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J Vasc Surg Cases Innov Tech
J Vasc Surg Cases Innov Tech
Journal of Vascular Surgery Cases, Innovations and Techniques
2468-4287
Elsevier

S2468-4287(24)00166-7
10.1016/j.jvscit.2024.101582
101582
Innovative technique
Intraoperative cell salvage technique in patients undergoing complex endovascular aortic repair
Park Simon S. PhD ab
Weise Lorela MD ab
Bechara Carlos F. MD abc
DeChristopher Phillip J. MD, PhD ad
Soult Michael C. MD Michael.soult@lumc.edu
abc∗
a Loyola University Chicago, Stritch School of Medicine, Maywood, IL
b Department of Surgery, Loyola University Medical Center, Maywood, IL
c Department of Surgery, Edward Hines Jr. Veterans Administration Hospital, Hines, IL
d Department of Pathology and Laboratory Medicine, Loyola University Medical Center, Maywood, IL
∗ Correspondence: Michael C. Soult, MD, Loyola University Medical Center, 2160 S First Ave, Maywood, IL 60153 Michael.soult@lumc.edu
22 7 2024
10 2024
22 7 2024
10 5 1015821 5 2024
3 7 2024
© 2024 The Authors
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Complex endovascular aortic repair (EVAR) requires the use of multiple small sheath cannulation inside a large sheath. Because the large sheath is not designed for multiple small sheath cannulation, large amounts of blood loss can be encountered in complex EVARs. Cell Saver can be used effectively in complex EVARs using a modified draping technique, allowing for increased cell salvage and autogenous transfusions as needed.

Keywords

Cell Saver
Autologous transfusion
Blood transfusion
Endovascular aneurysm repair
Blood management
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pmcOpen aortic surgery has been the gold standard for repair of complex thoracoabdominal aneurysms (TAAAs). However, open aortic repair is often associated with the potential for a large volume of blood loss. Adjuncts, like Cell Saver, have been used to help return autologous blood and minimize transfusion requirements.1 Intraoperative cell salvage is the process of aspirating blood from surgical sites and autotransfusing red blood cells (RBCs). Autologous transfusions have the advantage of superior oxygen delivery and decrease patient exposure to the adverse effects when transfused intraoperatively or shortly postoperatively.2 Autologous blood transfusions avoid the risk of acute transfusion reactions and sensitization to antigens that complicates future cross-matching, and reduces the risk of dose-dependent transfusion-related immunosuppression.2,3 Additionally, it allows for a more oncological way of volume expansion without the restrictions of patient blood management principles for allogeneic donations. It can offer a morally satisfactory option for some cultural groups who object to donor blood transfusions.

With the advent of endovascular aortic repair (EVAR), the more minimally invasive approach is associated with a significant reduction in blood loss during repair of complex TAAA.4 However, with the need to incorporate aortic branches in the repair through fenestrations and branches, it is not uncommon for patients to lose a significant amount of blood over the course of a complex endovascular procedure (eg, >500 mL) and, conversely, undergo short-term adverse events and mortality.5,6 This is due to the fact that the large-bore sheaths used are not designed to accommodate multiple wires and smaller sheaths, resulting in a continuous trickle of blood loss around these smaller sheaths. Blood management, therefore, remains an important practice vascular surgeons must consider when complex EVAR is carried out.

Intraoperative cell salvage is used selectively owing to the separation system that requires an adequate volume of RBCs or a certain hematocrit before the RBCs can be washed and reinfused. Additionally, there is a cost incurred when investing in training, machinery, and disposables. For this reason, it is recommended that Cell Saver be used for anticipated blood loss of >500 mL or 10% of estimated blood volumes, with patients at increased risk of bleeding, those with multiple antibodies or rare blood groups, or those who refuse donor blood products during surgeries with high anticipated blood loss. Cell Saver is underused in endovascular procedures, likely owing to the perception of significantly less blood loss compared with an open repair. Additionally, blood collection on the field during endovascular techniques can be challenging compared with the natural cavity that exists in an open repair, often yielding low volumes with frequent interruptions in the endovascular procedure.7,8 There are limited reports demonstrating the use and benefit of Cell Saver in complex EVARs in the literature.1

Technique

In our current practice, we developed a modified draping technique to facilitate the use of autologous transfusion systems, that we use uniformly in all our complex EVARs, including fenestrated EVARs (FEVAR) and branched EVARs (BEVAR). Cell Saver equipment and staff are on standby and used selectively in cases with high blood collection in these drapes. An angio drape with two adjacent circular cutouts to allow for groin access is placed in the usual fashion. An Ioban (3M, Saint Paul MN) drape with connecting pockets on all four sides (Model number 6617) is then fashioned over the groin access site in the following manner. One edge of the Ioban portion of the drape is lined up with the cranial edge of the circular cutouts on the angio drape. This positioning allows for the majority of the Ioban pockets to be positioned caudal to the end of the large bore sheaths, allowing blood that slowly drips from the large-bore sheaths during wire and small-bore sheath cannulation and exchange to collect in the pockets rather than in the drapes, towels, and laps. The posterior paper of the Ioban drape is peeled off from cranial to caudal, exposing the adhesive side of the Ioban and allowing it to be secured to the underlying angio drape. A sterile blue towel can be added over the Ioban portion to minimize splatter and help cover instruments securing closure devices to prevent wires and sheaths from catching during exchanges. Although the towel may absorb some of the blood loss, it can be wrung out in the pockets to salvage the still viable RBCs. The Cell Saver tubing is then secured at the cranial side of the Ioban drape, but outside the radiographic field. This allows the Cell Saver tubing and machine to sit on the patient's right side, away from the c-arm and above the controls, but still easily accessible to the surgeon. The end of the Cell Saver tubing with a suction tip sits inside the right pocket in the dependent portion to allow for continuous and passive blood suctioning throughout the procedure (Fig 1). This technique has the added advantage of better quantifying blood loss, providing Ioban coverage over the groin for added sterility and preventing blood spillage on the floor or collimator of the c-arm (Fig 2). The collected blood is reinfused either during the procedure or at the end when all the sheaths have been removed if there is sufficient volume collected.Fig 1 Modified draping preparation for perioperative fenestrated endovascular aortic repair (FEVAR) using Cell Saver.

