Blood Product Transfusion and Antifibrinolytic Choice Are Not Associated with Higher Rates of Intraluminal Thrombus...

Background: Intraluminal thrombus (ILT) is a recognized complication of aortic arch replacement surgery using a frozen elephant trunk (FET) prosthesis, with a postoperative incidence of around 10%. Risk factors for ILT include aneurysmal aortic disease, central graft positioning, and prothrombotic medical conditions. Perioperative blood product transfusion is frequently required in these patients to correct postoperative coagulopathy following cardiopulmonary bypass (CPB). We hypothesized that there may be an association between (i) intra- and postoperative blood product transfusion volumes and the development of ILT and (ii) whether the use of either aprotinin or tranexamic acid is associated with postoperative ILT formation. Methods: Retrospective analysis was carried out on all non-emergency aortic arch replacement procedures at our institution with FET implantation between January 2017 and June 2025. ILT was defined as the presence of thrombus within the aortic graft identified on postoperative computed tomography (CT). Statistical analysis was performed on transfusion data from anesthesia and intensive care unit records. Secondary analysis compared ILT incidence and blood product transfusion volume between patients receiving aprotinin versus tranexamic acid as antifibrinolytic therapy. Results: Of 162 patients, 10 (6.2%) developed postoperative ILT. All patients received blood product transfusion either intraoperatively or postoperatively. There was no statistically significant difference in the volume of individual blood products (red cells, platelets, fresh frozen plasma, cryoprecipitate, or fibrinogen concentrate) received between the ILT and non-ILT groups. The mean total blood product transfusion was 13.50 units (ILT group) versus 11.10 units (no ILT group), with p = 0.897, indicating no significant association. Among 46 patients receiving aprotinin, only one (2.2%) developed ILT, whereas nine of 114 patients (7.8%) receiving tranexamic acid developed ILT. This difference was not statistically significant (p = 0.232). Conclusions: In this single-centre retrospective cohort study, no statistically significant association was detected between perioperative blood product transfusion volume or choice of antifibrinolytic agent (aprotinin versus tranexamic acid) and intraluminal thrombus formation following non-emergency aortic arch replacement surgery. However, the small number of ILT events (n = 10) limits statistical power, and a clinically meaningful association cannot be excluded. These findings provide preliminary reassurance that correction of intra- and postoperative coagulopathy may not increase ILT risk, though larger multicentre studies with adjustment for confounding variables including postoperative anticoagulation practices are warranted.