Abstract
Objective
To evaluate the association between cerebral perfusion strategy and neurologic outcomes following extended arch repair for acute type A aortic dissection (ATAAD).
Methods
We identified patients who underwent extended arch repair for ATAAD at our institution between 2002 and 2024. Patients were stratified by cerebral perfusion strategyL antergrade certebral perfusion (ACP) or retrograde cerebral perfusion (RCP). Outcomes included stroke and a composite of 30-day mortality, stroke, and temporary neurologic dysfunction. Multivariable analysis was used to evaluate the association between cerebral perfusion strategy and the composite outcome.
Results
A total of 206 patients met the study inclusion criteria (median age, 58.7 years; 25.2% female). ACP was the most common cerebral perfusion strategy (58.7%; n = 121), followed by combined ACP and RCP (32.0%; n = 66) and then RCP (9.2%; n = 19). The median circulatory arrest time was longer in cases using combined ACP and RCP (62 minutes) compared to ACP (38 minutes) or RCP (34 minutes) (P < .001). Permanent stroke occurred in 22 patients (10.7%) and did not differ by cerebral perfusion strategy. The composite outcome occurred in 53 patients (25.7%), with the highest frequency in the combined group, although the difference was not significant on pairwise comparison. On adjusted analysis, cerebral perfusion strategy was not an independent predictor of the composite outcome.
Conclusions
Despite prolonged circulatory arrest times, cases using combined ACP and RCP were not associated with an increased rate of stroke. The combined approach may help extend the safe duration of circulatory arrest in extended arch repair for ATAAD.
Key Words: cerebral perfusion, circulatory arrest, acute type A aortic dissection
Postoperative stroke occurred in 10.7% and did not differ by cerebral perfusion strategy.
Central Message.
Despite prolonged circulatory arrest, cases using ACP and RCP were not associated with higher stroke rates. This approach may help extend the safe duration of circulatory arrest.
Perspective.
There is ongoing debate regarding the optimal cerebral protection strategies for operations requiring circulatory arrest. In this retrospective study at a high-volume institution, neurologic outcomes were similar across cerebral perfusion strategies. A combined approach using ACP and RCP was used preferentially in cases with prolonged circulatory arrest.
Acute type A aortic dissection (ATAAD) is a cardiovascular emergency requiring immediate surgical intervention. Despite advances in surgical technique and perioperative care, stroke remains a devastating complication.1, 2, 3 Cerebral protection strategies have improved neurologic outcomes in cases requiring circulatory arrest, yet the optimal approach to neuroprotection remains uncertain.
A growing body of evidence supports the use of extended arch repair in selected patients with ATAAD.4, 5, 6, 7 While this approach offers potential long-term benefits, the procedures are complex and require extended periods of circulatory arrest, heightening the risk of cerebral ischemia.8 Identifying the most effective cerebral protection practices in these cases is critical to minimize neurologic risk. To address this, we evaluated the association between cerebral perfusion strategy and postoperative stroke following extended arch repair for ATAAD.
Methods
This study was deemed exempt from review by the Institutional Review Board of the Hospital of the University of Pennsylvania (Protocol 855137) on July 16, 2024. The requirement for informed consent was waived.
Study Design and Patient Selection
This was a retrospective cohort study of patients undergoing ATAAD repair at the University of Pennsylvania. Our institutional type A aortic dissection (TAAD) database was queried for patients who underwent emergent extended arch repair for ATAAD between January 1, 2002, and December 31, 2024. Extended arch repair was defined as replacement of the ascending aorta and aortic arch with reimplantation of 1 or more supra-aortic vessels. Hemiarch procedures were not included. All patients in the final cohort underwent a period of circulatory arrest with cerebral perfusion. The cohort was stratified into 3 groups based on cerebral perfusion strategy: isolated antegrade cerebral perfusion (ACP), isolated retrograde cerebral perfusion (RCP), and combined ACP and RCP. The study period was divided into four 5-year increments to assess trends in cerebral protection strategies over time.
Cerebral Perfusion Techniques
Our group has described our approaches to establishing cerebral perfusion in previous work.9,10 Typically, isolated ACP is performed via the right axillary artery at a rate of 7 to 10 mL/kg/minute, and isolated RCP is performed via the snared superior vena cava at a rate of 250 to 350 mL/minutes, titrated up to a maximum central venous pressure of 25 mmHg. In combined ACP and RCP cases, RCP is usually initiated first, and once the arch is opened, the innominate and carotid arteries are directly cannulated for ACP using balloon-tipped cannulas.
