From the Western Vascular Society
Intraoperative blood product resuscitation and
mortality in ruptured abdominal aortic aneurysm
David S. Kauvar, MD,a,bMark R. Sarfati, MD,cand Larry W. Kraiss, MD,cFort Sam Houston, Tex;
Bethesda, Md; and Salt Lake City, Utah
Objectives: The resuscitation of patients with ruptured abdominal aortic aneurysms (RAAAs) has not been well
studied, and the potential benefit of autotransfusion (AT) is unknown. The increased use of fresh-frozen plasma
(FFP) has been associated with decreased mortality rates in trauma patients and may also improve RAAA survival.
We explored the influence of intraoperative AT and FFP resuscitation on mortality rates in massively transfused
Methods: A single-center review of RAAA patient records from April 1989 to October 2009 was undertaken. Clinical data
and outcomes were studied. Operative and anesthesia records were queried for intraoperative transfusion totals. Massive
transfusion was defined as >10 units of red blood cells (RBCs) inclusive of AT units.
Results: We identified 151 RAAA patients, of which 89 (60%) received a massive transfusion and comprised the study
population. These 89 patients had an in-hospital mortality rate of 44%. Univariate predictors of mortality included
increased age, preoperative hypotension, operative blood loss, and crystalloid, RBCs, and FFP volume. AT was used in 85
patients, with an increased ratio of AT:RBC units associated with survival. Mortality was 34% with AT:packed RBCs
(PRBC) >1 (high AT) and 55% with AT:PRBC of <1 (low AT; P ? .04). On multivariate analysis, age > 74 years (P ?
.03), lowest preoperative systolic blood pressure (SBP) <90 mm Hg (P ? .06), blood loss >6 liters (P ? .06), and low
AT (P ? .02) independently predicted mortality. The mean RBC:FFP ratio was similar in those that died (2.7) and in
those that lived (2.9; P ? .66). RBC:FFP <2 (high FFP) was present in 38 (43%) patients, with mortality of 49%.
RBC:FFP >2 (low FFP) had 40% mortality (P ? .39). RBC:FFP ratios decreased over time from 3.6 (years 1989 to 1999)
to 2.2 (years 2000 to 2009; P < .001), but more liberal use of FFP was not associated with decreased mortality (47% vs
41%; P ? .56). AT:PRBC ratios were stable over time (range, 1.4-1.2; P ? .18).
Conclusions: Greater use of AT but not of FFP was associated with survival in massively transfused RAAA patients. No
mortality benefit was seen with increased FFP, but few patients had high FFP transfusion ratios. Further study to identify
RAAA patients at risk for massive transfusion should be undertaken and a potentially greater role for AT in RAAA
resuscitation investigated. (J Vasc Surg 2012;55:688-92.)
Ruptured abdominal aortic aneurysm (RAAA) contin-
ues to have a high mortality rate despite recent advances in
critical care.1,2The mortality risk factors that have been
identified have been reported with an eye toward the triage
of patients in the attempt to determine the feasibility and
justification of repair in certain populations.3Most of the
identified predictors of death are pre-existing patient fac-
tors such as shock and renal failure and cannot be altered
during treatment, limiting their usefulness in planning a
strategy for preventing death.1
Refinements in the intraoperative blood product resus-
citation of massively bleeding trauma patients have resulted
in improved survival in military and civilian experiences.4,5
These refinements have resulted in the widespread accep-
tance of the principles of “damage control,” or “hemo-
static” resuscitation, focusing on increasing the ratio of
fresh frozen plasma (FFP) to packed red blood cell (PRBC)
transfusion in massively transfused patients.6Death in
RAAA patients has been consistently associated with
greater amounts of PRBC transfusion, and many RAAA
patients undergo massive transfusion, defined as the intra-
operative administration of ?10 units of blood. An im-
provement in survival with more liberal administration of
FFP in this population has been reported.7,8
The use of intraoperative autotransfusion (AT) has
been associated with decreased PRBC transfusion in elec-
tive aortic surgery, particularly in patients who require ?1
liter of blood9,10; however, a randomized, controlled trial
failed to confirm this finding.11In its minimal study in
RAAA, the use of AT was identified as being both protec-
tive12and potentially harmful.13
This study investigated our institution’s 20-year expe-
rience with the intraoperative blood product resuscitation
of RAAA patients. Our hypothesis was that more liberal
administration of FFP and increased use of AT would each
be associated with decreased mortality.
From the Vascular Surgery Service, San Antonio Military Medical Center,
Fort Sam Houstona; the Department of Surgery, Uniformed Services
Surgery, University of Utah, Salt Lake City.c
Competition of interest: none.
The views and opinions expressed herein are solely those of the authors and
do not represent those of the United States Department of Defense.
Presented at the Twenty-sixth Annual Meeting of the Western Vascular
Society, Kauai, Hawaii, September 17-20, 2011.
Reprint requests: David S. Kauvar, Vascular Surgery Service, San Antonio
Military Medical Center, 3851 Roger Brooke Drive, Fort Sam Houston,
TX 78234 (e-mail: email@example.com).
The editors and reviewers of this article have no relevant financial relation-
ships to disclose per the JVS policy that requires reviewers to decline
review of any manuscript for which they may have a competition of
Published by Elsevier Inc. on behalf of the Society for Vascular Surgery.