Rotational Thromboelastometry-Guided Hemostatic Therapy for Management of Cerebrospinal Fluid Catheter in Patients Undergoing Endovascular Aortic Repair.

Abstract

Central neuraxial techniques are typically avoided in patients with underlying coagulopathy or abnormal coagulation tests. Vertebral canal hematoma is a rare but devastating complication of those procedures. Although the sensitivity and specificity of standard laboratory tests in predicting this event are rather poor or unknown, these tests are commonly used to allow or advise against the insertion of an epidural or spinal catheter. Furthermore, the role of viscoelastic point-of-care tests, which are widely used to monitor coagulation in the perioperative setting, is unexplored. We report a patient presenting for endovascular repair of a dissecting thoracoabdominal aortic aneurysm, in which we placed a subarachnoid catheter for continuous cerebrospinal fluid drainage because of the high risk of spinal cord ischemia associated with the procedure. Unfortunately, the patient presented with an overt consumption coagulopathy that would have advised against performing any central neuraxial technique. Bedside monitoring, diagnosis, and goal-directed hemostatic therapy guided by thromboelastometry documented improved coagulation both at the time of insertion and removal of the subarachnoid device. No catheter-related complications occurred. Thromboelastometry proved useful to guide hemostatic therapy before subarachnoid catheter placement and extraction in a patient with severe coagulopathy when standard coagulation tests were of less benefit.