Management of bleeding in vascular surgery

Abstract

Management of acute coagulopathy and blood loss during major vascular procedures poses a significant haemostatic challenge to anaesthetists. The acute coagulopathy is multifactorial in origin with tissue injury and hypotension as the precipitating factors, followed by dilution, hypothermia, acidemia, hyperfibrinolysis and systemic inflammatory response, all acting as a self-perpetuating spiral of events. The problem is confounded by the high prevalence of antithrombotic agent use in these patients and intraoperative heparin administration. Trials specifically examining bleeding management in vascular surgery are lacking, and much of the literature and guidelines are derived from studies on patients with trauma. In general, it is recommended to adopt permissive hypotension with a restrictive fluid strategy, using a combination of crystalloid and colloid solutions up to one litre during the initial resuscitation, after which blood products should be administered. A restrictive transfusion trigger for red cells remains the mainstay of treatment except for the high-risk patients, where the trigger should be individualized. Transfusion of blood components should be initiated by clinical evidence of coagulopathy such as diffuse microvascular bleeding, and then guided by either laboratory or point-of-care coagulation testing. Prophylactic antifibrinolytic use is recommended for all surgery where excessive bleeding is anticipated. Fibrinogen and prothrombin complex concentrates administration are recommended during massive transfusion, whereas rFVIIa should be reserved until all means have failed. While debates over the ideal resuscitative strategy continue, the approach to vascular haemostasis should be scientific, rational, and structured. As far as possible, therapy should be monitored and goal directed.

Perioperative Outcomes After Use of Iliac Branch Devices Compared With Hypogastric Occlusion or Open Surgery for Elective Treatment of Aortoiliac Aneurysms in the NSQIP Database

“…However, patients undergoing major vascular surgery are often at risk for the adverse consequences of anemia because of the high prevalence of underlying coronary artery disease. 9 Although the optimal thresholds for transfusion are ill defined in this patient population, transfusions are not entirely benign. In the setting of major vascular surgery, perioperative transfusions have been consistently associated with an increased risk of death and myocardial infarction.…”

Editor's Choice – A Rotational Thromboelastometry Driven Transfusion Strategy Reduces Allogenic Blood Transfusion During Open Thoraco-abdominal Aortic Aneurysm Repair: A Propensity Score Matched Study

“…22 Although there is no literature regarding standardised ROTEM guided transfusion protocols during TAAA, several transfusion strategies have been developed. 9,23 These protocols generally follow the principles of empiric resuscitation, sometimes referred (22) .69 Coronary artery disease 82 (19) 27 (25) .11 15 (19) 14 (18) .83 Myocardial infarction 29 (7) 11 (10) .18 5 (6) 6 (8) .75 Arrhythmia 38 (9) 8 (7) .72 4 (5) 5 (6) .73 Previous percutaneous transluminal coronary angioplasty/coronary artery bypass grafting 58 (13) 17 (16) .43 11 (14) 10 (13) .81…”

“…A recent review on bleeding management in vascular surgery concluded that haemostasis as far as possible, should be monitored and goal directed. 10 This calls for a different management of bleeding, and the adoption of a transfusion algorithm guided by rotational thromboelastometry (ROTEM) could be an option. As ROTEM use has been validated in only a few settings, including cardiac surgery, further evaluation in acute settings and other patient categories is needed.…”

Effects of a targeted blood management programme on allogeneic blood transfusion in abdominal aortic aneurysm surgery

“…Most of the published literature relates to trauma patients or liver transplantation. A recent review article specific to vascular surgery recommended that ‘Blood, FFP and platelets should be administered early in major bleeding’(Chee et al ., ). Current massive bleeding treatment protocols recommend the administration of platelets and clotting factors in fixed ratios such as 1:1:1 or 1:1:2 (Holcomb et al ., ) as well as the early use of fibrinogen and prothrombin complex concentrate.…”