Abstract Body: Hybrid aortic arch repair is an emerging technique used to treat complex aortic arch aneurysms and dissections in patients at high-risk for conventional open repair. It combines surgical debranching of aortic arch vessels with endovascular stenting and grafting, avoiding deep hypothermic circulatory arrest. However, this introduces unique physiologic challenges, including risk of embolization, hypotension, and altered cerebral perfusion. These factors together pose a significant risk of neurologic injury, requiring careful anesthetic management to maintain cerebral perfusion.

This review evaluates whether the choice of anesthetic technique–volatile or total intravenous anesthesia (TIVA)–provides benefits or limitations during hybrid aortic arch repair, mainly regarding neuroinflammatory responses and cerebral metabolic regulation.
A narrative literature review was performed using PubMed, Google Scholar, and Embase to identify relevant studies examining anesthetic effects on cerebral physiology during aortic surgery. Search terms included: hybrid aortic arch repair, aortic arch repair, volatile anesthesia, total intravenous anesthesia, neurological perfusion, motor evoked potentials.

Current literature shows that volatile anesthetics reduce cerebral metabolic rate and cause dose-dependent cerebral vasodilation, increasing blood flow and collateral perfusion during aortic arch procedures. However, volatile agents suppress somatosensory and motor evoked potentials (MEP), limiting neurophysiological monitoring. Conversely, TIVA using propofol preserves somatosensory and MEP signals, providing more reliable intraoperative neurologic monitoring, although dose-dependent suppression can occur.

In conclusion, both anesthetic techniques have limitations and benefits in hybrid aortic arch repair. Volatile agents may improve collateral cerebral perfusion, but interfere with neuromonitoring, whereas TIVA may improve neurophysiologic signals, but doesn’t completely eliminate monitoring suppression. Understanding these different mechanisms can help guide anesthesiologic selection during hybrid aortic arch repair.