What is the management of hematoma and ecchymoses around suture areas 48 hours after Coronary Artery Bypass Grafting (CABG) in a patient on Aspirin (acetylsalicylic acid)?

Hematoma and Ecchymoses Around Suture Sites 48 Hours Post-CABG on Aspirin

Continue aspirin therapy and manage the bleeding conservatively with local measures, as aspirin should not be discontinued post-CABG given its critical role in graft patency and reduction of mortality, MI, and stroke—the modest increase in bleeding risk does not outweigh these life-saving benefits. 1

Primary Causes of Post-CABG Bleeding in Aspirin-Treated Patients

Expected Aspirin-Related Effects

• Aspirin continuation through CABG increases bleeding frequency but not severity: Perioperative aspirin use results in increased blood loss and need for reoperation, but critically shows no increase in mortality and is associated with improved saphenous vein bypass graft patency. 1
• The bleeding increase is modest and acceptable: Low-dose aspirin may result in increased frequency of procedural bleeding (relative risk 1.5) but not an increase in the severity of bleeding complications or perioperative mortality due to bleeding. 1
• Aspirin was likely continued appropriately: Non-enteric-coated aspirin (81-325 mg daily) should be administered preoperatively to patients undergoing CABG, and if not initiated preoperatively, should be started within 6 hours postoperatively. 1

Additional Contributing Factors to Evaluate

Concurrent P2Y12 inhibitor use (most critical to assess):

• Clopidogrel within 5 days pre-CABG: Increases major bleeding risk by 50% and transfusion requirements by 70%. 1
• Ticagrelor or prasugrel: Similar bleeding risks if discontinued <5 days (ticagrelor) or <7 days (prasugrel) before surgery. 1
• Review medication history carefully: Patients on dual antiplatelet therapy (DAPT) have significantly higher bleeding complications, with ticagrelor showing 33.3% surgical re-exploration rate versus 2.56% with clopidogrel when taken within 24 hours of surgery. 2

Technical and coagulation factors:

• Inadequate surgical hemostasis at time of closure
• Residual heparin effect or protamine underdosing
• Platelet dysfunction beyond aspirin effect
• Coagulopathy from bypass circuit or hypothermia

Management Approach

Do NOT Discontinue Aspirin

Aspirin must be continued indefinitely post-CABG: When given within 48 hours after CABG, aspirin reduces subsequent rates of mortality, MI, stroke, renal failure, and bowel infarction—these benefits far outweigh bleeding concerns. 1

Conservative Management Strategy

Local wound care measures:

• Apply direct pressure to ecchymotic areas
• Cold compresses to reduce hematoma expansion
• Monitor for signs of expanding hematoma or hemodynamic instability
• Serial hemoglobin/hematocrit monitoring

Assess for surgical intervention indications:

• Mediastinal re-exploration is indicated for: Hemodynamic instability, cardiac tamponade, or blood loss >500 mL at 6 hours postoperatively. 2
• Minor superficial hematomas and ecchymoses: Do not require surgical intervention and will resolve spontaneously. 2

Pharmacologic Considerations (If Bleeding is Significant)

Desmopressin is NOT recommended as routine prophylaxis:

• A prospective randomized trial of 100 CABG patients on aspirin showed desmopressin 0.3 mcg/kg did not reduce postoperative bleeding (606 mL vs 601 mL, p=0.93). 3
• More recent evidence shows desmopressin had no significant effect on bleeding control and may even delay hemostatic efficacy when combined with tranexamic acid. 4
• However, one older study showed benefit: A 1992 trial demonstrated reduced chest tube blood loss (833 mL vs 1176 mL, p=0.016) with desmopressin in aspirin-treated patients, though this has not been consistently replicated. 5

Tranexamic acid may be considered:

• In patients with dual antiplatelet therapy exposure, tranexamic acid infusion showed positive effects on hemostasis-related outcomes including reduced drainage volumes and blood product requirements. 4

Critical Pitfalls to Avoid

Never discontinue aspirin for minor bleeding: The benefit of postoperative aspirin on saphenous vein graft patency is lost when initiated 48 hours after surgery, and discontinuation increases risk of graft thrombosis, MI, and death. 1

Do not assume all post-CABG bleeding is aspirin-related: Systematically evaluate for concurrent P2Y12 inhibitor use, as this is the primary driver of major bleeding complications requiring re-exploration. 1, 2

Avoid prophylactic desmopressin: Current high-quality evidence does not support routine use in aspirin-treated patients, and it may interfere with other hemostatic agents. 3, 4

Monitor for progression, not just presence: Superficial ecchymoses and small hematomas at 48 hours are expected findings in aspirin-treated patients and do not require intervention unless expanding or causing hemodynamic compromise. 1, 2