Purpose <p>Coagulopathy is a common perioperative complication in aortic surgery, increasing the risk of bleeding and transfusion requirements. This study aimed to evaluate the impact of autologous plateletpheresis on reducing perioperative red blood cell (RBC) transfusion rates in adult aortic surgery patients.</p> Methods <p>This prospective, single-center, single-blind randomized controlled trial enrolled 134 participants undergoing aortic surgery with cardiopulmonary bypass, randomized in a 1:1 ratio. The primary outcome was the perioperative RBC transfusion rate and covariates included patient preoperative characteristics and intraoperative factors. Multivariable logistic regression models of the relative risk were evaluated.</p> Results <p>The intervention group demonstrated several clinical advantages, including significantly reduced perioperative blood transfusion requirements, lower Factor VII usage, and shorter surgical duration (all <i>p</i> &lt; 0.05). Storage of autologous platelet in citrate-containing bags resulted in increased calcium administration (median 3.00g vs 2.00g; <i>p</i> &lt; 0.05) and prolonged time between central venous catheter placement and heparinization in aortic root surgery (52.14 ± 7.75 vs 42.15 ± 6.13 min; <i>p</i> &lt; 0.001).</p> Conclusion <p>The autologous plateletpheresis technique reduces transfusion requirements, shortens surgical duration, enhances clinical outcomes, and accelerates recovery. However, careful calcium ion monitoring and coordination of pre-CPB preparation times are essential to maintain surgical workflow.</p> Trial Registration <p>Registered at the Chinese Clinical Trial Registry on November 16, 2022 (ID ChiCTR2200065834, <a href="https://www.chictr.org.cn/showproj.html?proj=185761">https://www.chictr.org.cn/showproj.html?proj=185761</a>).</p>