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Vriesendorp PA, Nanayakkara S, Heuts S, Ball J, Chandrasekar J, Dick R, Haji K, Htun NM, McGaw D, Noaman S, Palmer S, Cairo S, Shulman M, Lin E, Hastings S, Waldron B, Proimos G, Soon KH, Yudi MB, Zimmet A, Stub D, Walton AS. Routine Protamine Administration for Bleeding in Transcatheter Aortic Valve Implantation: The ACE-PROTAVI Randomized Clinical Trial. JAMA Cardiol 2024:2822233. [PMID: 39141396 PMCID: PMC11325237 DOI: 10.1001/jamacardio.2024.2454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/15/2024]
Abstract
Importance Vascular complications after transfemoral transcatheter aortic valve implantation (TAVI) remain an important cause of procedure-related morbidity. Routine reversal of anticoagulation with protamine at the conclusion of transfemoral TAVI could reduce complications, but data remain scarce. Objective To evaluate the efficacy and safety of routine protamine administration after transfemoral TAVI. Design, Setting, and Participants The ACE-PROTAVI trial was an investigator-initiated, double-blind, placebo-controlled randomized clinical trial performed at 3 Australian hospitals between December 2021 and June 2023 with a 1-year follow-up period. All patients accepted for transfemoral TAVI by a multidisciplinary heart team were eligible for enrollment. Interventions Eligible patients were randomized 1:1 between routine protamine administration and placebo. Main Outcomes and Measures The coprimary outcomes were the rate of hemostasis success and time to hemostasis (TTH), presented as categorical variables and compared with a χ2 test or as continuous variables as mean (SD) or median (IQR), depending on distribution. The major secondary outcome was a composite of all-cause death, major and minor bleeding complications, and major and minor vascular complications after 30 days, reported in odds ratios (ORs) with 95% CIs and P values. Results The study population consisted of 410 patients: 199 patients in the protamine group and 211 in the placebo group. The median (IQR) patient age in the protamine group was 82 (77-85) years, and 68 of 199 patients receiving protamine (34.2%) were female. The median (IQR) patient age in the placebo group was 80 (75-85) years, and 89 of 211 patients receiving the placebo (42.2%) were female. Patients receiving up-front protamine administration had a higher rate of hemostasis success (188 of 192 patients [97.9%]) than patients in the placebo group (186 of 203 patients [91.6%]; absolute risk difference, 6.3%; 95% CI, 2.0%-10.6%; P = .006); in addition, patients receiving up-front protamine had a shorter median (IQR) TTH (181 [120-420] seconds vs 279 [122-600] seconds; P = .002). Routine protamine administration resulted in a reduced risk of the composite outcome in the protamine group (10 of 192 [5.2%]) vs the placebo group (26 of 203 [12.8%]; OR, 0.37; 95% CI, 0.1-0.8; P = .01). This difference was predominantly driven by the difference in the prevalence of minor vascular complications. There were no adverse events associated with protamine use. Conclusions and Relevance In the ACE-PROTAVI randomized clinical trial, routine administration of protamine increased the rate of hemostasis success and decreased TTH. The beneficial effect of protamine was reflected in a reduction in minor vascular complications, procedural time, and postprocedural hospital stay duration in patients receiving routine protamine compared with patients receiving placebo. Trial Registration anzctr.org.au Identifier: ACTRN12621001261808.
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Affiliation(s)
- Pieter A Vriesendorp
- Heart Centre, The Alfred Hospital, Melbourne, Australia
- Heart+Vascular Center, Department of Cardiology, Maastricht University Medical Center, Maastricht, the Netherlands
- Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, the Netherlands
| | - Shane Nanayakkara
- Heart Centre, The Alfred Hospital, Melbourne, Australia
- Heart Failure Research Group, Baker Heart and Diabetes Institute, Melbourne, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Samuel Heuts
- Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, the Netherlands
- Department of Cardiothoracic Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Jocasta Ball
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Jaya Chandrasekar
- Department of Cardiology, Epworth HealthCare, Melbourne, Australia
- Department of Cardiology, Eastern Health, Melbourne, Australia
- Eastern Health Clinical School, Monash University, Melbourne, Australia
| | - Ronald Dick
- Department of Cardiology, Epworth HealthCare, Melbourne, Australia
| | - Kawa Haji
- Heart Centre, The Alfred Hospital, Melbourne, Australia
- Department of Cardiology, Epworth HealthCare, Melbourne, Australia
| | - Nay Min Htun
- Heart Centre, The Alfred Hospital, Melbourne, Australia
| | - David McGaw
- Department of Cardiology, Cabrini Health, Melbourne, Australia
| | - Samer Noaman
- Heart Centre, The Alfred Hospital, Melbourne, Australia
