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How to obtain hemostasis after aortic surgery
SESSION 7: HEMOSTASIS/INFECTION
How To Obtain Hemostasis After Aortic Surgery Lars G. Svensson, MD, PhD Department of Thoracic and Cardiovascular Surgery, Lahey Hitchcock Clinic, Burlington, Massachusetts
Background. The establishment of hemostasis without the excessive transfusion of homologous blood and blood products is critical to successful aortic surgery. Methods and Results. By using preoperative autologous blood donation and intraoperative blood conservation measures, 85% of patients can undergo aortic surgical procedures without homologous blood or product transfusions, and almost three-quarters of patients will still not have required homologous transfusions by the
time of discharge. In contrast, three-quarters of those patients who cannot donate blood preoperatively will require homologous blood transfusions. Conclusions. The strategy described is safe: our overall survival rate for 204 patients has been 98%, with a 1% incidence of stroke.
T
composite valve graft insertions, we prefer to sew a tube graft to the left main coronary artery, and to implant the right coronary artery as a felt-buttressed button [2, 3]: this allows for absolute hemostasis at these anastomoses. Rarely has there been a need to create a Cabrol fistula between an aneurysm sac and the right atrium [3]. Indeed, we avoid wrapping the aneurysm wall around the graft, but rather approximate the aneurysm wall without it being watertight because of the risk of false aneurysm formation or tamponade of the graft [3, 4]. For insertion of an “elephant trunk,” a modified technique is used: the graft is inverted into the descending aorta so that it is easier to sew the distal anastomosis; the suture line is automatically tightened and the contact area is increased when the distal inner graft is withdrawn [5]. Prior to withdrawal of the distal graft, the suture line is also strengthened with interrupted pledgeted sutures. For thoracoabdominal and descending thoracic repairs, transection of the aorta aids in obtaining hemostasis after the clamps are released [2]. After the administration of protamine and, if available, autologous blood products, coagulation studies— prothrombin time (PT) and platelet counts—should be sent at regular intervals to aid in the administration of blood and blood products. If only the PT is elevated, fresh frozen plasma (FFP) is usually required; if the PTT is elevated and fibrinogen levels are low, cryoprecipitate is necessary and possibly more protamine; if the platelet count is below 100,000, platelets are required, and if the hematocrit drops below 20%, further blood administration is needed. All patients receive 5 mg of Amicar on discontinuing cardiopulmonary or atriofemoral bypass, followed by 1 g per hour for 5 hours. Shed blood is routinely aspirated, washed, and reinfused. If the tissues still appear to be oozing at the time of closure, aprotinin is also started and continued postoperatively, but aprotinin is avoided in deep hypothermia and circulatory arrest patients because of reports of an increased risk of multiple organ failure. In the postoperative
he maintenance of hemostasis following aortic surgery without excessive blood transfusions is pivotal to the recovery of the patient. In a previous study, we demonstrated that patients who did not receive homologous blood transfusion did significantly better after surgery [1]. This report describes our approach to minimizing blood transfusions and obtaining hemostasis after surgery.
Methods For those patients in whom elective surgery can be planned, a careful evaluation for possible coagulation problems is required. Patients on aspirin, nonsteroidal antiinflammatory agents, and warfarin need to be taken off these medications at the appropriate interval prior to surgery. If feasible, patients should also begin donating autologous blood and plasma prior to surgery. A unit of blood per week is collected, and patients also donate platelets 3 to 5 days before surgery. Patients are started on iron supplements, but we have not found erythropoietin injections to be of much benefit (unpublished data). Intraoperatively, after induction of anesthesia, collection of further platelets and coagulation factors by plasmapheresis is also undertaken. The operations are conducted using well established surgical techniques [2]. Low porosity grafts are utilized, and special emphasis is placed on ensuring watertight suture lines. Prior to discontinuing cardiopulmonary bypass, all the anastomoses should be carefully checked for hemostasis, and pledgeted sutures liberally used. Any bleeding sites or potential gaps in the suture line should not be ignored, but should be further strengthened. For Presented at the Aortic Surgery Symposium VI, April 30 –May 1, 1998, New York, NY. Address reprint requests to Dr Svensson, Department of Thoracic and Cardiovascular Surgery, Lahey Hitchcock Clinic, 41 Mall Rd, Burlington, MA 01805.
