The authors have previously characterized laboratory coagulation abnormalit
ies in patients undergoing thoracoabdominal aneurysm (TAA) repair as a redu
ction in clotting factor activity and an increase in the fibrinolysis that
occurs after supraceliac clamping. A return to normal in these patients did
not occur until the time of skin closure and was influenced by fresh froze
n plasma (FFP) administration. To test the hypothesis that shortening the m
esenteric ischemic time would mitigate the defect earlier in the operative
course, the authors developed a technique of mesenteric shunting during TAA
repair and studied coagulation response prospectively.
Twelve consecutive elective patients had TAA repair carried out in standard
fashion. No heparin was used. After completion of the proximal anastomosis
, a coronary perfusion catheter was secured inside a previously sewn graft
side arm and inserted into either the superior mesenteric artery or the cel
iac axis; the graft was clamped below the side arm. Blood levels of fibrino
gen, F1.2, D-dimer, and Factors II, V, VII, VIII, IX, X, XI, and XII were a
nalyzed at induction, immediately prior to mesenteric shunt insertion, at r
eimplantation of the visceral button and 30 minutes after visceral button r
eimplantation. Clamp times, volume and timing of blood products, and clinic
al outcomes were recorded prospectively. A two-sided, paired t test (pairwi
se/intersample) was applied for each factor studied.
There was no coagulopathic bleeding. Indicators of fibrinolysis (fibrinogen
, D-dimer) continued to rise throughout the procedure as had been true in o
ur previous series. However, clotting factors returned to baseline shortly
after mesenteric shunting and prior to administration of exogenous clotting
factors.
The return to baseline of the coagulation factors studied began at the time
of the insertion of a mesenteric shunt. Visceral perfusion appears to have
an impact on coagulation response. Earlier reperfusion may help extend the
window of operative time by limiting coagulopathic bleeding that is occasi
onally seen during TAA repair.