Fibrinogen Concentrate Therapy Guided by Thromboelastometry as an Alternative to Fresh Frozen Plasma in Major Vascular Surgery

Abstract

TYPE IV THORACOABDOMINAL aortic aneurysm (TAAA) repair is a major vascular procedure that involves replacing the native abdominal aorta, from the level of the diaphragm to the aortic bifurcation, with a synthetic graft. During surgery there is a period of complete ischemia of the liver, bowel, and kidneys followed by reperfusion of these organs and a more prolonged period of pelvic and lower limb ischemia. The operation is associated with large blood loss, often exceeding the patient's intravascular volume. Hemostasis usually becomes severely impaired during surgery as the concentrations of fibrinogen, other coagulation factors, and platelets in the patient's blood are decreased by dilution, consumption, hyperfibrinolysis, and the effects of visceral ischemia and reperfusion. 1 Cinà C.S. Clase C.M. Coagulation disorders and blood product use in patients undergoing thoracoabdominal aortic aneurysm repair. Transfus Med Rev. 2005; 19: 143-154 Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar , 2 Gertler J.P. Cambria R.P. Brewster D.C. et al. Coagulation changes during thoracoabdominal aneurysm repair. J Vasc Surg. 1996; 24: 936-943 Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar In addition, patients undergoing TAAA repair may be receiving antiplatelet agents, such as aspirin and clopidogrel, and they usually receive anticoagulants, such as heparin, during surgery. In an attempt to correct coagulopathy during surgery, infusions of blood components, such as fresh frozen plasma (FFP) and cryoprecipitate, often are used. However, the efficacy of FFP has been questioned, 3 Stainsby D. Jones H. Asher D. et al. Serious hazards of transfusion: A decade of hemovigilance in the UK. Transfus Med Rev. 2006; 20: 273-282 Abstract Full Text Full Text PDF PubMed Scopus (286) Google Scholar , 4 Stanworth S.J. Brunskill S.J. Hyde C.J. et al. Is fresh frozen plasma clinically effective? A systematic review of randomized controlled trials. Br J Haematol. 2004; 126: 139-152 Crossref PubMed Scopus (347) Google Scholar , 5 Stanworth S.J. Brunskill S.J. Hyde C.J. et al. Appraisal of the evidence for the clinical use of FFP and plasma fractions. Best Pract Res Clin Haematol. 2006; 19: 67-82 Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar and the transfusion of allogeneic blood components carries risks, including incompatibility reactions, immunosuppression, transfusion-related acute lung injury and the transmission of bacterial, viral, and prion infections. The UK Government's Advisory Committee on the Safety of Blood, Tissues and Organs (SaBTO) has recommended that the use of UK-derived FFP should cease because of the concerns regarding variant Creutzfeldt-Jakob disease. 6 Summary of Seventh Meeting of SaBTO (Advisory Committee on the Safety of Blood, Tissues and Organs), July 14/15, 2009. http://www.dh.gov.uk/ab/SaBTO/DH_089412#_2 Google Scholar Cryoprecipitate has been withdrawn from use in many European Union countries and its continued use in the UK is under review by SaBTO. Is It Necessary to Maintain Fibrinogen During Hypothermia and Major Bleeding in Vascular Surgery?Journal of Cardiothoracic and Vascular AnesthesiaVol. 26Issue 5PreviewIn the case reports by Morrison et al,1 3 patients undergoing open thoracoabdominal aneurysm repairs received a continuous infusion of purified human plasma–derived fibrinogen concentrates (CSL Behring, Marburg, Germany) under the guidance of the FIBTEM assay on ROTEM (TEM International, Munich, Germany). There are some concerns about these cases. Full-Text PDF