Effects of four major brain protection strategies during proximal aortic surgery: A systematic review and network meta-analysis.

BACKGROUND

Reliable brain protection during proximal aortic surgery remains a formidable surgical challenge. Various cerebral protection techniques have been used in the clinic; however, there is no consensus regarding which strategy is best. In this network meta-analysis (NMA), we focused on permanent neurological deficits (PND) and perioperative mortality associated with four major brain protection strategies used during proximal aortic surgery.

METHODS

We performed a literature search of the MEDLINE, Embase, Cochrane Library and PubMed databases. The primary outcomes of this analysis were PND and perioperative mortality. Network rank and surface under the cumulative ranking curve (SUCRA) analyses were performed to evaluate and identify the superiority of different brain protection techniques.

RESULTS

Thirty-two studies involving 6772 participants were included in this review. The number of studies that involved DHCA, DHCA + ACP, DHCA + RCP and MHCA + ACP were 16, 19, 23 and 15, respectively. Based on SUCRA analyses, moderate hypothermic circulatory arrest with antegrade cerebral perfusion (MHCA + ACP) was the best choice in terms of PND (predictive probabilities: 77.5), and deep hypothermic circulatory arrest with retrograde cerebral perfusion (DHCA + RCP) was the best choice in terms of mortality (predictive probabilities: 65.4). Deep hypothermic circulatory arrest (DHCA) alone was inferior to the other techniques in terms of both PND and mortality.

CONCLUSIONS

Effective cerebral perfusion should be actively considered. Retrograde perfusion (RCP) can reduce mortality and will not increase risks of PND compared with antegrade perfusion (ACP) when performing DHCA. Moderate hypothermia should be recommended when performing ACP. DHCA + RCP and MHCA + ACP seem to be appropriate brain protection strategies during proximal aortic surgery and more clinical studies involving pairwise comparisons between them are needed.