Variables and Outcomes
Data on preoperative characteristics, operative details, and perioperative outcomes were collected from our institutional TAAD database and review of medical records. The primary outcome was permanent postoperative stroke. Permanent stroke was defined as neurologic dysfunction persisting until discharge or death, with radiographic evidence of cerebral or spinal cord infarction. Stroke was classified as dissection-related or procedure-related, as previously characterized by our group.9 The secondary outcome was a composite defined as the occurrence of ≥1 of the following events within 30 days: mortality, stroke, or temporary neurologic dysfunction. Temporary neurologic dysfunction was defined as any neurologic deficit attributable to cerebral or spinal cord ischemia that resolved prior to discharge or death. Perioperative outcomes were assessed up to and including postoperative day 30.
Statistical Analysis
The use of cerebral perfusion strategies was compared over time and across intraoperative temperatures. Continuous variables are reported as median (interquartile range); categorical variables, as frequency (percentage). Group comparisons used the Kruskal-Wallis test for continuous variables and the Pearson χ2 or Fisher exact test for categorical variables, with the Dunn test and Fisher exact test for post hoc pairwise analyses. Multivariable logistic regression was used to identify independent predictors of the composite outcome. Covariates were selected a priori based on clinical relevance and included age, prior stroke, cerebral perfusion strategy, degree of hypothermia, aortic cannulation, circulatory arrest time, and cross-clamp time. The reference groups were RCP (for cerebral perfusion strategy) and deep hypothermia (for degree of hypothermia). Missing data were assessed for all variables and were low (<5%) for each variable. Descriptive statistics were calculated using all available data, and complete cases were included for multivariable analysis. Statistical significance was set at P < .05 (Bonferroni-adjusted P < .0167 for pairwise comparisons). Analyses were performed with STATA 18.5 (StataCorp).
Results
Cohort Selection
Of 1379 patients undergoing TAAD repair between 2002 and 2024, 206 who underwent extended arch repair with circulatory arrest and cerebral perfusion composed the final study cohort (Figure 1). These included 121 patients (59%) who received ACP, 19 who received RCP (9%), and 66 who received both ACP and RCP (32%). The distribution of cases throughout the study period is shown in Figure E1.
Figure 1.
Study cohort selection. OR, Operating room; ACP, antegrade cerebral perfusion; RCP, retrograde cerebral perfusion.
Figure E1.
Distribution of cases over the study period.
Preoperative Characteristics
Preoperative variables are summarized in Table 1. The cohort had a median age of 58.7 years (interquartile range, 51.3-67.6 years) and was 25.2% female (n = 52). Baseline variables were similar across the 3 study groups except for previous cardiac surgery, which was more common in the ACP group.
Table 1.
Preoperative variables
| Variable | Overall (N = 206) |
ACP (N = 121) |
RCP (N = 19) |
ACP + RCP (N = 66) |
P value |
|---|---|---|---|---|---|
| Age, y, median (IQR) | 58.7 (51.3-67.6) | 60.4 (52.1-69.0) | 63.6 (49.9-68.0) | 56.8 (49.7-63.0) | .076 |
| Female sex, n (%) | 52 (25.2) | 24 (19.8) | 8 (42.1) | 20 (30.3) | .058 |
| Race, n (%) | .620 | ||||
| White | 114 (55.3) | 63 (52.1) | 11 (57.9) | 40 (60.6) | |
| Black | 56 (27.2) | 31 (25.6) | 6 (31.6) | 19 (28.8) | |
| Asian | 6 (2.9) | 5 (4.1) | 0 (0.0) | 1 (1.5) | |
