Management of Fulminant Fibrinolysis During Abdominal Aortic Surgery
Matthias Vorweg, MD, Burkhard Hartmann, MD, Dirk Knu¨ ttgen, MD, Monika Carola Jahn,
and Manfred Doehn, MD
I
N ABDOMINAL AORTIC ANEURYSM surgery, coagula-
tion complications can have a decisive impact on the patient’s
outcome. The origin of coagulation disorders are diverse, and their
effects and additional fibrinolytic events can be disastrous. Usually
no bedside coagulation monitoring is available during abdominal
aortic aneurysm surgery. Conventional thromboelastography for
detection of lysis is often too complicated and time-consuming for
therapeutic use. The authors have implemented a new monitoring
method based on the principle of conventional thromboelastogra-
phy. Four different activated tests are performed with the ROTEG
coagulation analyzer (Pentapharm, Munich, Germany). It com-
prises 4 channels for parallel examination, automatic pipetting,
and computer analysis. Using this technique, specific therapy can
be initiated within a few minutes, resulting in a lasting cessation of
bleeding.
CASE STUDY
A 73-year-old woman was scheduled for minimally invasive
surgery for an abdominal aortic aneurysm with an endovascular
aortic graft. The patient’s medical history included coronary artery
sclerosis with unstable angina pectoris, myocardial infarction,
mitral valve replacement, arterial hypertension, atrial fibrillation,
and transient ischemic attacks. She was on the following medica-
tions: metoprolol, furosemide, spironolactone, digoxin, warfarin,
and ranitidine. Warfarin had been discontinued 2 days before the
operation and had been replaced by low-dose heparin, 7,500 IU
twice a day. The evening before the operation, the patient received
2 U of fresh frozen plasma. The international normalized ratio
(INR) was 1.79, and partial thromboplastin time (PTT) was 61.8
seconds (normal value, Ͻ42 seconds). The other laboratory values
were within the normal range.
Induction of anesthesia and the first part of the operation were
uneventful. After 120 minutes, rupture of the iliac artery led to
hypotension and tachycardia. Initially the blood pressure could be
maintained with a bolus of 100
g of epinephrine. The surgeon
abandoned the primary procedure and turned to immediate lapa-
rotomy and clamped the aorta. In this situation, the circulation
could be maintained only with large amounts of epinephrine (0.2
g/kg/min). The patient developed ventricular fibrillation 3 times,
which was treated with defibrillation (currents of 200, 250, and
300 J). Under resuscitation conditions, the operation continued.
The course was complicated by additional diffuse bleeding on top
of the surgical bleeding. Tests from the emergency laboratory and
the ROTEG analyzer were used to monitor the bleeding situation
and guide further therapy.
The ROTEG monitor is similar to a conventional throm-
boelastography system used for analysis of clot formation.
Information concerning all phases of the coagulation process
can be gathered: beginning of coagulation (coagulation time
[r]), kinetics of coagulation (clot formation time [k]) , maximal
clot firmness (maximal amplitude [MA]), and extension of
fibrinolysis capacity (maximal lysis [ML]) (Fig 1). Handling
the device is simplified by the help of the computer-guided
program and the automatic pipette. In contrast to conventional
thromboelastography, the ROTEG monitor is unaffected by
vibration. Four channels are available for simultaneous mea-
surement. Each test requires 0.3 mL of citrate-anticoagulated
blood. The blood is recalcified with 20
L of calcium chloride,
and activation of coagulation can be performed with different
agents. Seven test kits are currently available from the manu-
facturer of ROTEG (Table 1):
1. Extrinsic thromboelastogram (Exteg): Extrinsic acti-
vation of coagulation with 20
L of tissue thrombo-
plastin for factors VII, X, V, II, and I and platelets.
2. Intrinsic thromboelastogram (Integ): Intrinsic activa-
tion of coagulation with 20
L of partial thromboplas-
tin for factors XII, XI, IX, VIII, X, V, II, and I and
platelets.
3. Aprotinin thromboelastogram (Apteg): Activation
with 20
L of a 9:1 mixture of Exteg and aprotinin.
Aprotinin inhibits fibrinolysis. Because of the 10%
share of aprotinin in the test substance, coagulation
time in the Apteg can be raised by 10 seconds com-
pared with the simple Exteg. Results regarding the
influence on hyperfibrinolysis by aprotinin in the
Apteg are available within 5 minutes.
4. Fibrinogen thromboelastogram (Fibteg): Exteg activa-
tion plus 10
L of abciximab (ReoPro). Abciximab
prevents accumulation of fibrin to platelets by occu-
pying the fibrin binding site, the glycoprotein IIb-IIIa
receptor. It is used to estimate the amount of fibrino-
gen in the coagulation process.
5. Heparinase thromboelastogram (HepTEG): Activation
after Integ plus 20
L of heparinase, a heparin pro-
cessing enzyme. By using heparinase in the test, a
heparin-induced coagulation disorder can be detected
immediately.
6. Ecarin thromboelastogram (Ecateg): Heparin-inde-
pendent activation of the intrinsic system with 20
L
of ecarin acid. This test allows monitoring of lepirudin
therapy during heparin-induced thrombocytopenia.
Ecateg is suitable for factors XII, XI, IX, VIII, X, V,
II, and I and platelets.
7. Native thromboelastogram (Nateg): Native throm-
boelastography can be done either from a freshly
drawn sample without anticoagulation or from a re-
calcified sample.
The normal values in Table 1 were established first from 30
healthy volunteers, then evaluated retrospectively in Ͼ300
From the Department of Anesthesiology, Klinikum Ko¨ln-Merheim,
Cologne, Germany.
Address reprint requests to Mattias Vorweg, MD, Department
of Anesthesia, Sta¨dtische Kliniken Ko¨ln, Krankenhaus Merheim,
Ostmerheimer Strasse 200, D-51109 Cologne, Germany. E-mail:
Mattias.Vorweg@uni-koeln.de
Copyright © 2001 by W.B. Saunders Company
1053-0770/01/1506-0022$35.00/0
doi:10.1053/jcan.2001.28337
Key words: abdominal aortic aneurysm, coagulation disorder,
thromboelastography, ROTEG coagulation analyzer, cardiopulmonary
resuscitation
764
Journal of Cardiothoracic and Vascular Anesthesia,
Vol 15, No 6 (December), 2001: pp 764-767