Protamine reduces bleeding complications associated with carotid endarterectomy without increasing the risk of stroke
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Authors
Stone, David H.Nolan, Brian W.
Schanzer, Andres
Goodney, Philip P.
Cambria, Robert A.
Likosky, Donald S.
Walsh, Daniel B.
Cronenwett, Jack L.
Vascular Study Group of Northern New England
UMass Chan Affiliations
Department of SurgeryDocument Type
Journal ArticlePublication Date
2010-03-05Keywords
AgedEndarterectomy, Carotid
Female
Heparin Antagonists
Humans
Logistic Models
Male
Myocardial Infarction
New England
Odds Ratio
Postoperative Hemorrhage
Prospective Studies
Protamines
Registries
Reoperation
Risk Assessment
Risk Factors
Stroke
Time Factors
Treatment Outcome
Surgery
Metadata
Show full item recordAbstract
OBJECTIVES: Controversy persists regarding the use of protamine during carotid endarterectomy (CEA) based on prior conflicting reports documenting both reduced bleeding as well as increased stroke risk. The purpose of this study was to determine the effect of protamine reversal of heparin anticoagulation on the outcome of CEA in a contemporary multistate registry. METHODS: We reviewed a prospective regional registry of 4587 CEAs in 4311 patients performed by 66 surgeons from 11 centers in Northern New England from 2003-2008. Protamine use varied by surgeon (38% routine use, 44% rare use, 18% selective use). Endpoints were postoperative bleeding requiring reoperation as well as potential thrombotic complications, including stroke, death, and myocardial infarction (MI). Predictors of endpoints were determined by multivariate logistic regression after associated variables were identified by univariate analysis. RESULTS: Of the 4587 CEAs performed, 46% utilized protamine, while 54% did not. Fourteen patients (0.64%) in the protamine-treated group required reoperation for bleeding compared with 42 patients (1.66%) in the untreated cohort (P = .001). Protamine use did not affect the rate of MI (1.1% vs 0.91%, P = .51), stroke (0.78% vs 1.15%, P = .2), or death (0.23% vs 0.32%, P = .57) between treated and untreated patients, respectively. By multivariate analysis, protamine (odds ratio [OR] 0.32, 95% confidence interval [CI], 0.17-0.63; P = .001) and patch angioplasty (OR 0.46, 95% CI, 0.26-0.81; P = .007) were independently associated with diminished reoperation for bleeding. A single center was associated with a significantly higher rate of reoperation for bleeding (OR 6.47, 95% CI, 3.02-13.9; P < .001). Independent of protamine use, consequences of reoperation for bleeding were significant, with a four-fold increase in MI, a seven-fold increase in stroke, and a 30-fold increase in death. CONCLUSION: Protamine reduced serious bleeding requiring reoperation during CEA without increasing the risk of MI, stroke, or death, in this large, contemporary registry. In light of significant complications referable to bleeding, liberal use of protamine during CEA appears warranted.Source
J Vasc Surg. 2010 Mar;51(3):559-64, 564.e1. Epub 2010 Jan 4. Link to article on publisher's siteDOI
10.1016/j.jvs.2009.10.078Permanent Link to this Item
http://hdl.handle.net/20.500.14038/49774PubMed ID
20045609Related Resources
Link to Article in PubMedae974a485f413a2113503eed53cd6c53
10.1016/j.jvs.2009.10.078