Key result
Neuroprotective strategies in aortic surgery show no consistent differences across hypothermia depths or perfusion techniques.
Why the study?
Optimal neuroprotection strategies for aortic arch surgery with circulatory arrest remain debated, and most existing evidence comes from observational studies rather than randomized trials.
Does the degree of hypothermia (deep vs moderate) or cerebral perfusion technique (retrograde vs antegrade) improve neurologic outcomes in patients undergoing aortic arch surgery with circulatory arrest?
Does the degree of hypothermia (deep vs moderate) or cerebral perfusion technique (retrograde vs antegrade) improve neurologic outcomes in patients undergoing aortic arch surgery with circulatory arrest?
Current randomized evidence from 9 trials fails to establish an optimal temperature or cerebral perfusion strategy for neuroprotection during aortic arch surgery with circulatory arrest, highlighting the need for larger trials with long-term follow-up and sensitive neurologic endpoints.
Answers are grounded in this paper and cite their sources.
Clinicians should not alter neuroprotective strategies based on inconsistent RCT data; this leaves open optimal cooling and perfusion choices pending larger trials with sensitive endpoints.
BACKGROUND Optimal neuroprotection strategies for aortic arch surgery continue to be debated among cardiovascular surgeons, and most existing evidence is derived from observational studies. This review provides a summary of current randomized controlled trials that compare neuroprotective strategies for circulatory arrest in aortic surgery. METHODS Randomized trials published from 2000 to 2025 assessing cerebral perfusion, temperature, or both for aortic surgery with circulatory arrest were included and summarized descriptively. RESULTS Nine randomized clinical trials published from 2001 to 2024 were included. Outcomes included structured neurologic tests, brain imaging, biomarkers, and markers of cerebral metabolism. No studies assessed outcomes beyond 1 year. Overall, studies did not demonstrate consistent differences based on degree of hypothermia (deep vs moderate) or cerebral perfusion technique (retrograde vs antegrade). Advanced neurologic assessments, including brain imaging and neurocognitive testing, appeared more sensitive for detecting neurologic injury than conventional clinical outcomes. CONCLUSIONS Based on available randomized evidence, the optimal temperature and cerebral perfusion strategy remain elusive. Most trials are limited by small sample size, and none has long-term (>1 year) follow-up. As current clinical care is largely surgeon or institution specific, future randomized controlled trials would require larger patient cohorts, long term follow-up, and sensitive neurologic endpoints to impact change in clinical practice.
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Bradshaw et al. (2026) conducted a review in Aortic arch surgery with circulatory arrest. Neuroprotection strategies (cerebral perfusion technique and degree of hypothermia) vs. Alternative hypothermia degree (deep vs moderate) or cerebral perfusion technique (retrograde vs antegrade) was evaluated on Structured neurologic tests, brain imaging, biomarkers, and markers of cerebral metabolism. Neuroprotective strategies in aortic surgery showed no consistent differences across 9 RCTs based on hypothermia degree (deep vs moderate) or cerebral perfusion (retrograde vs antegrade).
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