events in ATAAD surgeries are antegrade cerebral perfusion (ACP) and retrograde cerebral perfusion (RCP). We conducted a systematic review and meta-analysis to compare the outcomes of ACP and RCP methods during the ATAAD surgery.

Methods: In this study, we searched the databases until March 29th, 2023. Studies that reported the data for comparison of different types of brain perfusion protection during aortic surgery in patients with ATAAD were included.

Results: Twenty-six studies met the eligibility criteria. All studies had a low risk of bias as they were evaluated by the Joanna Briggs Institute (JBI) critical appraisal tool. Eventually, we included 26 studies in the current meta-analysis, and a total of 13,039 patients were evaluated. The calculated risk ratio (RR) for permanent neurologic dysfunction (PND) in ACP and RCP comparison was RR =1.23, 95% confidence interval (CI): (0.84, 1.80) (P value =0.2662), and in unilateral ACP (uACP) and bilateral ACP (bACP) was RR =1.2786, 95% CI: (0.7931, 2.0615) (P value =0.3132). When comparing the ACP-RCP and uACP-bACP groups, significant differences were found between ACP-RCP the groups in terms of circulatory arrest time (P value =0.0017 and P value =0.1995, respectively), cardiopulmonary bypass time (P value =0.5312 and P value =0.7460, respectively), intensive care unit (ICU)-stay time (P value =0.2654 and P value =0.0099), crossclamp time (P value =0.6228 and P value =0.2625), and operative mortality (P value =0.9368 and P value =0.2398, respectively), and when comparing the u-ACP and b-ACP groups for transient neurologic deficit (TND), an RR of 1.32, 95% CI: (1.05, 1.67) (P value =0.0199). The results showed high heterogeneity and no publication bias.

Conclusions: This study demonstrated that the ACP and RCP are both safe and acceptable techniques to use in emergent settings. The uACP technique is equivalent to bACP in terms of PND and mortality, however, uACP is preferred over bACP in terms of TND.

Keywords: Dissection; ascending aorta; cardiac surgical procedures; cardiopulmonary bypass (CPB); neurologic manifestations.

2024 Journal of Thoracic Disease. All rights reserved.

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Conflict of interest statement

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-23-1039/coif). The authors have no conflicts of interest to declare.

Figures

Figure 1
Figure 1

PRISMA flow chart. *, review articles, insufficient data, irrelevant articles, and other types of surgery methods. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Figure 2
Figure 2

CPB time in ACP vs. RCP. (A) The forest plot demonstrated that there is no significant difference between the groups. (B) The funnel plot is symmetrical. ACP, antegrade cerebral perfusion; RCP, retrograde cerebral perfusion; SD, standard deviation; MD, mean difference; CI, confidence interval; CPB, cardiopulmonary bypass.

Figure 3
Figure 3

CPB time in uACP vs. bACP. (A) The forest plot demonstrated that there is no significant difference between the groups. (B) The funnel plot is symmetrical. uACP, unilateral antegrade cerebral perfusion; bACP, bilateral antegrade cerebral perfusion; SD, standard deviation; MD, mean difference; CI, confidence interval; CPB, cardiopulmonary bypass.

Figure 4
Figure 4

CA time in ACP vs. RCP. (A) The forest plot demonstrated that CA time is significant between the groups. (B) The funnel plot is symmetrical. ACP, antegrade cerebral perfusion; RCP, retrograde cerebral perfusion; SD, standard deviation; MD, mean difference; CI, confidence interval; CA, circulatory arrest.

Figure 5
Figure 5

CA time in uACP vs. bACP. (A) The forest plot demonstrated that there is no significant difference between the groups. (B) The funnel plot is symmetrical. uACP, unilateral antegrade cerebral perfusion; bACP, bilateral antegrade cerebral perfusion; SD, standard deviation; MD, mean difference; CI, confidence interval; CA, circulatory arrest.

Figure 6
Figure 6

CCT in ACP vs. RCP. (A) The forest plot demonstrated that there is no significant difference between the groups. (B) The funnel plot is symmetrical. (C) The meta-regression of age and CCT estimated that there is an insignificant difference between the groups. ACP, antegrade cerebral perfusion; RCP, retrograde cerebral perfusion; SD, standard deviation; MD, mean difference; CI, confidence interval; CCT, cross-clamp time.

