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Calafiore et al. Vessel Plus 2023;7:18 Vessel Plus
DOI: 10.20517/2574-1209.2023.42

Review Open Access

Strategies of cerebral protection and neurologic

dysfunctions after circulatory arrest: back to the
future?

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Antonio M. Calafiore , Sotirios Prapas , Stefano Guarracini , Massimo Di Marco , Roberto Lorusso ,
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Domenico Paparella , Kostas Katsavrias , Antonio Totaro , Michele Di Mauro 4
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Department of Cardiac Surgery, Henry Durant Hospital, Athens 115 26, Greece.
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Department of Cardiology, “Pierangeli” Hospital, Pescara 65127, Italy.
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Department of Cardiology, “Santo Spirito” Hospital, Pescara 65124, Italy.
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Department of Cardio Thoracic Surgery, Heart and Vascular Centre, University Medical Centre (MUMC), Cardiovascular
Research Institute Maastricht (CARIM), Maastricht 6221, The Netherlands.
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Department of Medical and Surgical Sciences, University of Foggia, Foggia 71122, Italy.
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Department of Medicine and Health Sciences "V. Tiberio", University of Molise, Campobasso 86100, Italy.
Correspondence to: Prof. Antonio M. Calafiore, MD, Department of Cardiac Surgery, Henry Durant Hospital, Mesogeion 107,
Athens 115 26, Greece. E-mail: am.calafiore@gmail.com
How to cite this article: Calafiore AM, Prapas S, Guarracini S, Di Marco M, Lorusso R, Paparella D, Katsavrias K, Totaro A, Di
Mauro M. Strategies of cerebral protection and neurologic dysfunctions after circulatory arrest: back to the future? Vessel Plus
2023;7:18. https://dx.doi.org/10.20517/2574-1209.2023.42
Received: 28 May 2023 First Decision: 14 Jul 2023 Revised: 4 Aug 2023 Accepted: 18 Aug 2023 Published: 24 Aug 2023
Academic Editor: Frank W. Sellke Copy Editor: Fangling Lan Production Editor: Fangling Lan
Abstract
The introduction of deep hypothermic circulatory arrest (CA) was the factor that contributed to the diffusion of
aortic arch surgery in the surgical world. The progressive quest to improve the outcome of such a complex surgery
included the introduction of different tools to better protect the brain, such as retrograde or antegrade cerebral
perfusion. The increased experience not only resulted in a continuous improvement of the results, but also
facilitated the widespread adoption of arch surgery across most of the cardiac Centers. The trend moved towards a
gradual rise in the temperature (from ≤ 20 to 30 °C), coupled with a preference for selective/unilateral antegrade
cerebral perfusion for brain protection. Nevertheless, results are not perfect and neurologic dysfunctions,
temporary or permanent, remain a frequent complication. The spinal cord is not completely protected by cerebral
perfusion and ischemia of the lower body can cause organ malfunctions with severe consequences. After decades,
the field is still open for new strategies to minimize the damages intrinsic to the procedure. This review will briefly
describe the energetics of the brain, the mechanisms of neurologic dysfunctions, and the advantages and
disadvantages of the strategies of cerebral protection commonly used during CA for aortic arch surgery.

Keywords: Circulatory arrest, cerebral protection, aortic arch surgery, delayed rewarming

© The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0
International License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, sharing,
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