Fibrinogen concentrate administration attributes to significant reductions of blood loss and transfusion requirements in thoracic aneurysm repair

Abstract

Background: Repair of thoracic aortic aneurysm (TAA) is often associated with massive hemorrhage aggravated by dilutional coagulopathy with severe hypofibrinogenemia. Although only fresh frozen plasma (FFP) is available for acquired hypofibrinogenemia in Japan, the hemostatic effect of FFP has not been enough for dilutional coagulopathy in TAA surgery. There are increasing reports suggesting that fibrinogen concentrate may be effective in controlling perioperative bleeding and reducing transfusion requirements.

Methods: We retrospectively analyzed the hemostatic effect of fibrinogen concentrate compared with FFP in total 49 cases of elective TAA surgery. In 25 patients, fibrinogen concentrate was administered when the fibrinogen level was below 150 mg/dL at the cardiopulmonary bypass (CPB) termination. The recovery of fibrinogen level, blood loss, and transfused units during surgery were compared between cases of this agent and FFP (n = 24).

Results: We observed rapid increases in plasma fibrinogen level and subsequent improvement in hemostasis by administration of fibrinogen concentrate after CPB termination. The average volume of total blood loss decreased by 64% and the average number of transfused units was reduced by 58% in cases of fibrinogen concentrate given, in comparison with cases of only FFP transfused for fibrinogen supplementation.

Conclusions: In patients showing severe hypofibrinogenemia during TAA surgery, timely administration of fibrinogen concentrate just after removal from CPB is effective for hemostasis, and therefore in reducing blood loss and transfused volumes.

Figure 1

Time course of the fibrinogen level and transfusion with fresh frozen plasma in a patient receiving TAA surgery. The plasma fibrinogen level (mg/dL) and the platelet count are shown in a case of 71-year-old woman with dissecting aneurysm at aortic arch. The time points of administration of fresh frozen plasma (FFP) after cardiopulmonary bypass (CPB) are also indicated. The duration of CPB is shown as a gray box. FFP-5, 5 units of FFP.

Figure 2

Time course of the fibrinogen level and administration with fibrinogen concentrate in a patient receiving TAA surgery. The plasma fibrinogen level (mg/dL) and the platelet count are shown in a case of 63-year-old man with replacement of ascending thoracic aorta. The time points of administration of fibrinogen concentrate (FC) after cardiopulmonary bypass (CPB) are also indicated. The duration of CPB is shown as a gray box.

Figure 3

Time course of the fibrinogen level and administration with fibrinogen concentrate in a patient receiving TAA surgery. The plasma fibrinogen level (mg/dL) and the platelet count are shown in a case of 45-year-old man with replacement of aortic root. The time points of administration of fibrinogen concentrate (FC) after cardiopulmonary bypass (CPB) are also indicated. The duration of CPB is shown as a gray box.

Figure 4

Time course of the fibrinogen level and administration with fibrinogen concentrate in a patient receiving TAA surgery. The plasma fibrinogen level (mg/dL) and the platelet count are shown in a case of 59-year-old man with dissecting aneurysm of descending thoracic aorta. The time points of administration of fibrinogen concentrate (FC) after cardiopulmonary bypass (CPB) are also indicated. The duration of CPB is shown as a gray box.

Figure 5

Volume of blood loss and number of transfusion units during TAA surgery. Open bars: cases treated with only FFP (n = 24); Closed bars: cases treated with fibrinogen concentrate as well as conventional transfusion (n = 25). RBC, red blood cell; FFP, fresh frozen plasma; PC, platelet concentrate. One unit (U) of RBC contains 130 ml of red blood cells derived from 200 ml of whole blood. Five units of FFP contain 400 ml of whole plasma, while 10 units of PC contain 2–3 × 10¹¹ of platelets. The data are presented as the mean ± SD. *p < 0.05; **p < 0.01 (by unpaired t-test).