Fig 2 Perioperative fenestrated endovascular aortic repair (FEVAR) modified drape pockets for transferring blood to Cell Saver used in percutaneous and cutdown approaches.

Discussion

EVARs have become the first-line approaches for aortic aneurysmal disease in patients who are older and at increased risk of morbidity and mortality for open repairs. Our evolving knowledge and evolving devices have increased the technical success rates of anatomy that was thought not to be amenable to endovascular repair previously. One of its attractive features is the decrease in blood loss, and thus decrease in perioperative morbidity and mortality owing to blood loss and side effects of blood transfusion. Although the risk of sudden large volumes of hemorrhage are less likely, complex aortic endovascular repairs can result in a significant, and sometime comparable, amounts of blood loss as open aortic repairs from continuous leaks around sheath valves or access sites, and sudden losses during arteriotomy closures. Sen et al6 noted that in 370 patients treated by F-BEVAR for pararenal and TAAA, average blood loss was 799 ± 982 mL and was significantly higher for patients with TAAA compared with pararenal aneurysms. Intraoperative blood salvage was used in 52% of patients with a mean volume of 518 ± 446 mL. Thirty-day mortality and major adverse events occurred in 33% of patients, 20% of whom had an estimated blood loss of >1 L. Transfusion of packed RBCs of >1 L was associated with major adverse events and mortality.

In a large retrospective analysis of 959 patients who underwent elective FEVAR/BEVAR from 2008 to 2017, 24.8% experienced bleeding or anemia requiring transfusions (BAT). BAT after FEVAR/BEVAR was associated with higher in hospital (11.3% vs 2.6%), 30-day (12.2% vs 3.1%), and 90-day (18.5% vs 4.4%) mortality rates (all P < .001). Additionally, myocardial infarction (23.9% vs 2.8%) and paraplegia (9.7% vs 0.7%) were more frequent in the group requiring transfusions (all P < .001). In multivariable analyses, BAT was associated with worse short-term (odds ratio, 3.19; 95% confidence interval, 1.63-6.33; P = .001) and long-term survival (hazard ratio, 1.62; 95% confidence interval, 1.24-2.11; P < .001).9

Given the nature of the operative field on the pelvis, regardless of whether a cutdown is deployed, collection of lost blood is difficult and less effective than collecting blood from an abdominal cavity. This modified draping technique allows us to better quantify blood loss and effectively collect it without interference during the procedure.

Two methods of cell salvage include the more popular washing of RBCs with removal of platelets, clotting factors, toxic byproducts, debris and contaminants, or filtering of whole blood, allowing for the return of platelets and clotting factors but without the removal of harmful products.3,8,10 Within the RBC washing category, there are variations in RBC recovery and efficacy of removing byproducts. Cell Saver Autotransfusion Device (Haemonetics Corp., Braintree, MA) is one of the RBC washing devices with the highest RBC recovery, and is used at our facility.11

There is debate regarding the cost effectiveness of cell salvage devices. Many studies have looked at its use in high blood loss vascular surgeries, namely, open aortic reconstructions for aneurysmal or occlusive disease. The cost for set up of the Cell Saver Autotransfusion Device ranged from $325 to $475. The average cost of homologous blood purchased was estimated $200 per unit of RBCs, and more than double this to transfuse owing to the added cost of transport, storage, labeling, modifications, regulatory compatibility testing, and administration. Blood loss varied depending on the indication and complexity of the case and study, but generally averaged 500 to 1700 mL. Cell Saver volume salvaged and reinfused ranged from 600 to 1700 mL. Most estimated a cost saving of $300, with the most cost effective being for surgeries where blood loss was >1000 mL and Cell Saver return was >500 to 750 mL, which is the equivalent of 2 U of blood. Cell salvage was found to be safe in all studies, with most authors concluding that its use should be on a case-by-case basis, but is most beneficial during large or unexpected blood losses.12, 13, 14, 15

Conclusions

Large volumes of blood loss requiring transfusions is not uncommon in FEVAR/BEVAR. Cell Saver as a method for autologous transfusion and blood conservation is feasible during complex EVAR procedures. The use of this modified draping technique in adjunct with Cell Saver can decrease significantly the risks associated with bleeding and improve patient outcomes.

Disclosures

M.S. and C.F.B. perform consulting for W. L. Gore & Associates and Cook Medical.

The editors and reviewers of this article have no relevant financial relationships to disclose per the Journal policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest.
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