Neuroprotection during aortic arch surgery often involves hypothermia and the use of adjunctive cerebral perfusion. While antegrade cerebral perfusion (ACP) is favored for extended hypothermic circulatory arrest (HCA), debate continues regarding the optimal cerebral protection strategy during shorter durations of circulatory arrest. This study evaluates the association between cerebral perfusion strategies and stroke risk among patients undergoing aortic arch surgery with an HCA time <30 minutes.

Registry data from 1079 patients across 42 centers who underwent elective aortic surgery with HCA between 2018 and 2024 were analyzed. Patients with aortic dissection, HCA duration >30 minutes, or receiving both ACP and retrograde cerebral perfusion (RCP) were excluded. Cerebral perfusion strategies were categorized as no cerebral perfusion (NCP), RCP, or ACP. Preoperative, intraoperative, and postoperative variables were compared across cerebral perfusion strategies. Multivariable logistic regression was used to assess the associations between perfusion strategy and postoperative stroke, adjusting for age, sex, race, prior stroke, chronic lung disease, lowest HCA temperature, cardiopulmonary bypass (CPB) time, and duration of circulatory arrest.

ACP was the most common strategy (n = 560; 51.9%), followed by RCP (n = 264; 24.5%) and NCP (n = 255; 23.6%). Baseline characteristics were similar across cerebral perfusion strategies, although chronic lung disease was more frequent among ACP patients. The median HCA temperature was 19.4 °C (interquartile range [IQR], 18.0 °C-24.4 °C) in the NCP group, 25.8 °C (IQR, 22.9 °C-27.7 °C) in the ACP group, and 21.6 °C (IQR, 18.9 °C-23.5 °C) in the RCP group (P < .01). In the 3 groups, the median HCA time was 14 (IQR, 10-20) minutes, 14 (IQR, 9-20) minutes, and 16 (IQR, 13-19) minutes, and median CPB time was 201 (IQR, 158-250) minutes, 154 (IQR, 115-207) minutes, and 172 (IQR, 132–214) minutes, respectively (P < .01). Stroke rates were lowest in the RCP group, with an 86.5% reduction in the adjusted odds of stroke compared to NCP (adjusted odds ratio, 0.135, 95% confidence interval, 0.023-0.783; P = .03). There was a nonsignificant protective effect associated with ACP.

In this large, multicenter cohort of patients undergoing elective aortic arch surgery with short HCA times, RCP was associated with a significantly lower risk of postoperative stroke compared to NCP. Physician-led quality improvement collaboratives may provide an effective mechanism for advancing performance related to cerebral perfusion strategies and mitigation of stroke in the setting of elective aortic arch surgery with short circulatory arrest.