| Hispanic | 2 (1.0) | 2 (1.7) | 0 (0.0) | 0 (0.0) | |
| Other | 11 (5.3) | 8 (6.6) | 2 (10.5) | 1 (1.5) | |
| Unreported | 16 (7.8) | 11 (9.1) | 0 (0.0) | 5 (7.6) | |
| BMI, median (IQR) | 27.9 (24.5-32.2) | 28.2 (24.5-32.3) | 27.5 (25.5-34.3) | 27.6 (24.3-30.8) | .550 |
| Hypertension, n (%) | 178 (86.4) | 102 (84.3) | 17 (89.5) | 59 (89.4) | .680 |
| Diabetes, n (%) | 16 (7.8) | 12 (9.9) | 0 (0.0) | 4 (6.1) | .380 |
| COPD, n (%) | 14 (6.8) | 10 (8.3) | 1 (5.3) | 3 (4.5) | .770 |
| Smoking, n (%) | 50 (24.3) | 28 (23.1) | 2 (10.5) | 20 (30.3) | .300 |
| Dialysis, n (%) | 6 (2.9) | 2 (1.7) | 0 (0.0) | 4 (6.1) | .260 |
| CAD, n (%) | 22 (10.7) | 15 (12.4) | 4 (21.1) | 3 (4.5) | .060 |
| Previous stroke, n (%) | 17 (8.3) | 10 (8.3) | 2 (10.5) | 5 (7.6) | .860 |
| Previous cardiac surgery, n (%) | 17 (8.3) | 15 (12.4) | 0 (0.0) | 2 (3.0) | .040 |
| DeBakey class, n (%) | .340 | ||||
| DeBakey I | 194 (94.2) | 116 (95.9) | 18 (94.7) | 60 (90.9) | |
| DeBakey 2 | 12 (5.8) | 5 (4.1) | 1 (5.3) | 6 (9.1) | |
| Arch vessel dissection, n (%) | 116 (56.3) | 62 (51.2) | 15 (78.9) | 39 (59.1) | .063 |
| Preoperative hypotension or shock, n (%) | 33 (16.0) | 18 (14.9) | 4 (21.1) | 11 (16.7) | .710 |
ACP, Antegrade cerebral perfusion; RCP, retrograde cerebral perfusion; IQR, interquartile range; BMI, body mass index; COPD, chronic obstructive pulmonary disease; CAD, coronary artery disease.
Operative Variables
Operative data are presented in Table 2. The groups differed in terms of the arch procedure performed (P = .008), with total arch replacement more frequent in the ACP + RCP group (30.3%; n = 20). Arterial cannulation strategy also differed by cerebral perfusion group; axillary cannulation was most common in the ACP group (64.5%; n = 78), whereas aortic cannulation predominated in the RCP group (94.7%; n = 18) and the ACP + RCP group (77.3%; n = 51) (P < .001).
Table 2.
Operative variables
| Variable | Overall (N = 206) |
ACP (N = 121) |
RCP (N = 19) |
ACP + RCP (N = 66) |
P value |
|---|---|---|---|---|---|
| AVR, n (%) | 52 (25.2) | 29 (24.0) | 5 (26.3) | 18 (27.3) | .880 |
| Root replacement, n (%) | 45 (21.8) | 23 (19.0) | 5 (26.3) | 17 (25.8) | .500 |
| Arch procedure, n (%) | .008 | ||||
| Total arch | 46 (22.3) | 21 (17.4) | 5 (26.3) | 20 (30.3) | |
| Zone 1 | 11 (5.3) | 6 (5.0) | 4 (21.1) | 1 (1.5) | |
| Zone 2 | 149 (72.3) | 94 (77.7) | 10 (52.6) | 45 (68.2) | |
| FET, n (%) | 30 (14.6) | 15 (12.4) | 1 (5.3) | 14 (21.2) | .180 |
| Concomitant CABG, n (%) | 25 (12.1) | 17 (14.0) | 2 (10.5) | 6 (9.1) | .600 |
| Arterial cannulation site, n (%) | <.001 | ||||
| Aorta | 108 (52.4) | 39 (32.2) | 18 (94.7) | 51 (77.3) | |
| Axillary | 87 (42.2) | 78 (64.5) | 0 (0.0) | 9 (13.6) | |
| Femoral | 10 (4.9) | 4 (3.3) | 1 (5.3) | 5 (7.6) | |
| Other | 1 (0.5) | 0 (0.0) | 0 (0.0) | 1 (1.5) | |
| CPB time, min, median (IQR) | 247.0 (202.0-302.0) | 224.0 (187.0-281.0) | 229.0 (193.0-304.0) | 274.0 (246.0-321.0) | <.001 |
| Cross-clamp time, min, median (IQR) | 169.5 (130.0-221.0) | 155.0 (120.0-199.0) | 150.0 (115.0-214.0) | 200.0 (163.0-247.0) | <.001 |
| Circulatory arrest time, min, median (IQR) | 46.0 (34.0-63.0) | 38.0 (31.0-52.0) | 34.0 (30.0-49.0) | 62.0 (55.0-78.0) | <.001 |
| Degree of hypothermia, n (%) | <.001 | ||||
| Moderate (20 °C to ≤28 °C) | 108 (52.4) | 86 (71.1) | 5 (26.3) | 17 (25.8) | |
| Deep (≤20 °C) | 92 (44.7) | 32 (26.4) | 14 (73.7) | 46 (69.7) |
ACP, Antegrade cerebral perfusion; RCP, retrograde cerebral perfusion; AVR, aortic valve replacement; FET, frozen elephant trunk; CABG, coronary artery bypass grafting; CPB, cardiopulmonary bypass; IQR, interquartile range.
