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Page 16 of 21 Calafiore et al. Vessel Plus 2023;7:18 https://dx.doi.org/10.20517/2574-1209.2023.42

CONCLUSION
Cerebral protection during arch surgery is still a work in progress. The issue is complex, both in terms of
pathology (chronic aneurysms or dissections) and respective surgical strategies, which can be different
according to the anatomic presentation. It is then important that surgeons have in their armamentarium
many strategies of cerebral protection, choosing to perfuse or not the brain, the level of hypothermia, and so
on, to fit different surgical scenarios. Lacking randomized controlled trials, rarely performed and often with
a limited number of patients, the most important surgical aspect is the experience of the single team. We,
after having used RCP and ACP, came back to straight DHCA with DR, as we found very attractive the
concept of energy recovery before rewarming. But all the techniques described in this review are
underpinned by a rationale, yielding high-quality results. Perhaps a definitive answer on the most efficient
strategy will not be given, at least in the next years, but we have to recognize that the enormous progress
that arch surgery made in the last decades allowed the widespread diffusion of such a complex surgery, not
anymore confined in selected Centers. Nevertheless, we suggest that, at least in chronic patients, it is
advisable to have a better preoperative knowledge of cerebral perfusion (CT or MRI angiography) in order
to discover silent conditions predisposing to thrombosis or embolization and, if necessary, to adapt a
specific cerebral protection strategy, if necessary.

DECLARATIONS
Authors’ contributions
Conceptualization; formal analysis; methodology; writing - original draft; Writing - review & editing;
supervision: Calafiore AM
Conceptualization; writing - review & editing: Prapas S
Formal analysis; writing - review & editing: Guarracini S, Di Marco M
Methodology; formal analysis: Lorusso R, Paparella D
Writing - review & editing: Katsavrias K
Formal analysis; methodology: Totaro A
Methodology; supervision; writing - review & editing: Di Mauro M

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.

Conflicts of interest
All authors declared that there are no conflicts of interest.

Ethical approval and consent to participate
Not applicable.

Consent for publication
Not applicable.

Copyright
© The Author(s) 2023.