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Surgical Tips for Bleeding Control after Aortic Surgery

Case 1

• F/70• Dx : Acute Aortic Dissection (DeBakey I)

• 2012.11.17– Ascending and hemi arch replacement (Gelweave 28mm graft) – Bovine pericardial hood formation

• 2012.11.18– Second look operation– Gauze & hood removal

Hemoglobin

Case 2

• M/49• Dx : Acute Aortic Dissection (DeBakey II)

• 2012.12.26– Total Arch Replacement– Ascending aorta replacement

(w hemashield 4 branched graft [26-10-8-8-10]

& frozen elephant trunk 26x110mm)• 2012.12.26

– Reopen due to massive bleeding– Dehiscence on proximal anastomosis

• Postoperative hemorrhage, redo sternotomy for bleeding, and transfusion of blood products are all associated with poorer outcomes in cardiovasular surgery

• A number of case reports of disseminated intravascular coagulopathy (DIC) associated with aortic dissection, TAAA,and abdominal aortic aneurysms (AAAs)

• Bleeding is a life-threatening complication in thoracic aortic surgery

Asc Arch Desc TA AA

Blood 4 6 6 7 2

FFP 11 14 12 16 4

CellSaver

5 6 7 8 3

Platelet 20 20 20 20 0

Svensson LG,J Cardiovc Surgery 1997:12

• management of hemostasis during surgery has many key components that start, first and foremost, with good surgical technique

• advances in graft materials, hemostasis, and surgical techniques have facilitated surgery on the aorta.

Ann Thorac Surg 2005;79:796–800

Ann Thorac Surg 2003;76:499–502

Ann Thorac Cardiovasc Surg Advance Published Date: February 29, 2012

Asian Cardiovasc Thorac Ann 2007;15:261–3

ANNALS OF SURGERY

Vol. 234, No. 3, 336–343

© 2001

Ann Thorac Surg. 2007 May;83(5):1615-20.Midterm results of aortic repair using a fabric neomedia and fibrin glue for type A acute aortic dissection.Nakajima T, Kawazoe K, Kataoka T, Kin H, Kazui T, Okabayashi H, Niinuma H.Source

Department of Cardiovascular Surgery, Iwate Medical University Memorial Heart Center, Iwate Medical University, Morioka, Japan. t_nakajima@imu.ncvc.go.jp

(A) The fibrinogen solution and the thrombin solution were applied to the fabric strip, which was placed between the dissected layers. (B) Geometrically fashioned fabric was soaked in fibrinogen solution and was inserted into the false lumen of the aortic root to obliterate completely.

Journal of Cardiothoracic Surgery 2009, 4:66 doi:10.1186/1749-8090-4-66

Interactive CardioVascular and Thoracic Surgery 14 (2012) 677–679

Ann Thorac Surg 2011;91:1630–1

Ann Thorac Surg 2005;79:1422–4)

Ann Thorac Surg 2010;89:992–

Ann Thorac Surg 1998;65:1798–9

Ann Thorac Surg 2003;76:949–51

Ann Thorac Surg 2010;89:1685–7

Ann Thorac Surg 2001;71:2050–2

Ann Thorac Surg 2007;83:1906–7

Ann Thoruc Surg 7993;55:1578-9

Interposition of aortic valve leaflets for reinforcement of Bentall proximal anastomosisPrashant N Mohite2, Tanveer Ahmad1, Sudesh V Prabhu1, Shyam K Thingnam1

1 Department of Cardiothoracic and Vascular Surgery, Post Graduate Institute of Medical Research and Education, Sector-12, Chandigarh 160012, India2 Harefield Hospital, Harefield, UK

Asian Cardiovasc Thorac Ann 2012; 20:455-456

Ann Thorac Surg 2002;74:1071–4

Thank You

TOPICAL HEMOSTATIC AGENTS • Compression Hemostatic Agents

– Oxidized Regenerated Cellulose /Surgicel, Oxycel

• Collagen /Colgel, Helitene, Avitene • Thrombin Sealants /Thrombin, Thrombogen, Thrombistat • Composite Collagen and Thrombin Sealant /CoStasis • Cyanoacrylate Sealants /Omnex • Fibrin Sealants /Tisseel, Beriplast, Hemaseel, Crosseal/Quixil, Vivostat • Polyethylene Glycol Polymers /CoSeal, DuraSeal • Bovine Albumin and Gluteraldehyde /BioGlue • Gelatin and Thrombin /FloSeal • Microporous Polysaccharide Hemospheres /Arista AH, HemoStase MPH • Chitin and Chitosan-Based Hemostatic Agents /HemCon, Closure,

Chitoseal, or Celox

Ann Thorac Surg 2009;88:1377–83

insufficient

• Systemic Measure– Genera conditions– Blood components– Pharmacological components

• Local Measure– Topical agents– Surgical techniques

Topical Agents

• Mechanical Agents– Gelatin, gelfoam/surgifoam– Collagen, actifoam/instsat– Oxi regenerated cellulose, surgicel/oxycel

• Surgical Glue– Tissel/beriplast/greenplast/coseal/bioglue

• Others– Trombin/

Suturing Techniques

• Graft size.. Smallest appropriate diameter• Suture– Size, 3-0– Tie knot

• Techniques– Small bite in the graft, big bite on the aorta– Pledgeted mattress sutures

• The challenge of hemostasis in operative ther- apy remains first defining which patients are ei- ther likely to bleed or clot too much

• much infor- mation is still needed on how to optimize a patient’s hemostatic system to improve out- comes.

• Topical agents are immensely attractive but should not obscure the need to assess these agents carefully for effi- cacy and safety.

• The goal with hemostasis in operative therapy is to maintain physiologic bal- ance and avoid the complications of bleeding or thrombosis.

• Pitfall• As.. An hemolitic n sign of inflam

• Blood flow through the false lumen is a powerful activator of the hemostatic system even before the operation. This remarkable activation may influence postoperative outcome of AAD patients

• Ann Thorac Surg 2011;91:1364–70

Ann R CollSurgEngl2001;83

Case 1

• F/70• Dx : Acute Aortic Dissection (DeBakey I)

• 2012.11.17– Ascending and hemi arch replacement (Gelweave 28mm graft) – Bovine pericardial hood formation

• 2012.11.18– Second look operation– Gauze & hood removal

Hemoglobin

Case 2

• M/49• Dx : Acute Aortic Dissection (DeBakey II)

• 2012.12.26– Total Arch Replacement– Ascending aorta replacement

(w hemashield 4 branched graft [26-10-8-8-10]

& frozen elephant trunk 26x110mm)• 2012.12.26

– Reopen due to massive bleeding– Dehiscence on proximal anastomosis