Blood loss from coronary angiography increases transfusion requirements for coronary artery bypass graft surgery

Changes in blood biochemistry thrombosis parameters 24 hours after stent-assisted endovascular treatment of intracranial aneurysms

BACKGROUND AND PURPOSE

This study aims to elucidate the early changes in blood biochemistry thrombosis parameters following stent-assisted endovascular treatment of intracranial aneurysms.

METHODS

Consecutive patients with unruptured aneurysms undergoing stent implantation during endovascular treatment were included in this prospective study with approval from the local ethics committee. Blood samples were collected immediately before and 24 h after the procedure for biochemical analysis, including basic thrombosis indicators, bleeding tests, and a complete blood count.

RESULTS

The study included 80 patients (60 women, 20 men) with 134 aneurysms. A total of 135 stents (110 flow-diverting, 25 standard) were used. Additionally, intrasaccular coiling was utilized in 28 aneurysms among 27 patients. Following the procedure, there was a significant decrease in activated partial thromboplastin time, fibrinogen, hemoglobin, and platelet levels, and a significant increase in prothrombin time, D-dimer, von Willebrand factor (vWF) activity/antigen ratio, and leukocyte levels in all patients. Correlation analyses revealed significant positive associations between platelet and fibrinogen levels, and a negative association between D-dimer and fibrinogen levels in the coil (-) group. Additionally, there was a significant negative correlation between aneurysm volume and vWF activity/antigen ratio, and procedure duration and thrombocyte count, while a positive association was found between aneurysm number and leukocyte count in the coil (-) group.

CONCLUSIONS

Analysis of blood chemistry alterations indicates that intravascular thrombosis occurs in the intracranial circulation following stent-assisted endovascular treatment of intracranial aneurysms. This thrombotic process is more pronounced in patients whose aneurysms were left open (i.e. flow-diverting stent alone).

Assessment of Blood Loss during Neuroendovascular Procedures

(1) Background: Neuroendovascular procedures have generally been considered to have minor or inconsequential blood loss. No study, however, has investigated this question. The purpose of this study is to quantify the blood loss associated with neuroendovascular procedures and identify predictors of blood loss, using hemoglobin change as a surrogate for blood loss. (2) Methods: A retrospective review of 200 consecutive endovascular procedures (diagnostic and therapeutic) at our institution from January 2020 to October 2020 was performed. Patients had to have pre- and post-operative hematocrit and hemoglobin levels recorded within 48 h of the procedure (with no intervening surgeries) for inclusion. (3) Results: The mean age of our cohort was 60.1 years and the male representation was 52.5%. The mean pre-operative hemoglobin/hematocrit was significantly lower among females compared to males (12.1/36.2 vs. 13.0/38.5, p = 0.003, p = 0.009). The mean hemoglobin decrease was 0.5 g/dL for diagnostic angiograms compared to 1.2 g/dL for endovascular interventions (p < 0.0001), and 1.0 g/dL for all procedures combined. In a multivariate linear regression analysis, pre-operative antiplatelet/anticoagulant use was associated with a statistically significant decrease in hemoglobin. (4) Conclusions: Our data support that blood loss from diagnostic angiograms is marginal. Blood loss in endovascular interventions, however, tends to be higher. Pre-operative blood antiplatelet/anticoagulant use and increasing age appear to increase bleeding risk and may require closer patient monitoring.

One-stage hybrid coronary revascularization for the treatment of multivessel coronary artery disease— Periprocedural and long-term results from the “HYBRID-COR” feasibility study

Background

The constant growth of interest in hybrid coronary artery revascularization (HCR) is apparent. Yet, few studies report outcomes of the one-stage HCR. Consequently, the status of such procedures is not adequately supported in clinical guidelines. The aim of this study was to report the safety, feasibility, and long term-outcomes of the one-stage HCR.

Methods and results

Patients were enrolled in the prospective one-stage hybrid coronary revascularization program (HYBRID-COR). They underwent a one-stage hybrid revascularization procedure while on double antiplatelet therapy (DAPT) with Ticagrelor: endoscopic atraumatic coronary artery bypass grafting (EACAB) for revascularization of the left anterior descending (LAD) artery and percutaneous intervention in non-LAD arteries with contemporary drug-eluting stents. The composite primary endpoint included MACCE (major adverse cardiac and cerebrovascular events: death, myocardial infarction, stroke, and repeated revascularization) in long-term observation. The study cohort consisted of 30 patients (68% male) with stable coronary artery disease (26.7%) and unstable angina (73.3%). Procedural success was 100%. No death, myocardial infarction (MI), or stroke were observed in the perioperative period. One patient (3.3%) required chest revision and blood transfusion due to surgical bleeding. Kidney injury was noted in two patients (6.6%). In a long-term follow-up (median; IQR: 4.25; 2.62–4.69 years), two patients (6.6%) underwent repeated revascularization and one patient (3.3%) died due to MI. The overall primary endpoint rate was 9.9%.

Conclusion

One-stage hybrid revascularization, on DAPT, is a feasible, safe, and efficient way of achieving complete revascularization in selected patients. The complication rate is low and acceptable. Further randomized trials are required.

