It was with great interest that we read the study by Cai
et al. [
1] comparing unilateral (uACP), bilateral (bACP) and total antegrade cerebral perfusion (tACP) strategies utilized in the management of acute DeBakey type I aortic dissection, Clinical Application of Three Antegrade Cerebral Perfusion Strategies in Acute DeBakey Type I Aortic Dissection’ Heart Surgery Forum 2025; 28(7): E546–E554
doi: 10.59958/hsf.8417.The salient features of the outcome are tabulated below (Table
1). The authors presented insightful findings that indicated total (tACP) had achieved the lowest transient neurological dysfunction, and a better postoperative recovery progress than bACP or uACP, despite having the longest selective cerebral perfusion duration (median = 36 minutes). Our Aortic team started with uACP for all the Aortic surgeries, necessitating antegrade cerebral perfusion and evolved to bACP with moderate hypothermic circulatory arrest (24–28 °C) [
2].
Although this study could pave the way for more comparative studies, the definition and the surgical techniques implemented for different ACP strategies was not very clear. In the surgical technique section, the authors mentioned that the ascending aorta was cannulated in the tACP which would have been difficult unless the description was meant to be different. In the pictorial representation, tACP was demonstrated as having the cannulae in all the major supra-aortic vessels. If this was also done as end to end anastomosis, like they mentioned about the bACP, this was not documented raising the question of how they achieved shortest cardiopulmonary bypass time. In spite of positive results achieved, these findings appear to be arguable as one would expect the bACP to be better than uACP which was not true in this study. Also, conventional surgical principles indicate that extended duration of artificial cerebral perfusion correlate with increased neurological risk, as established in prior literature associating selective cerebral perfusion with neurocognitive decline [
3].
Interestingly, although the transient neurological dysfunction (TND) was the highest in uACP cohort (37.5%) and the lowest in tACP (10.6%), the permanent neurological dysfunction (PND) incidence was paradoxically higher in the bACP cohort (28.6%) compared to both uACP (12.5%) and tACP (17.7%). This contradictory pattern challenges a purely linear interpretation of neurological outcomes and may reflect the multifactorial nature of cerebral injury during these complex surgeries. What may also contribute to this discrepancy may be small sample sizes and the temporal differences between the groups, also with a potential of evolving surgical experience and perioperative management. These observations underscore the need for cautious interpretation of neurological outcomes underlying the importance of larger, carefully controlled studies to elucidate how nuances in perfusion and patient factors collectively influence both transient and permanent neurological outcomes in acute DeBakey type I aortic dissection repair.
One could justify that results of Cai
et al. [
1] group be due to better learning curve and evolving with complete cerebral coverage and meticulous techniques. The transition of uACP strategy to bACP and even tACP with good numbers emphasize the surgical complexity and perfusion management that has evolved overtime.
The authors were transparent about limitations that contextualize their positive findings. The unilateral ACP (uACP) group was relatively smaller in contrast to others (n = 28), potentially introducing a selection bias that brought about exaggerated observed differences in TND. Additionally, each perfusion strategy was implemented across different time periods (uACP: 2020, bACP: 2021–2022, tACP: 2023–2024, introducing a confounding ‘time bias’ as surgical techniques, anesthesia, perfusion management, and postoperative care may have improved overtime. The authors mitigated these factors through a consistent surgical team, standardization of protocols, and confirmed balanced baseline characteristics. However, incremental improvements that were made over time cannot be entirely excluded. Furthermore, as a single-center study, it may limit the generalizability of these results, warranting caution. Larger, multi-center, randomized trials comparing ACP strategies under standardized conditions would be valuable in advancing our understanding of optimal cerebral protection in acute aortic dissection surgery. The pros and cons of each strategy are tabulated for better understanding (Table
2).
The factors that demonstrated the recommendation of the use of tACP may partially reflect temporal trends, incorporating small sample effects in comparing groups, or center-specific practices, but primarily underscores the perfusion strategy’s direct impact. Notably, Cai
et al.’s results [
1] suggest that the extent of cerebral coverage and the precision of operative technique in tACP can offset, or even surpass, the theoretical risks posed by longer perfusion times. Their data show both a markedly diminished rate of TND compared to uACP (37.5%) and bACP (18.2%), and hence superior outcomes in terms of postoperative extubation and ICU duration in the tACP cohort. This could may well point to a more linear relationship between perfusion technique and neurological outcome; one where comprehensive cerebral protection and refined intraoperative management may be more determinative than duration alone.
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