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CytoSorb removal of ticagrelor/ rivaroxaban to help reduce bleeding complications

CytoSorb Therapy* in urgent and emergent cardiac surgery


Hemoadsorption is NOW included in the ESAIC Guidelines for Management of severe peri-operative bleeding

Hemoadsorption may be considered as an adjuvant therapy to reduce bleeding complications in patients on ticagrelor or rivaroxaban undergoing emergency cardiac/aortic surgery on cardiopulmonary bypass (6)

See whole article in the European Journal of Anaesthesiology (EJA)–>



Ticagrelor is a reversible inhibitor of the P2Y12 platelet receptor and is indicated for the prevention of atherothrombotic events in patients with acute coronary syndromes (ACS) or a history of myocardial infarction (MI) and a high risk of developing an atherothrombotic event.


Rivaroxaban, a factor Xa inhibitor, is a non-vitamin K antagonist oral anticoagulant (NOAC) indicated for the prevention of stroke in patients with atrial fibrillation and for prevention or treatment of deep vein thrombosis and pulmonary embolism.

In order to prevent bleeding complications, EACTS/EACTA
Guidelines recommend discontinuation of both drugs prior to cardiac surgery(1):

≥ 3 days for ticagrelor

≥ 2 days for rivaroxaban

In case of urgent or emergency surgery with no time to wait,
ticagrelor or rivaroxaban can lead to an increase in peri-operative bleeding.

CytoSorb is intended to remove ticagrelor or rivaroxaban during cardiopulmonary bypass surgery to help reduce bleeding complications.

Clinical outcome data (2)

* The CE mark of CytoSorb does not cover removal of any other anti-thrombotic medications.
** Similar CPB/cross clamp time in both groups.
*** P-values reflect significant differences in the means between patients treated with CytoSorb and the control group, irrespective of the drug.

Health economic impact

CytoSorb has a high probability of saving costs. (3)

NICE Medtech innovation briefing (MIB) showed that over a 30-day time period, removal of ticagrelor using CytoSorb during surgery was less costly than delaying surgery for natural ticagrelor washout without adjunctive therapy.(4)

It was calculated from Hassan 2019 study data, that CytoSorb group cost savings derived from: fewer blood product transfusions and re-thoracotomies, and shorter stay in the critical care unit / hospital than the control group.

0 % (2,5 ‡)
Operation time reduction
0 % (2,5 ‡)
RBC transfusions reduction
0 % (2,5 ‡)
PLT transfusions reduction
0 % (2,5 ‡)
ICU days reduction

No re-thoracotomies were observed (2, 5)


Principal investigator's conclusion

“The intraoperative use of the CytoSorb hemoadsorption in patients with ticagrelor or rivaroxaban treatment undergoing emergency open-heart operations is a safe and effective method to reduce bleeding complications and to improve the postoperative outcome. (2)

“We recommend the use of CytoSorb adsorption for safety in patients undergoing emergency cardiac surgery and medication with ticagrelor or rivaroxaban.“ (2)

Study description(2)

CytoSorb adsorption during emergency cardiac operations in patients at high risk of bleeding
Hassan K, Kannmacher J, Wohlmuth P, Budde U, Schmoeckel M, Geidel S
Annals of Thoracic Surgery 2019;108:45–51

This study included 55 consecutive patients undergoing emergency open-heart operations who were at high risk of bleeding due to prior treatment with anti-thrombotic medications (43 patients on ticagrelor, 12 on rivaroxaban). In 39 of 55 cases, CytoSorb adsorption was installed into the cardiopulmonary bypass. Bleeding complications during and after surgery were analyzed in detail and compared to the 16 patients without CytoSorb (11 patients on ticagrelor, 5 on rivaroxaban).

‡ Weighted average calculated based on data provided by Hassan et al.(2)

CytoSorb integration into CPB

Watch Prof. Pascal Leprince and PD Dr. Stephan Geidel present their clinical outcome data

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(1) Boer C et al., Journal of Cardiothoracic and Vascular Anesthesia 2018; 32: 88–120

(2) Hassan K et al., Annals of Thoracic Surgery 2019;108(1):45-51

(3) Javanbakht M et al., PharmacoEconomics Open 2020;4:307-319

(4) NICE Medtech innovation briefing, February 2021, (5) Data on file (6) Kietaibl S et al., Eur J Anaesthesiol 2023; 40: 226-304 

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