Figure 7
Figure 7

CCT in uACP vs. bACP. (A) The forest plot demonstrated that there is no significant difference between the groups. (B) The funnel plot is symmetrical. (C) The meta-regression of age and CCT estimated that there is a significant difference between the groups. uACP, unilateral antegrade cerebral perfusion; bACP, bilateral antegrade cerebral perfusion; SD, standard deviation; MD, mean difference; CI, confidence interval; CCT, cross-clamp time.

Figure 8
Figure 8

ICU-stay time in ACP vs. RCP. (A) The forest plot demonstrated that there is no significant difference between the groups. (B) The funnel plot is symmetrical. (C) The meta-regression age and ICU-stay time demonstrated that there is insignificant change between the groups. ACP, antegrade cerebral perfusion; RCP, retrograde cerebral perfusion; SD, standard deviation; MD, mean difference; CI, confidence interval; ICU, intensive care unit.

Figure 9
Figure 9

ICU-stay time in uACP vs. bACP. (A) The forest plot demonstrated that ICU-stay time is significantly different between the groups. (B) The funnel plot is symmetrical. (C) The meta-regression of age and ICU-stay time estimated that there is a significant change between the groups. uACP, unilateral antegrade cerebral perfusion; bACP, bilateral antegrade cerebral perfusion; SD, standard deviation; MD, mean difference; CI, confidence interval; ICU, intensive care unit.

Figure 10
Figure 10

TND in ACP vs. RCP. (A) The forest plot demonstrated that there is no significant difference between the groups. (B) The funnel plot is symmetrical. ACP, antegrade cerebral perfusion; RCP, retrograde cerebral perfusion; RR, risk ratio; CI, confidence interval; TND, transient neurologic deficit.

Figure 11
Figure 11

TND in uACP vs. bACP. (A) The forest plot demonstrated that TND is significantly different between the groups. (B) The funnel plot is symmetrical. uACP, unilateral antegrade cerebral perfusion; bACP, bilateral antegrade cerebral perfusion; RR, risk ratio; CI, confidence interval; TND, transient neurologic deficit.

Figure 12
Figure 12

PND in ACP vs. RCP. (A) The forest plot demonstrated that there is no significant difference between the groups. (B) The funnel plot is symmetrical. ACP, antegrade cerebral perfusion; RCP, retrograde cerebral perfusion; RR, risk ratio; CI, confidence interval; PND, permanent neurologic deficit.

Figure 13
Figure 13

PND in uACP vs. bACP. (A) The forest plot demonstrated that there is no significant difference between the groups. (B) The funnel plot is symmetrical. uACP, unilateral antegrade cerebral perfusion; bACP, bilateral antegrade cerebral perfusion; RR, risk ratio; CI, confidence interval; PND, permanent neurologic deficit.

Figure 14
Figure 14

Operative mortality in ACP vs. RCP. (A) The forest plot demonstrated that there is no significant difference between the groups. (B) The funnel plot is symmetrical. ACP, antegrade cerebral perfusion; RCP, retrograde cerebral perfusion; RR, risk ratio; CI, confidence interval.

Figure 15
Figure 15

Operative mortality in uACP vs. bACP. (A) The forest plot demonstrated that there is no significant difference between the groups. (B) The funnel plot is symmetrical. uACP, unilateral antegrade cerebral perfusion; bACP, bilateral antegrade cerebral perfusion; RR, risk ratio; CI, confidence interval.

Figure 16
Figure 16

Core temperature in ACP vs. RCP. (A) The forest plot demonstrated that core temperature is significantly different between the groups. (B) The funnel plot is symmetrical. ACP, antegrade cerebral perfusion; RCP, retrograde cerebral perfusion; SD, standard deviation; MD, mean difference; CI, confidence interval.

Figure 17
Figure 17

Core temperature in uACP vs. bACP. (A) The forest plot demonstrated that there is no significant difference between the groups. (B) The funnel plot is symmetrical. uACP, unilateral antegrade cerebral perfusion; bACP, bilateral antegrade cerebral perfusion; SD, standard deviation; MD, mean difference; CI, confidence interval.

Figure 18
Figure 18

Operation time in uACP vs. bACP. (A) The forest plot demonstrated that there is no significant difference between the groups. (B) The funnel plot is symmetrical. uACP, unilateral antegrade cerebral perfusion; bACP, bilateral antegrade cerebral perfusion; SD, standard deviation; MD, mean difference; CI, confidence interval.

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