TAA or TAAA repair is associated with significant hemorrhage from multiple causes, including surgical dissection, hypothermia, CPB, fibrinolysis, dilution or consumption of coagulation factors, anticoagulant therapy, preoperative antithrombotic therapy, and congenital or acquired coagulopathies. About 5 to 10 units of packed red blood cells (pRBCs) should be immediately available in the operating room, with a similar number of units available in the blood bank. About 5 to 10 units of fresh frozen plasma, typically given in a ratio of 1:1 or 1:2 pRBCs transfused, should be readily available. Thrombocytopenia and platelet dysfunction develop secondary to hypothermia and the use of extracorporeal mechanical support, and the need for platelet transfusion is common.

The use of prothrombin complex concentrates (PCCs) is useful in cases with refractory international normalized ratio (INR) elevation as the cause of coagulopathy or in patients with depressed cardiac or renal function. PCCs offer the advantage of rapid correction of INR with a minimal volume load without the need for crossmatching. Caution must be exercised, given the possibility of thrombosis. In patients with heparin-induced thrombocytopenia (HIT), PCCs should not be administered because most contain heparin.

Fibrinolysis develops not only from the use of CPB but also from supraceliac aortic cross-clamping and peripheral ischemia, which can be attenuated by the use of selective SMA perfusion. Supraceliac cross-clamping and peripheral ischemia promote activation of tissue-type plasminogen activator and decrease plasminogen activator inhibitor. The use of lysine analogues ε-aminocaproic acid and tranexamic acid is common in TAA repairs, but its use has been derived from studies in other cardiac surgeries. There is currently no literature to support prophylactic use of antifibrinolytic medications in TAA repair.

The use of a blood-salvaging device ("cell saver") is essential to decreasing allogeneic red blood cell transfusions. Unfortunately, the use of a cell saver is associated with the loss of platelets, plasma proteins, and coagulation factors. In heparinized patients, the use of cardiotomy suction permits the autotransfusion of filtered unwashed whole blood, which preserves platelets and coagulation factors.

References

• Ferraris VA, Brown JR, Despotis GJ, et al. 2011 update to the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists blood conservation clinical practice guidelines. Ann Thorac Surg. 2011;91:944-982.
• Ghadimi K, Levy JH, Welsby IJ. Prothrombin complex concentrates for bleeding in the perioperative setting. Anesth Analg. 2016;122:1287-1300.
• Levine WC, Lee JJ, Black JH, et al. Thoracoabdominal aneurysm repair: anesthetic management. Int Anesthesiol Clin. 2005;43:39-60.