© 1999 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
(Ann Thorac Surg 1999;67:1981–2) © 1999 by The Society of Thoracic Surgeons
0003-4975/99/$20.00 PII S0003-4975(99)00351-3
HCRYO 5 homologous cryoprecipitate;
2.3 6 1.8 2.5 6 1.4
Data are mean 6 standard deviation.
3.3 6 2.5 4.0 6 6.8 957 6 519 197 6 497 28.9 6 4.2 30.7 6 3.9 34.0 6 4.2 36.7 6 5.0 Autologous 40.7 6 3.8 Non autologous
AFFP 5 autologous fresh frozen plasma; APLT 5 autologous platelets; ARBC 5 autologous red blood cell units; plasma; HPLT 5 homologous platelets; HRBC 5 homologous red blood cell units.
0.2 6 0.75 4.3 6 9.6 0.2 6 0.6 4.8 6 8.16
0.7 6 2.5 0.3 6 1.8 7.1 6 10.3 3.4 6 13.4
94% 68%
6.5% 7%
HFFP 5 homologous fresh frozen
Ann Thorac Surg 1999;67:1981–2
4.7 6 4.3
HFFP Discharge Preoperation
Hematocrit %
Predonation
Plasmapheresis (mL)
Washed Cells
ARBC
AFFP
APLT
HRBC
HPLT
HCRYO
Amicar (%)
Aprotinin (%)
SVENSSON AORTIC SURGERY HEMOSTASIS
Table 1. Blood and Blood Product Usage for Ascending and Arch Operations
1982
period, accumulated blood is autotransfused, except in patients bleeding excessively.
Results Before March 31, 1998, a total of 204 patients had undergone ascending and arch operations at our institution, with 4 deaths in-hospital before 30 days: 98% survival. Two patients suffered strokes (1%); in 1 the deficit was transient. Of these 204 patients, 96 were able to donate blood before surgery: 85% (82/96) did not require any operative homologous blood or blood product transfusion. Blood and blood product requirements are shown in Table 1. In contrast, of 105 patients who could not donate autologous blood and products, 75% (77/105) required intraoperative blood transfusion, and 76% (80/ 105) required in-hospital transfusion. Data were not available on 3 patients. Of the entire group, 5 patients (5/204, 2.5%) required reoperation for postoperative bleeding.
Comment In a previous study, we reported that significant (p , 0.05) multivariate predictors for homologous blood transfusion were age, bypass time, and postoperative chest tube drainage [1]. Preoperative autologous blood donation was associated with a lower risk of subsequent need for homologous blood transfusion. Thus, we continue strongly to favor preoperative blood donation. We have carried out even type II thoracoabdominal aneurysm reoperation without the need for homologous blood transfusion. With the use of autologous blood donation and meticulous attention to establishing hemostasis prior to administration of protamine, homologous blood usage can be reduced considerably. Furthermore, patients who had blood conservation measures, including autologous blood donation, in addition to having a significantly (p , 0.05) lower incidence of homologous blood transfusion, also required less intraoperative shed blood washing, had a shorter hospital stay, and were discharged in a better dyspnea functional class. These results have been achieved without the liberal use of aprotinin: costs have been reduced as the result of diminished use of aprotinin, homologous blood transfusions, and blood products.
References 1. Svensson LG, Sun J, Nadolny E, Kimmel WA. Prospective evaluation of minimal blood use for ascending aorta and aortic arch operations. Ann Thorac Surg, 1995;59:1501– 8. 2. Svensson LG, Crawford ES. Cardiovascular and Vascular Disease of the Aorta. Philadelphia: W.B. Saunders, 1997. 3. Svensson LG, Crawford ES, Hess KR, et al. Composite valve graft replacement of the proximal aorta: comparison of techniques in 348 patients. Ann Thorac Surg 1992;54:427–39. 4. Kouchoukos NT, Wareing TH, Murphy SF, Perillo JB. Sixteen year experience with aortic root replacement. Results of 172 operations. Ann Surg 1991;214:308–18. 5. Svensson LG. Rationale and technique for replacement of the ascending aorta, arch, and distal aorta using a modified elephant trunk procedure. J Cardiac Surg 1992;7:301–12.
