HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Svensson, L. G. Articles by Kimmel, W. A. Search for Related Content PubMed PubMed Citation Articles by Svensson, L. G. Articles by Kimmel, W. A.

Ann Thorac Surg 1995;59:1501-1508
© 1995 The Society of Thoracic Surgeons

Prospective Evaluation of Minimal Blood Use for Ascending Aorta and Aortic Arch Operations

Center for Aortic Surgery, Lahey Clinic, Burlington, Massachusetts

Accepted for publication February 23, 1995.

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment Conclusion Appendix 1. Appendix 2. Appendix 3. Appendix 4. Appendix 5. Appendix 6. Acknowledgments References

 
The feasibility, safety, and impact on postoperative hospital stay of performing ascending aorta and aortic arch operations without homologous blood transfusions have not been evaluated. Sixty consecutive patients, 38 (63%) of whom also had aortic valve replacements and 17 (28%) of whom also had coronary artery bypass grafting, were evaluated for participation in blood conservation measures. Of the 45 who were able to use blood conservation techniques, 87% (39/45) required no intraoperative and 69% (31/45) required no in-hospital homologous blood transfusions. The 30-day survival rate was 98.3% (59/60), and no patient sustained a new stroke, neurologic cognitive deficit, or infection. Multivariate analysis of the 60 patients showed that the predictors of in-hospital homologous transfusion were (p < 0.05) age, cardiopulmonary bypass time, and postoperative chest tube drainage. Preoperative autologous blood donation was associated with a significantly lower risk of homologous transfusion (p = 0.0006). Indeed, patients participating in blood conservation techniques had a significantly (p < 0.05) lower incidence of homologous transfusions, required less intraoperative shed blood washing, were extubated earlier, gained less weight, had shorter hospital stays, and were discharged in a better dyspnea functional class. Most major elective cardiovascular operations on the ascending aorta and aortic arch can be safely performed without homologous transfusions.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment Conclusion Appendix 1. Appendix 2. Appendix 3. Appendix 4. Appendix 5. Appendix 6. Acknowledgments References

 
The risk of human immunodeficiency virus infection is believed to be approximately 1:153,000 for homologous blood transfusion and that of hepatitis infection, 1:200 [1]. Thus, the need of preoperative autologous blood donation has become increasingly important to reduce the homologous blood shortages and the risks of homologous blood donation because of viral infections and transfusion-related illnesses [2]. Several studies involving patients undergoing a heart operation [3–8] have documented the value of applying blood conservation techniques, including preoperative autologous blood donation, erythropoietin, intraoperative blood salvage, intraoperative plasmapheresis, and postoperative reinfusion of shed blood from chest tubes, to reduce the risk of transfusion of homologous blood and blood products. Such studies, however, have not been reported for patients undergoing cardiovascular operations on the ascending aorta or the aortic arch probably because of the sheer magnitude of these types of operations and the general expectation that large blood transfusions will be unavoidable.

Previously, the average number of intraoperative homologous units of blood required for ascending aorta or aortic arch operations has been reported to be, respectively, 4 and 6 red blood cell units, 11 and 14 fresh frozen plasma units, 20 and 20 platelet units, and 6.5 and 10 cryoprecipitate units [5]. For patients requiring these operations in conjunction with deep hypothermia and circulatory arrest, the average intraoperative requirements have been reported to be 6 red blood cell units, 16 fresh frozen plasma units, 20 platelet units, and 20 units of cryoprecipitate [5, 9]. These large blood transfusions, however, are associated with several complications such as development of coagulation problems, postoperative respiratory problems, multiple-organ failure, and delayed viral infections (including cytomegalovirus, hepatitis B and C viruses, and human immunodeficiency virus) [5, 10]. In a prospective, nonrandomized study, we evaluated the feasibility and safety of using blood conservation techniques for patients undergoing operation on the ascending aorta, the aortic arch, or both.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment Conclusion Appendix 1. Appendix 2. Appendix 3. Appendix 4. Appendix 5. Appendix 6. Acknowledgments References