A protocol for prospective observational study to determine if non-anaemic iron deficiency worsens postoperative outcome in adult patients undergoing elective cardiac surgery: the IDOCS study

Background

Pre-operative anaemia has been associated independently with worse outcomes after cardiac surgery in adults and is often caused by absolute or functional iron deficiency. Iron deficiency is a continuum ending with anaemia, and therefore it is plausible that pre-operative early or ‘non-anaemic’ iron deficiency may also be associated with worse outcomes in patients undergoing cardiac surgery.

Methods

We have designed a prospective, observational study to determine if there is an association between non-anaemic iron deficiency and worse outcomes after cardiac surgery in adults. Patients without anaemia undergoing elective cardiac surgery will be allocated to an iron-deficient and an iron-replete group based on standard pre-operative blood tests (ferritin, transferrin saturation and C-reactive protein). The primary outcome is days alive and at home on postoperative day 30. The key secondary outcomes are days alive and at home on postoperative day 90 and readmission to acute care. Other secondary outcomes include health-related quality of life questionnaires, quality of postoperative recovery, postoperative complications, changes in haemoglobin concentration, and requirement for allogeneic blood products. The planned study sample size is 240 patients per group, which has 83% power to detect a median difference of 1.25 days in the primary outcome. The study commenced in March 2018, and recently completed recruitment, with data audit and cleaning ongoing.

Discussion

This study will be conducted using a rigorous, prospective observational design; it will provide peak bodies and clinicians with high-quality evidence concerning the associations between non-anaemic iron deficiency and patient-centred outcomes after elective cardiac surgery. Our primary and key secondary outcomes are known to have great importance to clinicians and patients alike and align with the recommendations of the StEP-COMPAC group for outcomes in prospective peri-operative research. The definition used for iron deficiency accounts for both absolute and functional iron deficiency and make use of standard pre-operative blood tests to make this determination, easing the transition of results into clinical practice. The study will be conducted in two relatively high-volume centres in a single high-income country. This limits the generalisability of study results to similar centres.

Trial registration

Australian and New Zealand Clinical Trials Registry (ACTRN12618000185268). Registered 5 February 2018.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13741-022-00239-2.

Decline in serum hemoglobin in the 7 days after cardiac catheterization

OBJECTIVES

Bleeding is an established complication following cardiac catheterization and lower preoperative hemoglobin concentration is a potentially modifiable risk factor for adverse outcomes after cardiac surgery. However, typical changes in serum hemoglobin concentration after cardiac catheterization are poorly defined. The authors sought to identify the pattern of change in serum hemoglobin concentration within 7 days after cardiovascular catheterization, factors associated with this change and any association with adverse outcomes.

DESIGN

Retrospective observational study over a 1-year period.

SETTING

U.S. academic medical institution.

PARTICIPANTS

Participants were 284 adult patients with baseline hemoglobin concentration≥12 g/dL undergoing nonemergent cardiac surgery after cardiovascular catheterization via the femoral arterial route.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Lowest daily hemoglobin concentration was recorded where available for up to 7 days after catheterization and before surgery. Generalized estimating equations identified the pattern of change in serum hemoglobin while regression models identified factors associated with hemoglobin decline. Following cardiovascular catheterization average serum hemoglobin declined over time, reaching a nadir 1.4 g/dL (95% CI 1.0-1.8) below baseline 6 days after catheterization. A higher baseline hemoglobin concentration and lower body mass index were associated with greater maximal decline in hemoglobin concentration after catheterization. Acute preoperative hemoglobin decline was not associated with acute kidney injury (AKI) or a composite adverse outcome that may reflect organ ischemia.

CONCLUSIONS

In a cohort of patients before cardiac surgery serum hemoglobin declines during the week after cardiac catheterization, with maximal average decline observed 5 to 7 days after catheterization.

Antifibrinolytic Use and Bleeding During Surgery on the Descending Thoracic Aorta: A Multivariate Analysis

OBJECTIVES

The purpose of this study was to determine the potential benefit of antifibrinolytic (AF) therapy in improving hemostasis in descending aortic surgery in which extracorporeal distal perfusion is used.

DESIGN

Retrospective database study.

SETTING

University hospital.

PARTICIPANTS

Seventy-two patients who underwent descending thoracic or thoracoabdominal aortic replacement during the period from January 1993 through December 1996 when the use of AF therapy was emerging.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Seventy-two records met criteria for inclusion. The use of AF therapy had no significant effect on any bleeding or transfusion outcome in any model. Excessive chest tube drainage postoperatively was independently associated with repeat surgery and intraoperative hypothermia. The risk of receiving a red blood cell (RBC) transfusion was independently predicted by low preoperative hemoglobin and age > or =65 years. Cross-clamp was an independent predictor of receiving a transfusion of non-RBC products (p = 0.03).

CONCLUSIONS

The authors could not show a beneficial effect of AF therapy on bleeding and transfusion, although current practice shows that this therapy continues to be used. Because heterogeneity of patient population exists and bias cannot be completely excluded, a prospective investigation evaluating efficacy and safety in this population is warranted.

