APROTININ SAFELY REDUCES BLEEDING COMPLICATIONS WHEN EXTREME HYPOTHERMIC CARDIOPULMONARY BYPASS IS USED FOR CRANIOTOMY

Abstract

Introduction: Extreme hypothermic cardiopulmonary bypass (EHCPB) with or without circulatory arrest (CA) is used to facilitate surgery for very complex, otherwise inoperable, cerebrovascular lesions. Hemorrhagic complications causing severe morbidity or mortality occur in up to 38% of patients undergoing EHCPB for neurosurgery. [1] Aprotinin has been shown to significantly reduce excessive hemorrhage during cardiac surgery requiring cardiopulmonary bypass (CPB). [2] This study is the first to examine the use of aprotinin for intracranial surgery requiring EHCPB with or without CA. Methods: After IRB approval, we reviewed records of 12 patients who received aprotinin during craniotomy under EHCPB with or without CA from 1993-1998. Demographics, surgical procedure, minimal patient temperature, and duration of surgery, CPB, and CA were recorded. Aprotinin dose (full or half Hammersmith) was noted. We obtained intraoperative blood loss and transfusion requirements. Preoperative creatinine (Cr) was compared to peak 72 hour postoperative Cr using a t-test (P<0.05 significant). The incidence of reoperation for bleeding, myocardial infarction (MI), deep venous thrombosis (DVT), or pulmonary embolism (PE) was noted during the first 7 postoperative days. Data are presented as the mean +/- s.d. except as noted. Results: Twelve patients (11 female, 1 male), 50 +/- 12 years of age, underwent craniotomy with EHCPB for repair of 11 aneurysms and 1 arteriovenous fistula. Surgical duration was 559 +/- 100 min and CPB lasted 193 +/- 59 min. Seven of 12 patients underwent CA for 21 +/- 8 min. Minimum body temperature was 15 +/- 1.5[degree sign]C. Ten patients were given full Hammersmith dose aprotinin and 2 patients received half dose. Intraoperative blood loss was 750 +/- 579 ml. Median (range) intraoperative transfusion requirements were: packed red cells 3 (0-5) units, cell saver 675 (450-1250) ml, platelets 3 (0-6) units, and fresh frozen plasma 0 (0-4) units. Preoperative and peak 72 hour postoperative Cr were not statistically different. No patients required reoperation for bleeding or developed DVT, PE, or MI. Discussion: This is the only review of aprotinin use for intracranial surgery requiring EHCPB with or without CA. We have shown no morbidity or mortality from hemorrhage in our study compared to previous studies. [1,3] Additionally, none of our patients developed the thrombotic complications that were described by others in their attempts to achieve hemostasis. [3,4] Finally, no evidence of renal dysfunction was noted in our patients despite the association of aprotinin with renal dysfunction following EHCPB with CA for aortic surgery. [4] EHCPB with or without CA combined with aprotinin can provide suitable conditions for surgical correction of complex cerebrovascular lesions by reducing bleeding complications while avoiding renal or thrombotic complications.