 
Sixty consecutive patients referred to one of us (L.G.S.) between October 1, 1991, and July 14, 1994, were prospectively evaluated for the possibility of undergoing operation without homologous blood or blood product transfusion. Those patients (n = 15) who were excluded from donating autologous blood and blood products preoperatively because of time constraints or safety reasons had one or more of the following: emergency operation, 9; severe coronary artery disease with unstable angina, 9; New York Heart Association class IV angina or dyspnea, 8; aortic rupture, 3; unstable acute aortic dissection, 3; severe infection associated with endocarditis or infection of grafts previously inserted elsewhere, 2; and severe aortitis with symptomatic cerebrovascular disease, 1.

The 45 patients who could undergo an elective procedure were referred for preoperative autologous blood donation. The collected blood was separated into packed red blood cells and the plasma frozen for later use as fresh frozen plasma. In addition, between 1 day and 5 days preoperatively, patients also donated platelet-rich plasma. After induction of anesthesia, blood was continuously processed from the patients and separated into red blood cell units and platelet-rich plasma by plasmapheresis at the commencement of the operation. Intraoperatively, all blood that was collected either before anticoagulation with heparin sodium or after reversal of anticoagulation with protamine sulfate was centrifuged for reinfusion as red blood cell concentrates. Patients also received 5 g of -aminocaproic acid intraoperatively with reversal of anticoagulation by protamine followed by 1 g/h for 5 hours thereafter to reduce the risk of fibrinolysis. No aprotinin was used in this study, and only 1 patient received erythropoietin preoperatively. After reversal of anticoagulation, collected autologous blood and blood products were reinfused. Postoperatively in the intensive care unit, shed blood from the chest tubes was reinfused after filtration with a 120-µm filter at 4-hour intervals for the first 12 to 16 hours.

If the hematocrit dropped to less than 15% during cardiopulmonary bypass or if the hematocrit was less than 20% postoperatively, the patient was given packed cells to raise the hematocrit. However, if the patient was less than 60 years of age and there was no evidence of acidosis, a postoperative hematocrit of 17% was accepted. If the patient was in hemodynamically unstable condition postoperatively or showed evidence of organ dysfunction or acidosis, a higher hematocrit was obtained by transfusion of packed red blood cells.

Surgical Management
All patients underwent repair of the ascending aorta, the aortic arch, or both. Briefly, patients with only ascending aortic aneurysms had insertion of a tube graft with end-to-end sutured proximal and distal anastomoses without watertight wrapping of the transected proximal and distal aorta [10]. No intraluminal grafts were used. For patients with separate aortic valve and ascending aortic disease with a preserved sinotubular ridge, the aortic valve and ascending aorta were repaired separately [10].

In patients with Marfan's syndrome or a flask-shaped Erdheim-type deformity of the ascending aorta, a composite valved graft was inserted [11–15]. The most frequently used technique was that of reattachment of the right coronary artery as a buttressed aortic button and reanastomosis of the left main coronary artery by a tube graft from the ascending aortic graft to the left main coronary ostium [15]. This has been found to reduce the amount of blood loss from the anastomoses without early or late complications. For those patients with Marfan's syndrome who also had mitral valve disease that was not reparable, replacement of the mitral valve was performed through the aortic annulus.

In patients who required replacement of the aortic arch or who underwent operation for acute dissection, deep hypothermia with circulatory arrest was used as described previously [16–19]. In addition, retrograde perfusion of the brain by way of the superior vena cava and jugular veins was performed for further protection of the brain in 11 patients as previously described [9].

For patients who had extensive aneurysms involving the ascending aorta, aortic arch, and descending thoracic or thoracoabdominal aorta, the two-stage, so-called elephant trunk operation was performed, which entailed replacing the ascending aorta and aortic arch and leaving the distal end of tube graft free in the descending aorta for later use at the second stage [19]. One patient, however, was not a candidate for this operation because of a very large, symptomatic aneurysm. The patient underwent successful replacement of the entire aorta from the aortic valve to the aortic bifurcation during one operation using both a mediastinal approach and a left thoracoabdominal incision with deep hypothermia and circulatory arrest with retrograde brain perfusion [20]. One other patient, who had acute dissection of the ascending aorta associated with coarctation of the aorta at the isthmus, had insertion of a composite valved graft and insertion of a tube graft from the ascending aorta to the supraceliac aorta during the same operation without the need of a homologous blood or blood product transfusion.

