Fibrinolytic and hemorheologic alterations during and after elective aortic graft surgery: implications for postoperative management.

The hemorheologic and fibrinolytic variables of 15 patients undergoing elective aortic graft surgery were investigated before, during, and after surgery. During the operation, a relative hemodilution was induced intentionally by an infusion of crystalloids and albumin. This led to a decrease in hematocrit (35.5 +/- 6.3-->31.8 +/- 5.6%, P < 0.01), fibrinogen, and platelets, as well as a decrease in fibrinolysis (Euglobulin Clot Lysis Time increases 246 +/- 52-->300 +/- 46 min and fast-acting plasminogen activator inhibitor 1 [PAI-1] activity increases 10.5 +/- 6.9-->15.1 +/- 9 IU/mL, P < 0.01). There was also specific rheologic impairment with a dissociation of erythro-aggregates (primary aggregation time 3.37 +/- 2.63-->7.18 +/- 7.2 s). Tissue-type plasminogen activator (t-PA) antigen was only increased just after surgery (8.3-->14.5 ng/mL, P < 0.01). During the first postoperative week, the acute-phase response subsided. This was accompanied by an increase in fibrinogen, von Willebrand factor antigen, and plasma viscosity (1.33 +/- 0.13-->1.49 +/- 0.13 mPa x s, P < 0.01). Hematocrit and the extrinsic fibrinolytic system (t-PA/PAI) returned to baseline values, whereas intrinsic fibrinolysis remained altered (the Euglobulin Clot Lysis Time, reflecting total activity of plasminogen activators, was still increased). Postoperative management may benefit from a recognition of these two distinct phases induced by surgery. The acute-phase reaction of the first postoperative week is an added vascular risk factor and requires a specific therapeutic approach.