- Department of Cardiology, Epworth HealthCare, Melbourne, Australia
| | - Sonny Palmer
- Heart Centre, The Alfred Hospital, Melbourne, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Australia
| | - Sesto Cairo
- Department of Medicine, The University of Melbourne, Melbourne, Australia
- Cabrini Anaesthetics Department, Cabrini Health, Melbourne, Australia
| | - Mark Shulman
- Heart Centre, The Alfred Hospital, Melbourne, Australia
- Cabrini Anaesthetics Department, Cabrini Health, Melbourne, Australia
| | - Enjarn Lin
- Heart Centre, The Alfred Hospital, Melbourne, Australia
- Cabrini Anaesthetics Department, Cabrini Health, Melbourne, Australia
| | - Stuart Hastings
- Heart Centre, The Alfred Hospital, Melbourne, Australia
- Cabrini Anaesthetics Department, Cabrini Health, Melbourne, Australia
| | - Benedict Waldron
- Heart Centre, The Alfred Hospital, Melbourne, Australia
- Cabrini Anaesthetics Department, Cabrini Health, Melbourne, Australia
| | - George Proimos
- Department of Cardiology, Epworth HealthCare, Melbourne, Australia
| | - Kean H Soon
- Department of Cardiology, Epworth HealthCare, Melbourne, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Australia
| | - Matias B Yudi
- Department of Cardiology, Epworth HealthCare, Melbourne, Australia
- Department of Cardiology, Austin Health, Melbourne, Australia
| | - Adam Zimmet
- Heart Centre, The Alfred Hospital, Melbourne, Australia
| | - Dion Stub
- Heart Centre, The Alfred Hospital, Melbourne, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Cardiology, Cabrini Health, Melbourne, Australia
| | - Antony S Walton
- Heart Centre, The Alfred Hospital, Melbourne, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Cardiology, Epworth HealthCare, Melbourne, Australia
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Penton A, Kelly R, Le L, Blecha M. Temporal Trends and Contemporary Regional Variation in Management of Patients Undergoing Carotid Endarterectomy. Vasc Endovascular Surg 2023; 57:869-877. [PMID: 37303024 DOI: 10.1177/15385744231183750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
INTRODUCTION The purpose of this study is to investigate regional variation and temporal trends in seven quality metrics amongst CEA patients: discharge on antiplatelet after CEA; discharge on statin after CEA; protamine administration during CEA; patch placement at conventional CEA site; continued statin usage at the time of most recent follow-up; continued antiplatelet usage at the time of most recent follow-up; and smoking cessation at the time of long term follow up. METHODS There are 19 de-identified regions within the VQI database in the United States. Patients were placed into one of three temporal eras based on the time of their CEA: 2003-2008; 2009-2015; and 2016-2022. We first investigated temporal trends across the seven quality metrics for all regions combined on a national basis. The percentage of patients in each time era with the presence/absence of each metric was identified. Chi-squared testing was performed to confirm statistical significance of the differences across eras. Next, analysis was performed within each region and within each time metric. We separated out the 2016-2022 patients within each region to serve as the status of each metric application in the most modern era. We then compared the frequency of metric non-adherence in each region utilizing Chi-squared testing. RESULTS There was statistically significant improvement in achievement of all seven metrics between the initial 2003-2008 era and the modern 2016-2022 era. The most marked change in practice pattern was noted for lack of protamine usage at surgery (decreased from 48.7% to 25.9%), discharge home postoperatively without statin (decreased from 50.6% to 15.3%), and lack of statin usage confirmed at time of most recent long term follow up (decreased from 24% to 8.9%). Significant regional variation exists across all metrics (P < .01 for all). Lack of patch placement at the time of conventional endarterectomy ranges from 1.9% to 17.8% across regions in the modern era. Lack of protamine utilization ranges from 10.8% to 49.7%. Lack of antiplatelet and statin at the time of discharge varies from 5.5% to 8.2% and 4.8% to 14.4% respectively. Adherence to the various measures at the time of most recent follow up are more tightly aligned across regions with ranges of: 5.3% to 7.5% for lack of antiplatelet usage; 6.6% to 11.7% lack of statin utilization; and 13.3 to 15.4% for persistent smoking. CONCLUSIONS Prior studies and societal initiatives on CEA documenting the beneficial effects of patch angioplasty, protamine use at surgery, smoking cessation, antiplatelet utilization and statin compliance have positively impacted adherence to these measures over time. In the modern 2016-2022 era the widest regional variation is noted in patch placement, protamine utilization and discharge medications allowing individual geographic areas to identify areas for potential improvement via internal VQI administrative feedback.