How To Obtain Hemostasis After Aortic Surgery Lars G. Svensson, MD, PhD Department of Thoracic and Cardiovascular Surgery, Lahey Hitchcock Clinic, Burlington, Massachusetts
Background. The establishment of hemostasis without the excessive transfusion of homologous blood and blood products is critical to successful aortic surgery. Methods and Results. By using preoperative autologous blood donation and intraoperative blood conservation measures, 85% of patients can undergo aortic surgical procedures without homologous blood or product transfusions, and almost three-quarters of patients will still not have required homologous transfusions by the
time of discharge. In contrast, three-quarters of those patients who cannot donate blood preoperatively will require homologous blood transfusions. Conclusions. The strategy described is safe: our overall survival rate for 204 patients has been 98%, with a 1% incidence of stroke.
T
composite valve graft insertions, we prefer to sew a tube graft to the left main coronary artery, and to implant the right coronary artery as a felt-buttressed button [2, 3]: this allows for absolute hemostasis at these anastomoses. Rarely has there been a need to create a Cabrol fistula between an aneurysm sac and the right atrium [3]. Indeed, we avoid wrapping the aneurysm wall around the graft, but rather approximate the aneurysm wall without it being watertight because of the risk of false aneurysm formation or tamponade of the graft [3, 4]. For insertion of an “elephant trunk,” a modified technique is used: the graft is inverted into the descending aorta so that it is easier to sew the distal anastomosis; the suture line is automatically tightened and the contact area is increased when the distal inner graft is withdrawn [5]. Prior to withdrawal of the distal graft, the suture line is also strengthened with interrupted pledgeted sutures. For thoracoabdominal and descending thoracic repairs, transection of the aorta aids in obtaining hemostasis after the clamps are released [2]. After the administration of protamine and, if available, autologous blood products, coagulation studies— prothrombin time (PT) and platelet counts—should be sent at regular intervals to aid in the administration of blood and blood products. If only the PT is elevated, fresh frozen plasma (FFP) is usually required; if the PTT is elevated and fibrinogen levels are low, cryoprecipitate is necessary and possibly more protamine; if the platelet count is below 100,000, platelets are required, and if the hematocrit drops below 20%, further blood administration is needed. All patients receive 5 mg of Amicar on discontinuing cardiopulmonary or atriofemoral bypass, followed by 1 g per hour for 5 hours. Shed blood is routinely aspirated, washed, and reinfused. If the tissues still appear to be oozing at the time of closure, aprotinin is also started and continued postoperatively, but aprotinin is avoided in deep hypothermia and circulatory arrest patients because of reports of an increased risk of multiple organ failure. In the postoperative
he maintenance of hemostasis following aortic surgery without excessive blood transfusions is pivotal to the recovery of the patient. In a previous study, we demonstrated that patients who did not receive homologous blood transfusion did significantly better after surgery [1]. This report describes our approach to minimizing blood transfusions and obtaining hemostasis after surgery.
Methods For those patients in whom elective surgery can be planned, a careful evaluation for possible coagulation problems is required. Patients on aspirin, nonsteroidal antiinflammatory agents, and warfarin need to be taken off these medications at the appropriate interval prior to surgery. If feasible, patients should also begin donating autologous blood and plasma prior to surgery. A unit of blood per week is collected, and patients also donate platelets 3 to 5 days before surgery. Patients are started on iron supplements, but we have not found erythropoietin injections to be of much benefit (unpublished data). Intraoperatively, after induction of anesthesia, collection of further platelets and coagulation factors by plasmapheresis is also undertaken. The operations are conducted using well established surgical techniques [2]. Low porosity grafts are utilized, and special emphasis is placed on ensuring watertight suture lines. Prior to discontinuing cardiopulmonary bypass, all the anastomoses should be carefully checked for hemostasis, and pledgeted sutures liberally used. Any bleeding sites or potential gaps in the suture line should not be ignored, but should be further strengthened. For Presented at the Aortic Surgery Symposium VI, April 30 –May 1, 1998, New York, NY. Address reprint requests to Dr Svensson, Department of Thoracic and Cardiovascular Surgery, Lahey Hitchcock Clinic, 41 Mall Rd, Burlington, MA 01805.
