Packing the chest –harbinger of death or a useful hemostatic manoeuvre in aortic surgery – a matched case-control study.

Ishtiaq A Rahman,  Mahmoud Loubani, Aaron Ranasinghe, Reena Panchal, Viv Barnett, Timothy R Graham, Ian C Wilson, Domenico Pagano, Steve Rooney, Jorge G Mascaro,  Robert S Bonser,

American Association for Thoracic Surgery

Aortic Symposium 2010, New York

Objectives

Packing the field with swabs may be the last resort for persistent intra-operative bleeding.

We aimed to compare outcomes in such cases versus matched controls.

Methods

Patients undergoing aortic surgery via median sternotomy identified (1997-2009).

Patients requiring mediastinal packing individually matched via operative database for controls.

Matching performed by investigators blinded to outcome for operation type, urgency, age, gender, operative priority, number of previous operations, era of operation, vascular pathology.

Results

Aortic procedures via median sternotomy n=790

Patients requiring packing n=49

Non-packed Controlsn=49

Results

Packed group (n=49)

Non-packed controls (n=49)

P=

Age (years) 54±17 55±16 0.82

Gender (male:female) 32:17 32:17 1.00

Operative priority

Emergency/Urgent

26 26 1.00

Elective 23 23Logistic Euroscore 13(3.4-20.3) 16.6(8.5-26.0) 0.2

1

Results

Packed Non-packed

Pathology Degenerative 21 21Acute dissection 16 18Chronic dissection 2 3Mycotic/infective 3 4Connective tissue disorder

6 1

Pseudoaneursym 1 0Operative Type

Root±ascending±CABG 33 27Ascending±Valve 12 12Arch replacement±other 3 5Arch+descending±TAAA 1 3

Redo procedures n=(%) 17(34) 15(30)

Results – Transfusions in Theatre

Packed group (n=49)

Non-packed controls (n=49)

p=

RBC 2(1-3) 1(1-2) 0.50FFP 2(1-4) 2(1-4) 0.80Platelets 2(0-2) 2(0-2) 0.23Cumulative CPB (mins) 278±100 215±73 <0.01Cumulative AXC (mins) 168±59 141±32 <0.01

Results – Transfusions on ITU

Packed group (n=49)

Non-packed controls (n=49)

p=

RBC 3(2-5) 1(1-3) 0.01FFP 2(0-4) 1(0-2) 0.02Platelets 1(0-2) 0(0-0) <0.01Blood loss (packing) (ml)

1128±813

Time (packing) (mins) 2112±1931Total blood loss (mls) 2250±1238 1203±829 <0.01

Results

Packed(n=49)

Non-packed(n=49)

p=

ITU stay (days) 7(5-13) 5(2-9) 0.09

Ventilation (days) 3(2-9) 1(1-4) 0.29

Inotropic support 37/47(79%)

27/45(60%) 0.07

Stroke 3/49(6%) 3/49(6%) 1.0New hemofiltration 12/47(25%

)4/44(9%) 0.0

5Non-sternal infection 13/46(28%

)8/43(19%) 0.3

3Post-operative stay (days)

14(9-21) 13(8-25) 0.35

In-hospital mortality 11/49(22%)

6/47(13%) 0.29

Results

Survived to discharge

Overall follow-up 3.1yrs

Packed group Non-packed group

3 year survival for all cause mortality

82% 93%

Results – long term survival

p=0.192

Follow_up500040003000200010000

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2-censored1-censored21

Group

Survival Functions

Conclusion

Packing is a reasonable treatment option when primary haemostasis cannot be achieved.

Similar survival to matched controls, without an increase in infective complications, but is associated with an increased transfusion and ventilation time.

It remains an important bail-out technique to secure haemostasis in this high risk population.