Systematic Review of Hemostatic Agents used in Vascular Surgery

SLR - February 2021 - Tung V. Dao

Reference: Allotey JK, King AH, Kumins NH, Wong VL, Harth KC, Cho JS, Kashyap VS. Systematic Review of Hemostatic Agents used in Vascular Surgery. J Vasc Surg. 2020 Nov 27:S0741-5214(20)32489-7.

Level of Evidence: II

Scientific Literature Review

Reviewed By: Tung V. Dao, DPM
Residency Program: Grant Medical Center – Columbus, OH

Podiatric Relevance: Maintaining peri-operative hemostasis in podiatric surgery is essential to decrease blood loss, complications, and operative time. This study aims to conduct a systematic review of topical hemostatic agents used in vascular surgery with measured “time to hemostasis” as the primary outcome but also looks into the mechanism of action, cost and safety of agents.

Methods: Different groups of hemostatic agents were compared using bleeding rates, decreased operation time and complications. All studies included were single center or multicenter prospective randomized control trials involving greater than 10 patients. Open vascular surgeries included carotid, aortic, femoral and peripheral vascular repairs.

Results: There were 12 articles included in this study. Time to hemostasis was shorter with lyostypt than in surgicell. 54.2 percent of patients treated with fibrin sealants (ZLB and Bioplasma) experienced immediate hemostasis compared to 0 percent of patients treated with surgical or manual pressure. Hemostasis was achieved in four minutes in 76.1 percent (83/109) of patients treated by fibrin Sealant Grifols compared to 22.8 percent (13/57 patients) of control patients. Quicker hemostasis, mean blood loss during operation, and mean blood loss after clamp removal favored fibrin sealant, Tachosil, compared to manual compression. At a polymerization time of two minutes, 62.5 percent (15/24) of subjects treated with Tisseel experienced 4-minute hemostasis compared to 34.8 percent (8/23) treated with manual compression. Four minute hemostasis was achieved in 62.9 percent (44/70) treated with Tisseel compared to 31.4 percent (22/70) control. Time to hemostasis was shorter for the Floseal group than for the thrombin soaked gel foam (TSG) group. There was no statistically significant difference in hemostasis within 15 minutes between patients treated with Tisseel (12/24) and TSG (12/23) (P =.882). In four minutes, hemostasis was achieved in 63 percent (64/101) of Fibrin sealant Beriplast P. treated patients compared to 40 percent (40/99) of control subjects treated with TSG (P=.0018). Time to hemostasis, blood loss and time to wound closure were less in the TSG agent. Sites treated with CoSeal demonstrated immediate anastomotic sealing compared to Gelfoam/Thrombin treated sites (80 percent vs. 37 percent). Ultimate sealing was realized in significantly more CoSeal-treated sites than control sites (87 percent vs. 51 percent). The follows agents are listed from least to most expensive: absorbable agents, biologically active, dual agents, and synthetic adhesives. Porcine and bovine products carry the risk of causing anaphylactic reactions in some patients.

Conclusions: There is a lack of literature that compares efficacy, safety, and prices of available hemostatic agents. There were agents which demonstrated faster hemostasis than others, but most were able to achieve hemostasis within 10 minutes. A limitation of this study is the possible inclusion of outdated information on some hemostatic agents. In conclusion, less expensive absorbable agents may suffice for adequate hemostasis.