Cardiopulmonary bypass, cross-clamp, and circulatory arrest times all differed significantly by cerebral perfusion strategy (P < .001 for each) and were longest in the combined group. Temperature management strategies also differed significantly among the 3 groups (P < .001) (Figure 2). MHCA was most common in the ACP group (71.1%; n = 86), while DHCA was predominant in the RCP group (73.7%; n = 14) and the ACP +RCP group (69.7%; n = 46). The most common cerebral protection strategy was ACP with MHCA, followed by combined ACP + RCP with DHCA (Figure E2).
Figure 2.
Temperature by cerebral perfusion strategy. MHCA, Moderate hypothermic circulatory arrest; DHCA, deep hypothermic circulatory arrest; ACP, antegrade cerebral perfusion; RCP, retrograde cerebral perfusion.
Figure E2.
Frequency of combined cerebral perfusion and temperature management strategies. ACP, Antegrade cerebral perfusion; RCP, retrograde cerebral perfusion.
Post hoc pairwise comparisons were performed for intraoperative variables that differed among the study groups (Table E1). Compared to both the ACP-only and RCP-only groups, the ACP + RCP group had significantly longer cross-clamp and circulatory arrest times. Additional comparisons are provided in Table E1.
Perioperative Outcomes
Thirty-day outcomes are presented in Table 3. In the overall cohort, 30-day mortality was 9.7% (n = 20), and permanent stroke occurred in 10.7% (n = 22); neither outcome differed by cerebral perfusion strategy. Temporary neurologic dysfunction that resolved by discharge occurred in 8.7% of patients (n = 18) at a similar rate across the 3 groups. The composite outcome of 30-day mortality, stroke, or temporary neurologic dysfunction occurred in 25.7% of the patients (n = 53) and differed significantly by cerebral perfusion strategy (P = .046), with the highest incidence in the ACP + RCP group (36.4%, n = 24). Post hoc pairwise comparisons showed no significant differences among the groups, however (Table E1).
Table 3.
Perioperative outcomes
| Outcome | Overall (N = 206) |
ACP (N = 121) |
RCP (N = 19) |
ACP + RCP (N = 66) |
P-value |
|---|---|---|---|---|---|
| Mortality, n (%) | 20 (9.7) | 9 (7.4) | 2 (10.5) | 9 (13.6) | .37 |
| Permanent stroke, n (%) | 22 (10.7) | 10 (8.3) | 3 (15.8) | 9 (13.6) | .38 |
| Etiology, n (%) | .67 | ||||
| Dissection-related | 6 (2.9) | 3 (2.5) | 0 (0.0) | 3 (4.5) | |
| Procedure-related | 16 (7.8) | 7 (5.8) | 3 (15.8) | 6 (9.1) | |
| Temporary neurologic dysfunction, n (%) | 18 (8.7) | 9 (7.4) | 0 (0.0) | 9 (13.6) | .17 |
| Composite, n (%) | 53 (25.7) | 24 (19.8) | 5 (26.3) | 24 (36.4) | .046 |
| Reexploration for bleeding, n (%) | 35 (17.0) | 22 (18.2) | 1 (5.3) | 12 (18.2) | .39 |
| Renal failure requiring dialysis, n (%) | 36 (17.5) | 20 (16.5) | 3 (15.8) | 13 (19.7) | .87 |
| Coma, n (%) | 7 (3.4) | 2 (1.7) | 1 (5.3) | 4 (6.1) | .29 |
| ICU LOS, d, median (IQR) | 5.0 (3.0-13.0) | 5.0 (3.0-13.0) | 4.4 (2.0-11.0) | 5.5 (2.5-12.5) | .85 |
| Total LOS, d, median (IQR) | 15.0 (9.0-26.0) | 16.0 (10.0-28.0) | 11.0 (9.0-20.0) | 15.0 (9.0-22.0) | .11 |
| Readmission, n (%) | 38 (18.4) | 23 (19.0) | 4 (21.1) | 11 (16.7) | .94 |
| Discharge location, n (%) | .35 | ||||
| Home | 102 (49.5) | 56 (46.3) | 9 (47.4) | 37 (56.1) | |
| Rehabilitation facility | 78 (37.9) | 52 (43.0) | 8 (42.1) | 18 (27.3) | |
| LTACH | 10 (4.9) | 6 (5.0) | 0 (0.0) | 4 (6.1) | |
| In-hospital death | 16 (7.8) | 7 (5.8) | 2 (10.5) | 7 (10.6) |
ACP, Antegrade cerebral perfusion; RCP, retrograde cerebral perfusion; ICU, intensive care unit; LOS, length of stay; IQR, interquartile range; LTACH, long-term acute-care hospital.