Figure 1 shows preoperative and postoperative films from a patient who was seen with a type I aortic dissection after insertion of a porcine aortic valve. The aortic dissection had ruptured in the abdominal aorta. The abdominal aorta was initially repaired with a bifurcated aortic graft followed later by a repair of the ascending aorta and aortic arch using a composite valved graft, a right coronary artery bypass graft, replacement of the aortic arch, and a descending aortic elephant trunk graft for the later second-stage descending aortic repair. This patient, undergoing a reoperation, required only 10 units of cryoprecipitate intraoperatively for a low fibrinogen level. One patient who underwent a successful aortic valve, ascending aorta, and aortic arch replacement with a proximal descending aortic elephant trunk procedure required no intraoperative or postoperative blood transfusion, nor did he require a blood transfusion for the later descending thoracic aortic replacement.

View larger version (171K): [in this window] [in a new window]   Fig 1. . (A) Preoperative diagram, angiogram, and computed tomographic scans, from a patient with previous aortic valve replacement, aortic dissection, and intraabdominal rupture of the aortic dissection. (B) Postoperative diagram and angiogram after insertion of composite valved graft, right coronary artery bypass graft, and replacement of the ascending aorta, aortic arch, and descending thoracic aorta. The abdominal aortic repair of the rupture with a bifurcated tube graft was performed before the ascending aorta and aortic arch repair.

Statistical Analysis
A total of 103 potential univariate variables associated with homologous blood or blood product transfusion were collected prospectively. Variables were analyzed by ² analysis or Student's t test and stepwise multivariate logistic regression analysis. The stepwise logistic regression analyses were performed using the data from all 60 patients with the Biomedical Data Processing package (BMDP; UCLA, Los Angeles, CA), as multivariate analysis would adjust for risk factors and differences between the patients, including between the patients who did and did not participate in the blood conservation measures. Mean values ± the standard deviation are reported. Simple linear regression analysis was performed to elucidate variables that had a close correlation.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment Conclusion Appendix 1. Appendix 2. Appendix 3. Appendix 4. Appendix 5. Appendix 6. Acknowledgments References

 
Of the 60 patients prospectively evaluated, 15 were deemed to be unsuitable candidates for autologous blood donation or blood conservation techniques as previously described. Blood conservation techniques were used in the remaining 45 patients. These 45 patients preoperatively donated the following: a mean of 2.07 ± 1.2 units of autologous red blood cells; 1.89 ± 1.7 units of autologous fresh frozen plasma; 5.87 ± 5.1 units of platelets; and 843.2 ± 459.2 mL of intraoperative platelet-rich plasma. -Aminocaproic acid was given to 42 (93.3%) of the 45 patients. Of the 45 patients in the blood conservation program, 39 (87%) had no intraoperative homologous blood or blood product transfusions, and 31 (69%) had no transfusions during hospitalization for the operation. For the entire group of 60 patients, a mean of 2.17 ± 8.8 units of homologous red blood cells, 2.2 ± 10.4 units of fresh frozen plasma, 2.8 ± 10.3 units of platelets, and 2.3 ± 14.4 units of cryoprecipitate concentrate were required. The overall mean number of days patients (n = 60) required hospitalization after operation was 12.4 ± 10.9 days. The mean, however, was considerably shorter for the blood conservation group (n = 45), (mean time, 10.6 ± 9.3 days) compared with the patients who did not have blood conservation measures (n = 15) (mean time, 17.7 ± 13.9 days; p = 0.0296). The influence of variables on patients receiving homologous blood or blood products by univariate and multivariate analyses is shown in Appendices 1 and 2.