A comparison of bleeding and transfusion in patients who undergo coronary artery bypass grafting via sternotomy with and without cardiopulmonary bypass

OBJECTIVE

To determine whether there is a difference between on-pump cardiopulmonary bypass (CABG) and off-pump coronary artery bypass grafting (OPCAB) without heparin reversal with regard to bleeding, transfusion requirements, and incidence of surgical re-exploration of the mediastinum.

DESIGN

Retrospective chart review.

SETTING

A large academic medical center.

PARTICIPANTS

Two hundred adult patients undergoing cardiac surgery.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

One hundred CABG patients were compared with 100 OPCAB patients. Statistical significance was measured with P values of <or=0.05. The heparin was not reversed in the OPCAB patients. CABG patients received more intraoperative allogeneic red blood cells (median 250 mL v 0 mL, p = 0.002), intraoperative autotransfusion (IAT) (550 mL v 425 mL, p = 0.001), platelets (9% v 1%, p = 0.009), and less albumin (0 mL v 250 mL, p = 0.001) than OPCAB patients. Postoperatively, CABG patients were more likely to receive fresh-frozen plasma (19% v 8%, p = 0.03) and less likely to receive IAT than the OPCAB group. During the initial 4-hour postoperative period, OPCAB patients exhibited greater blood loss via chest tube (290 mL v 385 mL, p = 0.003); however, at 12 hours and 24 hours postoperatively, there was no statistical difference in blood loss between the 2 groups. There were no statistically significant differences in surgical re-exploration of the mediastinum between the CABG and OPCAB groups.

CONCLUSION

Despite not reversing the heparin at the end of the OPCAB surgery, OPCAB surgery was associated with an overall reduction in allogeneic transfusion requirements.

Review of the clinical practice literature on patient characteristics associated with perioperative allogeneic red blood cell transfusion

There is evidence to suggest that there exists considerable variation in red blood cell (RBC) transfusion practices, especially in the surgical specialties. This is in large part related to difficulties in defining specific transfusion threshold criteria, given that there is no minimum acceptable hemoglobin threshold concentration and there is variability in assigning importance to patient factors. The purpose of this study is to identify patient-related factors that might be associated with the need for allogeneic RBC transfusion in surgical patients. We systematically identified, selected, and reviewed all observational or interventional studies describing patient-specific or related variables associated with the need for allogeneic RBC transfusion in the surgical patient population. We also evaluated the methodological characteristics of the individual studies. Sixty-two studies met our inclusion criteria and were analyzed for this review. Most of these studies were conducted in patients undergoing cardiac surgery (n = 30) and orthopedic surgery (n = 16). Decreased preoperative red cell reserve was most frequently associated with RBC transfusions, being identified as a significant variable in 46 studies. The other factors commonly associated with transfusion were advancing age (n = 28), female gender (n = 21), and small body size (n = 14). Only 2 studies attempted to prospectively validate a predictive model for RBC transfusion based on the variables identified. This systematic review shows that preoperative anemia, advancing age, female gender, and small body size are often associated with perioperative allogeneic RBC transfusion. However, the retrospective nature of most of the studies and the small sample sizes make it difficult to formulate a clinically useful prediction rules regarding allogeneic RBC transfusion. Ongoing research in designing large prospective cohort studies evaluating transfusion patterns are needed to further elucidate how patient characteristics impact the transfusion threshold.

Risk factors for ischemic optic neuropathy after cardiopulmonary bypass: a matched case/control study

Visual loss (acuity or field) secondary to ischemic optic neuropathy (ION) is a rare but devastating complication of cardiac surgery involving cardiopulmonary bypass (CPB). We determined clinical features and risk factors for ION by a retrospective time-matched, case-control study. ION was identified in 17 (0.06%) patients out of 27,915 patients who underwent CPB between January 1, 1976, and December 31, 1994. For each ION patient, two patients who underwent CPB exactly 2 wk before the ION patient were selected as controls. Data were analyzed by using conditional logistic regression with the 1:2 matched-set feature of 17 cases and 34 controls. Two-tailed P values < or =0.05 were considered significant. From bivariate analysis, smaller minimum postoperative hemoglobin concentration (odds ratio [OR] = 1.9, P = 0.047) and the presence of atherosclerotic vascular disease (OR = 7.0, P = 0.026) were found to be independently associated with ION after CPB, as were smaller minimum postoperative hemoglobin concentration (OR = 2.2, P = 0.027) and preoperative angiogram within 48 h of surgery (OR = 7.2, P = 0.042). In ION patients, 13 (76.5%) of 17 experienced a minimum postoperative hemoglobin value of < 8.5 g/dL, whereas only 14 (41.2%) of 34 control patients experienced values < 8.5 g/dL.

IMPLICATIONS

Patients with clinically significant vascular disease history or preoperative angiogram may be at increased risk for ischemic optic neuropathy after cardiac surgery, especially if the hemoglobin remains low in the postoperative period.