Multivariable logistic regression was performed to identify predictors of the composite outcome (Table E2). After adjustment, cerebral perfusion strategy was not associated with the composite outcome. Similarly, age, previous stroke, degree of hypothermia, aortic cannulation, circulatory arrest time, and cross-clamp time were not significant predictors of the composite outcome.
Temporal Trends in Management
The number of ATAAD cases with extended arch repair at our institution generally increased over the study period, peaking in 2021 (Figure E1). Trends in cerebral protection strategies are illustrated in Figures 3 and 4.
Figure 3.
Trend in cerebral perfusion strategy over time. ACP, Antegrade cerebral perfusion; RCP, retrograde cerebral perfusion.
Figure 4.
Trend in temperature management over time. MHCA, Moderate hypothermic circulatory arrest; DHCA, deep hypothermic circulatory arrest.
Discussion
In this 2-decade, single-center experience of extended arch repair for ATAAD, permanent stroke rates did not differ by cerebral perfusion strategy, and cerebral perfusion strategy was not an independent predictor of the composite outcome of 30-day mortality, stroke, or temporary neurologic dysfunction. DHCA, first described by Griepp and colleagues in 1975,11,12 was the traditional approach to cerebral protection in aortic arch surgery. But although DHCA may provide acceptable cerebral protection for up to 30 minutes, longer durations are associated with increased risk of neurologic injury and mortality.13 DHCA is also associated with systemic complications, including coagulopathy, endothelial dysfunction, and multisystem organ dysfunction.14,15 Consequently, once cerebral perfusion techniques were developed, practice patterns have shifted from use of DHCA alone to more moderate degrees of hypothermia combined with cerebral perfusion.16 This approach extends the safe duration of circulatory arrest while reducing the systemic complications of profound hypothermia.17, 18, 19 Major guidelines recommend cerebral perfusion over isolated DHCA during circulatory arrest20,21 because it is associated with lower rates of neurologic injury and mortality.22, 23, 24 For extended arch repair, expert consensus supports the use of ACP with either MHCA or DHCA.20
Although randomized data comparing ACP and RCP are lacking, ACP has emerged as the preferred cerebral perfusion strategy owing to its physiologic antegrade flow and presumed superior cerebral oxygenation.8,17,22 Nonetheless, multiple studies have failed to demonstrate superior outcomes with ACP.25, 26, 27, 28 In line with widespread trends, our institutional experience reflects increasing use of ACP over time (alone or in combination with RCP), while RCP alone continues to be used infrequently. In our study, ACP with MHCA was the most frequently used cerebral protection strategy overall, in 43.0% of cases.
Extended arch repair for ATAAD is inherently complex and carries a high risk of neurologic complications owing to prolonged periods of circulatory arrest and arch manipulation. Prior studies report permanent neurologic injury rates between 7% and 18%.29,30 Our observed stroke rate of 10.7% aligns with those findings and did not differ significantly by cerebral perfusion strategy.
The composite outcome of 30-day mortality, permanent stroke, and temporary neurologic dysfunction occurred in 25.7% of our cohort. Although the incidence of the composite outcome was highest among patients in the ACP + RCP group (36.4%), pairwise comparisons showed no significant differences across the 3 groups. Additionally, cerebral perfusion strategy was not independently associated with the composite outcome on adjusted analysis.
