Perisurgical Monitoring of Activated Coagulation Time in Carotid Endarterectomy

Česká verzia

Authors: M. Sameš ¹; E. Provazníková ¹; F. Cihlář ²; D. Bejšovec ³; R. Bartoš ¹; A. Hejčl ¹; I. Humhej ¹; P. Vachata ¹
Authors place of work: Krajská zdravotní a. s., Masarykova nemocnice v Ústí nad Labem, o. z. Neurochirurgická klinika UJEP ¹; Krajská zdravotní a. s., Masarykova nemocnice v Ústí nad Labem, o. z. Radiologické odd. ²; Krajská zdravotní a. s., Masarykova nemocnice v Ústí nad Labem, o. z. Odd. intenzivní medicíny ³
Published in the journal: Cesk Slov Neurol N 2011; 74/107(3): 325-329
Category: Short Communication

Summary

The aim of this study was to determine the ideal amount of heparin per kilogram of patient body weight and the amount of protamine necessary for its subsequent neutralization with relation to initial heparin dose and with respect to activated coagulation time (ACT).

Patients and methods:
The prospective study group consisted of 80 patients (20 female, 60 male) 44 of them treated for asymptomatic stenosis, mean age 65.8, range 39–82 years, bilateral stenosis in 4 of them, upon whom a total of 84 carotid endarterectomies had been performed between April 2008 to May 2009. Patients were divided into three groups, according to the amount of heparin administered (1, 1.5 and 2 mg of heparin per kilogram).

Results:
In first group, median ACT after heparin administration was 268.0 seconds; in second 334.0 and in the third group 375.0 (p <0.01). Median ACT after protamine administration in the first group was 130 seconds, in the second 137 seconds and in the third group 128 seconds (p = 0.79). A total of 7 postoperative complications occurred, including 2 wound haematomas requiring surgical revision (2.4%), 3 neurological complications (3.6%) and 2 cardiological complications (2.4%). After three months all patients had recovered ad integrum at ambulatory check-up; permanent morbidity is thus 0%.

Conclusion:
One milligram of heparin per kilogram is a sufficient dose to achieve adequate anticoagulation, minimizing the risk of postoperative haematoma without increasing the risk of peri-operative ischemic stroke.

Key words:
carotid endarterectomy – activated coagulation time – heparin – protamine

Zdroje

1. Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med 1998 12; 339(20): 1415–1425.

2. Executive Committee for the asymptomatic carotid atherosclerosis study. Endarterectomy for asymptomatic carotid artery stenosis. JAMA 1995; 273(18): 1421–1428.

3. Šilhart Z, Hillová Mannová J, Kysela P, Hamtilová I, Ničovský J, Ševčík P et al. Zhodnocení výsledků operací karotických tepen v letech 1997–2009. Cesk Slov Neurol N 2010; 73/106(3): 294–298.

4. Poisik A, Heyer EJ, Solomon RA, Quest DO, Adams DC, Baldasserini CM et al. Safety and efficacy of fixed-dose heparin in carotid endarterectomy. Neurosurgery 1999; 45(3): 434–441.

5. Treiman RL, Cossman DV, Foran RF, Levin PM, Cohen JL, Wagner WH. The influence of neutralizing heparin after carotid endarterectomy on postoperative stroke and wound hematoma. J Vasc Surg 1990; 12(4): 440–445.

6. de Sousa AA, Dellaretti MA, Faglioni W jr, Carvalho GT. Monitoring of activated coagulation time in carotid endarterectomy. Surg Neurol 2005; 64 (Suppl 1): S6–S9.

7. Dorman BH, Elliott BM, Spinale FG, Bailey MK, Walton JS, Robison JG, Brothers TE, Cook MH. Protamine use during peripheral vascular surgery: a prospective randomized trial. J Vasc Surg 1995; 22(3): 248–255.

8. Mauney MC, Buchanan SA, Lawrence WA, Bishop A, Sinclair K, Daniel TM et al. Stroke rate is markedly reduced after carotid endarterectomy by avoidance of protamine. J Vasc Surg 1995; 22(3): 264–269.

9. Coyne TJ, Wallace MC, Benedict C. Peri-operative anticoagulant effects of heparinization for carotid endarterectomy. Aust N Z J Surg 1994; 64(10): 679–683.

10. Paty PS, Darling RC jr, Kreienberg PB, Chang BB, Groudine SB, Sakawi Y et al. The use of low-dose heparin is safe in carotid endarterectomy and avoids the use of protamine sulfate. Cardiovasc Surg 1999; 7(1): 39–43.

11. Groudine SB, Sakawi Y, Patel MK, Darling C 3rd, Abdel-Raouf A, Paty P et al. Low-dose heparin appears safe and can eliminate protamine use for carotid endarterectomy. J Cardiothorac Vasc Anesth 1998; 12(3): 295–298.

12. Assadian A, Knöbl P, Hübl W, Senekowitsch C, Klingler A, Pfaffelmeyer N et al. Safety and efficacy of intravenous enoxaparin for carotid endarterectomy: a prospective randomized pilot trial. J Vasc Surg 2008; 47(3): 537–542.

13. McMahon GS, Webster SE, Hayes PD, Jones CI, Goodall AH, Naylor AR. Low molecular weight heparin significantly reduces embolisation after carotid endarterectomy – a randomised controlled trial. Eur J Vasc Endovasc Surg 2009; 37(6): 633–639.

14. Zouny JA, Kisker CT, Doty DB. Adequate anticoagulation during cardiopulmonary bypass determined by activated clotting time and the appearance of fibrin monomer. Ann Thorac Surg 1978; 26(3): 231–240.

15. Esposito R, Culliford AT, Colvin SB, Thomas SJ, Lackner H, Spencer FC. The role of the activated clotting time in heparin administration and neutralization for cardiopulmonary bypass. J Thorac Cardiovasc Surg 1983; 85(2): 174–185.

16. Rosenwasser RH, Garrido E, Freed MH, Shupak RC. Monitoring of activated clotting time during carotid endarterectomy: a preliminary report. Neurosurgery 1981; 9(5): 521–523.

17. Hattersley PG. Activated coagulation time of whole blood. JAMA 1966; 196(5): 436–440.

18. Mabry CD, Thompson BW, Read RC. Activated clotting time (ACT) monitoring of intraoperative heparinization in peripheral vascular surgery. Am J Surg 1979; 138(6): 894–900.

19. Brother TE, Robinson JG. Intraoperative anticoagulation and reversal. In: Loftus CM, Kresowik TF (eds). Carotid artery surgery. New York: Thieme 2000: 391–398.

20. Levison JA, Faust GR, Halpern VJ, Theodoris A, Nathan I, Kline RG et al. Relationship of protamine dosing with postoperative complications of carotid endarterectomy. Ann Vasc Surg 1999; 13(1): 67–72.

21. Dellagrammaticas D, Lewis SC, Gough MJ; GALA Trial Collaborators. Is heparin reversal with protamine after carotid endarterectomy dangerous? Eur J Vasc Endovasc Surg 2008; 36(1): 41–44.