Clinical Outcome
The overall survival rate was 98.3% for the 60 consecutive patients with only one 30-day postoperative death. This patient, who died intraoperatively of respiratory failure, could not be ventilated at the end of cardiopulmonary bypass despite the use of 100% oxygen, maximal positive end-expiratory pressure, and attempts at jet ventilation. The request for a postmortem examination was denied, and the cause of the respiratory failure was never established.

No patient sustained a new postoperative stroke or neurologic cognitive change including those patients who had deep hypothermic circulatory arrest with retrograde perfusion of the brain. There were no postoperative graft infections, wound infections, myocardial infarctions, or multiple-organ failures. One patient undergoing a third reoperation with insertion of a composite valved graft and coronary bypass grafting for destruction of the aortic root by Staphylococcus aureus associated with aortic dissection required reexploration for postoperative bleeding.

On late follow-up, there were no late viral infections, no strokes, and no reoperations. One patient with preoperative cirrhosis associated with both hepatitis A and chronic hepatitis B infections had development of hepatic failure after operation and died 54 days postoperatively. One other late death was sudden and due to unknown reasons 1 year after operation. The patient had extensive aortitis with occlusion of the right internal carotid artery and left common carotid artery and stenosis of the left subclavian artery with the brain being perfused by the left vertebral artery. The patient had previously undergone bilateral carotid endarterectomies. In addition to the aortic operation, bypass grafts from the aortic arch to the left common carotid and left subclavian arteries were performed. No postmortem examination was undertaken.

Correlation Analysis
Simple linear regression analysis elucidated that there was a close correlation between the following variables: postoperative extubation day and postoperative discharge day (p < 0.0001, r = 0.7754); postoperative weight gain and postoperative discharge day (p = 0.0002, r = 0.5140); intraoperative units of homologous red blood cells and postoperative discharge day (p = 0.0002, r = 0.4680); cardiopulmonary bypass time and postoperative discharge day (p = 0.0001, r = 0.4781); and intraoperative homologous red blood cell units and day of extubation (p = 0.0002, r = 0.4602).

Multivariate Analysis
In-hospital homologous blood or blood product transfusion was determined by (p < 0.05) increasing patient age, cardiopulmonary bypass time, and chest tube drainage after operation (Appendix 3). Autologous blood donation was associated with a reduced risk (p = 0.0006) of homologous transfusions. The determinants of patients being discharged more than 8 days after operation were as follows (p < 0.05): preoperative valvular or aortic infection, in-hospital homologous blood or blood product transfusion, grade of aortic disease, lack of autologous fresh frozen plasma, increasing cardiopulmonary bypass time, delayed postoperative extubation, preoperative weight, and postoperative homologous blood transfusion (Appendix 4). The only significant difference on multivariate analysis of preoperative and operative variables between the two groups of patients was that the blood conservation group donated preoperative autologous blood (p = 0.0021) (Appendix 5). Analysis of outcomes by multivariate analysis showed that patients who had blood conservation measures (p < 0.05) were discharged from the hospital earlier, had less intraoperative homologous blood or blood product transfusions, required less collected intraoperative blood washed and retransfused, required less postoperative blood products, and were discharged in a better New York Heart Association class for dyspnea (Appendix 6).

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment Conclusion Appendix 1. Appendix 2. Appendix 3. Appendix 4. Appendix 5. Appendix 6. Acknowledgments References

 
This prospective, nonrandomized study has shown that elective major aortic operations can be safely performed without homologous blood or blood products using blood conservation techniques. Further, this study suggests that blood conservation measures, when feasible, may benefit the patient, reduce the risk of disease transmission, result in earlier extubation, shorten postoperative hospital stay, and may result in cost savings. Obviously, these patients may have been at better risk to undergo operation; nevertheless, we believe they did better with blood conservation techniques. The use of blood conservation techniques for major operations on the ascending aorta and aortic arch to reduce the use of homologous blood has not been reported previously probably because these are among the largest operations performed and generally have required large volumes of blood transfusions [5, 9]. However, reduction of homologous blood usage is obviously feasible. Clearly, only a prospective, randomized study could prove conclusively that patients who have blood conservation measures have a shorter hospital stay resulting in less cost.