© 1999 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
(Ann Thorac Surg 1999;67:1981–2) © 1999 by The Society of Thoracic Surgeons
0003-4975/99/$20.00 PII S0003-4975(99)00351-3
HCRYO 5 homologous cryoprecipitate;
2.3 6 1.8 2.5 6 1.4
Data are mean 6 standard deviation.
3.3 6 2.5 4.0 6 6.8 957 6 519 197 6 497 28.9 6 4.2 30.7 6 3.9 34.0 6 4.2 36.7 6 5.0 Autologous 40.7 6 3.8 Non autologous
AFFP 5 autologous fresh frozen plasma; APLT 5 autologous platelets; ARBC 5 autologous red blood cell units; plasma; HPLT 5 homologous platelets; HRBC 5 homologous red blood cell units.
0.2 6 0.75 4.3 6 9.6 0.2 6 0.6 4.8 6 8.16
0.7 6 2.5 0.3 6 1.8 7.1 6 10.3 3.4 6 13.4
94% 68%
6.5% 7%
HFFP 5 homologous fresh frozen
Ann Thorac Surg 1999;67:1981–2
4.7 6 4.3
HFFP Discharge Preoperation
Hematocrit %
Predonation
Plasmapheresis (mL)
Washed Cells
ARBC
AFFP
APLT
HRBC
HPLT
HCRYO
Amicar (%)
Aprotinin (%)
SVENSSON AORTIC SURGERY HEMOSTASIS
Table 1. Blood and Blood Product Usage for Ascending and Arch Operations
1982
period, accumulated blood is autotransfused, except in patients bleeding excessively.
Results Before March 31, 1998, a total of 204 patients had undergone ascending and arch operations at our institution, with 4 deaths in-hospital before 30 days: 98% survival. Two patients suffered strokes (1%); in 1 the deficit was transient. Of these 204 patients, 96 were able to donate blood before surgery: 85% (82/96) did not require any operative homologous blood or blood product transfusion. Blood and blood product requirements are shown in Table 1. In contrast, of 105 patients who could not donate autologous blood and products, 75% (77/105) required intraoperative blood transfusion, and 76% (80/ 105) required in-hospital transfusion. Data were not available on 3 patients. Of the entire group, 5 patients (5/204, 2.5%) required reoperation for postoperative bleeding.
Comment In a previous study, we reported that significant (p , 0.05) multivariate predictors for homologous blood transfusion were age, bypass time, and postoperative chest tube drainage [1]. Preoperative autologous blood donation was associated with a lower risk of subsequent need for homologous blood transfusion. Thus, we continue strongly to favor preoperative blood donation. We have carried out even type II thoracoabdominal aneurysm reoperation without the need for homologous blood transfusion. With the use of autologous blood donation and meticulous attention to establishing hemostasis prior to administration of protamine, homologous blood usage can be reduced considerably. Furthermore, patients who had blood conservation measures, including autologous blood donation, in addition to having a significantly (p , 0.05) lower incidence of homologous blood transfusion, also required less intraoperative shed blood washing, had a shorter hospital stay, and were discharged in a better dyspnea functional class. These results have been achieved without the liberal use of aprotinin: costs have been reduced as the result of diminished use of aprotinin, homologous blood transfusions, and blood products.
References 1. Svensson LG, Sun J, Nadolny E, Kimmel WA. Prospective evaluation of minimal blood use for ascending aorta and aortic arch operations. Ann Thorac Surg, 1995;59:1501– 8. 2. Svensson LG, Crawford ES. Cardiovascular and Vascular Disease of the Aorta. Philadelphia: W.B. Saunders, 1997. 3. Svensson LG, Crawford ES, Hess KR, et al. Composite valve graft replacement of the proximal aorta: comparison of techniques in 348 patients. Ann Thorac Surg 1992;54:427–39. 4. Kouchoukos NT, Wareing TH, Murphy SF, Perillo JB. Sixteen year experience with aortic root replacement. Results of 172 operations. Ann Surg 1991;214:308–18. 5. Svensson LG. Rationale and technique for replacement of the ascending aorta, arch, and distal aorta using a modified elephant trunk procedure. J Cardiac Surg 1992;7:301–12.