van Haeren Maite M T, Bozic Caitlin, Breel Jennifer S, Eberl Susanne, Jamaludin Faridi S, Veelo Denise P, Müller Marcella C A, Vlaar Alexander P J, Hermanns Henning
Department of Anesthesiology, Amsterdam University Medical Centers, 1105 AZ Amsterdam, The Netherlands.
Department of Intensive Care, Amsterdam University Medical Centers, 1105 AZ Amsterdam, The Netherlands.
J Clin Med. 2025 Jun 5;14(11):4001. doi: 10.3390/jcm14114001.
Patients undergoing open thoracic aortic surgery have the highest bleeding complication rates within cardiac-vascular surgery, but research on coagulation management mostly targets general cardiac surgery. This scoping review evaluates current evidence on intraoperative hemostatic agents and their effect on bleeding and blood transfusions in these patients. : We searched MEDLINE (PubMed), Embase, and Cochrane Library on 2 July 2024. Eligible studies included randomized controlled (RCT) and observational trials with a comparison group and at least a sub-analysis regarding thoracic aortic surgery (excluding thoracoabdominal and isolated descending aorta surgery). Our search yielded 4697 articles, with 33 included. These covered antifibrinolytics (3 RCTs, 10 observational studies), fibrinogen supplementation (3 RCTs, 4 observational studies), recombinant factor VIIa (rFVIIa, 8 observational studies), blood products (3 observational studies), and factor eight inhibitor bypassing activity (FEIBA, 1 RCT, 1 observational study). The impact of blood product transfusion on bleeding control is unclear due to a lack of placebo or no-transfusion comparisons, though it appears associated with more complications. Both FEIBA studies suggest reduced blood product use in aortic dissection surgery-one as rescue therapy, the other as standard treatment. Evidence on fibrinogen supplementation is mixed: a multicenter RCT showed increased transfusions, while smaller RCTs and observational studies showed reductions, possibly due to differences in pretreatment fibrinogen levels and patient selection. Observational studies on rFVIIa show conflicting results, likely due to selection bias. Two small RCTs-one on TXA, one on aprotinin-suggest reduced transfusions and blood loss. Comparative studies of different types of antifibrinolytics yielded conflicting results. : Evidence on hemostatic agents in thoracic aortic surgery is limited. Small studies suggest potential for the routine use of antifibrinolytics, FEIBA, and fibrinogen supplementation-but only in bleeding patients with hypofibrinogenemia. High-quality RCTs focused on thoracic aortic procedures are needed to determine optimal coagulation management.
接受开胸主动脉手术的患者在心血管手术中出血并发症发生率最高，但凝血管理的研究大多针对普通心脏手术。本综述评估了目前关于术中止血剂及其对这些患者出血和输血影响的证据。2024年7月2日，我们检索了MEDLINE（PubMed）、Embase和Cochrane图书馆。符合条件的研究包括随机对照试验（RCT）和有对照组的观察性试验，且至少有一项关于胸主动脉手术的亚分析（不包括胸腹主动脉和孤立性降主动脉手术）。我们的检索共得到4697篇文章，其中33篇被纳入。这些文章涵盖了抗纤溶药物（3项RCT，10项观察性研究）、纤维蛋白原补充剂（3项RCT，4项观察性研究）、重组因子VIIa（rFVIIa，8项观察性研究）、血液制品（3项观察性研究）以及凝血因子VIII抑制剂旁路活性药物（FEIBA，1项RCT，1项观察性研究）。由于缺乏安慰剂或无输血对照，血液制品输血对出血控制的影响尚不清楚，不过它似乎与更多并发症相关。两项关于FEIBA的研究均表明，在主动脉夹层手术中血液制品的使用减少——一项作为挽救治疗，另一项作为标准治疗。关于纤维蛋白原补充剂的证据不一：一项多中心RCT显示输血增加，而较小的RCT和观察性研究则显示输血减少，这可能是由于预处理纤维蛋白原水平和患者选择的差异。关于rFVIIa的观察性研究结果相互矛盾，可能是由于选择偏倚。两项小型RCT——一项关于氨甲环酸，一项关于抑肽酶——表明输血和失血量减少。不同类型抗纤溶药物的比较研究结果相互矛盾。胸主动脉手术中止血剂的证据有限。小型研究表明抗纤溶药物、FEIBA和纤维蛋白原补充剂有常规使用的潜力，但仅适用于纤维蛋白原血症的出血患者。需要开展专注于胸主动脉手术的高质量RCT来确定最佳凝血管理方案。