Previously, Svensson and Crawford [5, 10] noted that patients who underwent cardiovascular operations on the ascending aorta or aortic arch with large blood transfusions in the early 1980s later occasionally had development of viral infections, such as human immunodeficiency virus infection, resulting in acquired immunodeficiency syndrome, hepatitis types B and C, and cytomegalovirus infection, leading to late death in some patients. Similarly, viral infections have been reported after coronary artery bypass operations, particularly those performed in the early 1980s [2]. With the improving safety of operation on the ascending aorta, aortic arch, or both, including reduced mortality rates and reduced stroke incidence as demonstrated in this and other reports [10–19], we thought it was important to reduce the risk of homologous blood transfusions and late viral infections after these operations by combining various blood conservation techniques.

Therefore, we combined the use of preoperative autologous blood donation, donation of autologous blood products, intraoperative collection of platelet-rich plasma, retransfusion of washed salvaged red blood cells intraoperatively, and reinfusion of chest tube blood output after operation [3–8]. Using these techniques, homologous blood transfusion requirements were significantly reduced. Hemoglobin substitutes that are being developed may allow for greater volumes of autologous blood to be collected [21], even from patients who have heart failure and severe coronary disease who are currently excluded from preoperative autologous blood donation because of the risk of increasing symptoms, precipitating myocardial infarction, or precipitating death [3].

Pharmacologic agents that have been evaluated with varying degrees of success in reducing the risk of homologous blood or blood product transfusion have included -aminocaproic acid, aprotinin, and erythropoietin [4, 22, 23]. We chose to use aminocaproic acid because this agent is less expensive (approximately $10 for a 10-g postoperative course) and has been shown to be effective in coronary artery bypass operations [22]. The other two pharmacologic agents are expensive, with a preoperative course of erythropoietin costing approximately $3,000 and the intraoperative use of aprotinin costing approximately $1,200 per patient for each operation.

Although aprotinin is clearly effective in reducing the risk of both blood coagulation abnormalities associated with cardiopulmonary bypass and homologous blood transfusion, it has been associated with increased risk of postoperative renal dysfunction in patients undergoing reoperation for coronary artery disease, particularly in patients receiving high-dose aprotinin. In one study [23], renal dysfunction developed in 24.6% of such patients compared with 17% in the control group. Further, there is the reported increased risk of coronary artery bypass graft occlusions, resulting in a greater risk of postoperative myocardial infarction [23]. A cautionary study [24] found that aprotinin in combination with deep hypothermia and circulatory arrest for aortic operations may be hazardous because of the risk of renal failure and multiple-organ failure. For these reasons, we did not use aprotinin, although it might have further reduced the risk of homologous blood transfusions.

In this study, we did not prospectively evaluate the cost of the operations and how blood conservation measures affected cost. Nevertheless, the current cost of collecting a unit of autologous blood and separating it into autologous packed red blood cells and fresh frozen plasma for our blood bank is $40.86 and $5.30, respectively, and for the collection of preoperative platelet-rich plasma, the cost is $191.04. Performing intraoperative collection of platelet-rich plasma in addition costs $58.74. Postoperative reinfusion of shed red blood cells costs $31.00 per reinfusion, which was performed every 4 hours for 12 to 16 hours after operation.

Despite the cost of these blood conservation techniques, hospital stay after operation was shortened and earlier extubation in the intensive care unit was achieved, thus resulting in considerable savings in intensive care and hospital expense. Further, autologous blood and blood product collection is considerably cheaper than purchasing packed red blood cells, fresh frozen plasma, and platelets, the respective costs being $94.58 per unit, $58.70 per unit, and $504.60 for 6 units of homologous random platelets. Thus, the lesser cost of autologous blood collection further supports the use of blood conservation techniques in these patients. An added incentive for blood conservation measures in these patients is that with the shortage of blood and blood products becoming increasingly frequent, we are confident that on the basis of this study, less blood needs to be available for these large operations, a finding that results in further savings in cost, reduces the possibility of blood shortage, and does not overburden the blood transfusion service with unused cross-matched homologous blood.

