Intraoperative Hemostatic Agents in Thoracic Aortic Surgery-A Scoping Review

Background/Objectives: 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. Methods: 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). Results: 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. Conclusions: 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.