In our study, combined ACP and RCP was associated with significantly longer circulatory arrest times (62 minutes vs 38 minutes with ACP vs 34 minutes with RCP), suggesting its selective use in more complex cases. Prior studies have examined cerebral perfusion techniques in the setting of prolonged circulatory arrest. In the ARCH International database, stroke and mortality rates remained stable for ischemic periods up to 80 minutes with ACP,31 whereas Tanaka and colleagues32 reported a linear increase in stroke rate with longer circulatory arrest times with RCP. An analysis comparing ACP and RCP for circulatory arrest times between 40 and 80 minutes found similar stroke rates but a higher incidence of temporary neurologic dysfunction with RCP.33 These findings suggest that ACP may be superior to isolated RCP for prolonged circulatory arrest, although direct comparative data remain limited.
In the present study, combined ACP and RCP was used in 32% of cases. Reports on this approach are limited, although it was the predominant cerebral perfusion strategy for aggressive arch replacement in a study by Yang and colleagues,30 and Estrera and colleagues34 reported on its use in cases with prolonged circulatory arrest. While the combined approach adds complexity, our present findings suggest that it may offer additional neuroprotection in selected high-risk cases. There is a theoretical basis for its use: ACP provides physiologic antegrade flow and oxygen delivery, prolonging the safe interval of circulatory arrest, while RCP, although not providing substantial perfusion, maintains cerebral hypothermia and flushes air and embolic debris from cerebral vessels.35 By targeting the 2 major mechanisms of neurologic injury after circulatory arrest—hypoperfusion and embolism—the combined strategy may provide synergistic neuroprotection in complex aortic arch surgery.
This study was limited by its retrospective nature and single-center design. Procedures were performed at a single, high-volume aortic center by a small number of surgeons. Cerebral perfusion strategy likely was influenced by individual surgeon preference, which we did not account for. Although the 3 cerebral perfusion groups were similar with respect to measured preoperative characteristics, residual confounding from differences in operative factors may have influenced outcomes.
In conclusion, complex aortic arch repair for ATAAD carries unique neurologic risk owing to the required period of circulatory arrest. In this study, stroke rates did not differ by cerebral perfusion strategy. Notably, circulatory arrest times were significantly longer in the ACP + RCP group, suggesting that this approach may mitigate the neurologic risk associated with prolonged ischemic periods. These findings may support the selective use of a combined cerebral perfusion strategy in complex extended arch repair for ATAAD.
Conflict of Interest Statement
W.Y.S. serves as an investigator, speaker, and/or advisory board member for Abbott, Artivion, Edwards Lifesciences, Medtronic, and Terumo Aortic. N.D.D. serves as a consultant for WL Gore & Associates and Terumo Aortic. All other authors reported no conflicts of interest.
The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.
Footnotes
This study was deemed exempt from review by the Institutional Review Board of the Hospital of the University of Pennsylvania (Protocol 855137) on July 16, 2024. The requirement for informed consent was waived.
Appendix E1
Table E1.
P values from post hoc pairwise comparisons for selected variables that differed significantly by cerebral perfusion group
| Comparison | CPB time | Cross-clamp time | Circulatory arrest time | Degree of hypothermia | Composite outcome |
|---|---|---|---|---|---|
| ACP vs ACP + RCP | <.001 | <.001 | <.001 | <.001 | .022 |
| RCP vs ACP + RCP | .021 | .008 | <.001 | .603 | .584 |
| ACP vs RCP | .740 | .898 | .456 | <.001 | .546 |
Bonferroni adjustment was applied for a corrected α value of 0.0167. Significant P values are in bold type. CPB, Cardiopulmonary bypass; ACP, antegrade cerebral perfusion; RCP, retrograde cerebral perfusion.
Table E2.
Results from multivariable logistic regression model for the composite outcome
| Covariate | OR | 95% CI | P value |
|---|---|---|---|
| Age | 1.025 | 0.996-1.053 | .087 |
| Previous stroke | 1.310 | 0.406-4.226 | .652 |
| Cerebral perfusion strategy | |||
| ACP | 0.608 | 0.164-2.254 | .456 |
| RCP | Reference | ||
| ACP + RCP | 1.409 | 0.418-4.749 | .580 |
| Degree of hypothermia | |||
| Moderate (20 °C to ≤28 °C) | 1.025 | 0.488-2.157 | .947 |
| Deep (≤20 °C) | Reference | ||
| Aortic cannulation | 0.754 | 0.339-1.678 | .490 |
| Circulatory arrest time (min) | 0.995 | 0.978-1.012 | .553 |
| Cross-clamp time (min) | 1.006 | 1.000-1.012 | .051 |
OR, Odds ratio; CI, confidence interval; ACP, antegrade cerebral perfusion; RCP, retrograde cerebral perfusion.
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