	Conclusion

Top Footnotes Abstract Introduction Material and Methods Results Comment Conclusion Appendix 1. Appendix 2. Appendix 3. Appendix 4. Appendix 5. Appendix 6. Acknowledgments References

 
Most elective cardiovascular operations involving the ascending aorta and aortic arch can be safely performed without homologous blood or blood products intraoperatively, and more than two thirds of patients can have such an operation without in-hospital homologous blood or blood product transfusions, thus resulting in a shortened hospital stay. These results have been achieved without the regular use of erythropoietin or aprotinin. The use of erythropoietin or aprotinin might have resulted in even better results, although at a greater financial cost and for aprotinin, the possible additional risk of renal failure and multiple organ failure, particularly in patients undergoing deep hypothermia with circulatory arrest.

	Appendix 1.

Top Footnotes Abstract Introduction Material and Methods Results Comment Conclusion Appendix 1. Appendix 2. Appendix 3. Appendix 4. Appendix 5. Appendix 6. Acknowledgments References

 

	Appendix 2.

Top Footnotes Abstract Introduction Material and Methods Results Comment Conclusion Appendix 1. Appendix 2. Appendix 3. Appendix 4. Appendix 5. Appendix 6. Acknowledgments References

 

	Appendix 3.

Top Footnotes Abstract Introduction Material and Methods Results Comment Conclusion Appendix 1. Appendix 2. Appendix 3. Appendix 4. Appendix 5. Appendix 6. Acknowledgments References

 

	Appendix 4.

Top Footnotes Abstract Introduction Material and Methods Results Comment Conclusion Appendix 1. Appendix 2. Appendix 3. Appendix 4. Appendix 5. Appendix 6. Acknowledgments References

 

	Appendix 5.

Top Footnotes Abstract Introduction Material and Methods Results Comment Conclusion Appendix 1. Appendix 2. Appendix 3. Appendix 4. Appendix 5. Appendix 6. Acknowledgments References

 

	Appendix 6.

Top Footnotes Abstract Introduction Material and Methods Results Comment Conclusion Appendix 1. Appendix 2. Appendix 3. Appendix 4. Appendix 5. Appendix 6. Acknowledgments References

 

	Acknowledgments

Top Footnotes Abstract Introduction Material and Methods Results Comment Conclusion Appendix 1. Appendix 2. Appendix 3. Appendix 4. Appendix 5. Appendix 6. Acknowledgments References

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment Conclusion Appendix 1. Appendix 2. Appendix 3. Appendix 4. Appendix 5. Appendix 6. Acknowledgments References

 
Address reprint requests to Dr Svensson, Center for Aortic Surgery, Department of Cardiovascular Surgery, Lahey Clinic, 41 Mall Rd, Burlington, MA 08105.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment Conclusion Appendix 1. Appendix 2. Appendix 3. Appendix 4. Appendix 5. Appendix 6. Acknowledgments References

 

1. Cummings PD, Wallace EL, Schorr JB, Dodd RY. Exposure of patients to human immunodeficiency virus through transfusion of blood components that test antibody negative. N Engl J Med 1989;321:941–6.[Abstract]
2. Cohen ND, Munoz A, Reitz BA, et al. Transmission of retroviruses by transfusion of screened blood in patients undergoing cardiac surgery. N Engl J Med 1989;320:1172–6.[Abstract]
3. Britton LW, Eastlund DT, Dziuban SW, et al. Predonated autologous blood use in elective cardiac surgery. Ann Thorac Surg 1989;47:529–32.[Abstract]
4. Goodnough LT, Rudnick S, Price TH, et al. Increased preoperative collection of autologous blood with recombinant human erythropoietin therapy. N Engl J Med 1989;321:1163–8.[Abstract]
5. Svensson LG, Crawford ES. Aortic dissection and aortic aneurysm surgery: clinical observations, experimental investigations, and statistical analyses. Part I. Curr Probl Surg 1992;19:819–912.
6. Jones JW, Rawitscher RE, McLean TR, Beall AC Jr, Thornby JI. Benefit from combining blood conservation measures in cardiac operations. Ann Thorac Surg 1991;51:541–6.[Abstract]
7. Cosgrove DM, Thurer RL, Lytle BW, Gill CG, Peter M, Loop FD. Blood conservation during myocardial revascularization. Ann Thorac Surg 1979;28:184–9.[Abstract]
8. Axford TC, Dearani JA, Ragno G, et al. Safety and therapeutic effectiveness of reinfused shed blood after open heart surgery. Ann Thorac Surg 1994;57:615–22.[Abstract]
9. Svensson LG, Crawford ES, Hess KR, et al. Deep hypothermia with circulatory arrest. Determinants of stroke and early mortality in 656 patients. J Thorac Cardiovasc Surg 1993;106:19–31.[Abstract]
10. Svensson LG, Crawford ES. Aortic dissection and aortic aneurysm surgery: clinical observations, experimental investigations, and statistical analyses. Part III. Curr Probl Surg 1993;30:1–172.[Medline]
11. Gott VL, Pyeritz RE, Cameron DE, Greene PS, McKusick VA. Composite graft repair of Marfan aneurysm of the ascending aorta: results in 100 patients. Ann Thorac Surg 1991;52: 38–45.[Abstract]
12. Svensson LG, Crawford ES, Hess KR, Coselli JS, Safi HJ. Composite valve graft replacement of the proximal aorta: comparison of techniques in 348 patients. Ann Thorac Surg 1992;54:427–39.[Abstract]
13. Crawford ES, Svensson LG, Coselli JS, Safi HJ, Hess KR. Surgical treatment of aneurysm and/or dissection of the ascending aorta, transverse aortic arch, and ascending aorta and transverse aortic arch. Factors influencing survival in 717 patients. J Thorac Cardiovasc Surg 1989;98:659–73.[Abstract]
14. Kouchoukos NT, Wareing TH, Murphy SF, Perrillo JB. Sixteen-year experience with aortic root replacement. Results of 172 operations. Ann Surg 1991;214:308–18.[Medline]
15. Svensson LG. Approach for insertion of aortic composite valve grafts. Ann Thorac Surg 1992;54:376–8.[Abstract]
16. Griepp RB, Stinson EB, Hollingsworth JF, et al. Prosthetic replacement of the aortic arch. J Thorac Cardiovasc Surg 1975;70:1051–63.[Abstract]
17. Svensson LG, Crawford ES, Hess KR, Coselli JS, Safi HJ. Dissection of the aorta and dissecting aortic aneurysms. Improving early and long-term surgical results. Circulation 1990;82(Suppl 4):24–38.
18. Crawford ES, Kirklin JW, Naftel DC, Svensson LG, Coselli JS, Safi HJ. Surgery for acute dissection of ascending aorta. Should the arch be included? J Thorac Cardiovasc Surg 1992;104:46–59.[Abstract]
19. Svensson LG. Rationale and technique for replacement of the ascending aorta, arch, and distal aorta using a modified elephant trunk procedure. J Cardiac Surg 1992;7:301–12.[Medline]
20. Svensson LG, Shahian DM, Davis FG, et al. Replacement of entire aorta from aortic valve to bifurcation during one operation. Ann Thorac Surg 1994;58:1164–6.[Abstract]
21. Slanetz PJ, Lee R, Page R, Jacobs EE Jr, LaRaia PJ, Vlahakes GJ. Hemoglobin blood substitutes in extended preoperative autologous blood donation: an experimental study. Surgery 1994;115:246–54.[Medline]
22. Daily PO, Lamphere JA, Dembitsky WP, Adamson RM, Dans NF. Effect of prophylactic epsilon-aminocaproic acid on blood loss and transfusion requirements in patients undergoing first-time coronary artery bypass grafting. A randomized, prospective, double-blind study. J Thorac Cardiovasc Surg 1994;108:99–108.[Abstract/Free Full Text]
23. Cosgrove DM III, Heric B, Lytle BW, et al. Aprotinin therapy for reoperative myocardial revascularization: a placebo-controlled study. Ann Thorac Surg 1992;54:1031–8.[Abstract]
24. Sundt TM III, Kouchoukos NT, Saffitz JE, Murphy SF, Wareing TH, Stahl DJ. Renal dysfunction and intravascular coagulation with aprotinin and hypothermic circulatory arrest. Ann Thorac Surg 1993;55:1418–24.[Abstract]

This article has been cited by other articles:

				T. M. Fleck, H. Koinig, M. Czerny, D. Hutschala, E. Wolner, M. Ehrlich, and M. Grabenwoger Impact of surgical era on outcomes of patients undergoing elective atherosclerotic ascending aortic aneurysm operations Eur. J. Cardiothorac. Surg., August 1, 2004; 26(2): 342 - 347. [Abstract] [Full Text] [PDF]

				L. G. Svensson Progress in ascending and aortic arch surgery: minimally invasive surgery, blood conservation, and neurological deficit prevention Ann. Thorac. Surg., November 1, 2002; 74(5): S1786 - 1788. [Abstract] [Full Text] [PDF]

				V. Casati, L. Sandrelli, G. Speziali, G. Calori, M. A. Grasso, and S. Spagnolo Hemostatic effects of tranexamic acid in elective thoracic aortic surgery: A prospective, randomized, double-blind, placebo-controlled study J. Thorac. Cardiovasc. Surg., June 1, 2002; 123(6): 1084 - 1091. [Abstract] [Full Text] [PDF]

				K. Shibata, S. Takamoto, Y. Kotsuka, and H. Sato Effectiveness of combined blood conservation measures in thoracic aortic operations with deep hypothermic circulatory arrest Ann. Thorac. Surg., March 1, 2002; 73(3): 739 - 743. [Abstract] [Full Text] [PDF]

				J. A. Elefteriades Invited commentary Ann. Thorac. Surg., March 1, 2002; 73(3): 743 - 744. [Full Text] [PDF]

				M. P. Vallely, C. F. Hughes, P. G. Bannon, P. N. Hendel, B. G. French, and M. S. Bayfield Composite graft replacement of the aortic root after previous cardiac surgery: a 20-year experience Ann. Thorac. Surg., September 1, 2000; 70(3): 851 - 855. [Abstract] [Full Text] [PDF]

				L. G. Svensson How to obtain hemostasis after aortic surgery Ann. Thorac. Surg., June 1, 1999; 67(6): 1981 - 1982. [Abstract] [Full Text] [PDF]

				C. L. Stowe, M. A. Baertlein, M. D. Wierman, M. Rucker, and G. Ebra Surgical management of ascending and aortic arch disease: refined techniques with improved results Ann. Thorac. Surg., August 1, 1998; 66(2): 388 - 395. [Abstract] [Full Text] [PDF]

				L. G. Svensson Central Nervous System Injury After Aortic Operations: Profits of Amending Old Ways Ann. Thorac. Surg., January 1, 1997; 63(1): 9 - 11. [Full Text]

				T. K. Rosengart, KarlH. Krieger, and J. A. Magovern Predicting Transfusion Ann. Thorac. Surg., December 1, 1996; 62(6): 1885 - 1886. [Full Text]

				L. H. Cohn, R. J. Rizzo, D. H. Adams, S. F. Aranki, G. S. Couper, N. Beckel, and J. J. Collins Jr Reduced Mortality and Morbidity for Ascending Aortic Aneurysm Resection Regardless of Cause Ann. Thorac. Surg., August 1, 1996; 62(2): 463 - 468. [Abstract] [Full Text]

This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Svensson, L. G. Articles by Kimmel, W. A. Search for Related Content PubMed PubMed Citation Articles by Svensson, L. G. Articles by Kimmel, W. A.