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Affiliation(s)
- Ashley Penton
- Division of Vascular Surgery and Endovascular Therapy, Loyola University Health System, Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
| | - Robert Kelly
- Division of Vascular Surgery and Endovascular Therapy, Loyola University Health System, Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
| | - Linda Le
- Department of Cardiovascular Surgery, Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, TX, USA
| | - Matthew Blecha
- Division of Vascular Surgery and Endovascular Therapy, Loyola University Health System, Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
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Kallur AS, Bhogal S, Waksman R, Bernardo NL. Protamine-induced Acute Thrombosis in a Post-TAVR Patient: A Word of Caution. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2023; 53S:S171-S173. [PMID: 35779996 DOI: 10.1016/j.carrev.2022.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 06/07/2022] [Indexed: 11/29/2022]
Abstract
Major vascular complications after transcatheter aortic valve replacement (TAVR) are a pertinent issue and associated with increased morbidity and mortality. We herein describe a case of acute limb ischemia following the administration of protamine sulfate (PS) that was administered to mitigate a bleeding complication post-failure of a vascular access closure device. PS should be used cautiously for the prevention or management of bleeding-site complications following TAVR. The patient described in this case has consented to having his case described in this manuscript.
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Affiliation(s)
- Akhil S Kallur
- Internal Medicine, MedStar Washington Hospital Center, Washington, DC, USA
| | - Sukhdeep Bhogal
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Ron Waksman
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA.
| | - Nelson L Bernardo
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
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Kanitra JJ, Bjorklund RL, Clausen DJ, Hayward RD, Paxton RA, Haouilou JC. Protamine use in transcarotid arterial revascularization. Vascular 2023; 31:312-316. [PMID: 35040739 DOI: 10.1177/17085381211067047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The literature suggests that heparin reversal with protamine in transcarotid arterial revascularization (TCAR) decreases postoperative bleeding complications without an increase in stroke or death. However, the dosing of protamine in TCAR has not yet been evaluated. We aimed to evaluate our experience with intraoperative heparin reversal with protamine. METHODS This was a single-center, retrospective, observational study that evaluated the heparin and protamine doses used during TCAR. All adult patients who underwent TCAR between 9/1/2019 and 4/2/2021 were included. Demographic data was obtained from the Vascular Quality Initiative and protamine/heparin doses were obtained from a chart review. Multivariate logistic regression models were used to assess the association between the protamine/heparin dose ratio and other variables. RESULTS Sixty-two patients were included. The average protamine/heparin dose ratio used was 0.96 ± 0.12 mg/U; seven had a ratio less than 0.8 mg/U, and one was greater than 1.2 mg/U. Two patients experienced bleeding complications, which were managed non-operatively. No patient with a protamine/heparin ratio greater than 0.8 mg/U had postoperative bleeding. Postoperative bradycardia was observed in 32.3% of patients and hypotension in 35%, with 19% requiring vasopressors. No relationship was identified between the protamine/heparin ratio and bleeding, bradycardia, or hypotension. No 30-day myocardial infarction, stroke or death occurred. CONCLUSIONS We identified a near 1:1 ratio of a protamine/heparin dosing regimen for the reversal of heparin during TCAR, with postoperative bleeding complications similar to those reported in the literature. However, patients who received a lower protamine/heparin ratio did not experience bleeding complications. In the era of protamine shortages, a future larger-scale study is needed to evaluate the impact of a lower protamine dose on postoperative complications.
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Affiliation(s)
- John J Kanitra
- Department of Surgery, 21928Ascension St John Hospital, Detroit, MI, USA
| | | | - David J Clausen
- Department of Surgery, 21928Ascension St John Hospital, Detroit, MI, USA
| | - R David Hayward
- Department of Surgery, 21928Ascension St John Hospital, Detroit, MI, USA
| | - Renee A Paxton
- Department of Surgery, 21928Ascension St John Hospital, Detroit, MI, USA
| | - Jimmy C Haouilou
- Department of Surgery, 21928Ascension St John Hospital, Detroit, MI, USA
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Lin M, Yu L, Xiao L, Fan J. A cysteine enzyme hemostat for efficient heparin-tolerant blood coagulation. J Mater Chem B 2023; 11:1079-1089. [PMID: 36625414 DOI: 10.1039/d2tb02220f] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
It is challenging to stop bleeding effectively in patients treated with heparin which leads to enhanced risk of uncontrolled bleeding during operation. Herein, we report an easy-to-use and heparin-tolerant hemostatic agent based on a thrombin-like cysteine enzyme (papain), which catalyzes the hydrolysis of fibrinogen and cross-linking of fibrin clots. A papain-based hemostat with increased procoagulant activity is developed through immobilizing papain on the cellulose carrier, which displays short clotting time in both normal and heparinized plasmas. The excellent hemostatic performance of the papain-based hemostat is further confirmed with reduced hemostatic time and limited blood loss in a mouse tail amputation model, rabbit auricular artery injury model and rat liver injury model, in which a natural coagulation system fails to function on account of heparin. This bio-hemostat has great potential to reverse the effect of heparin and stop topical hemorrhage rapidly in surgical procedures.
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Affiliation(s)
- Mengchi Lin
- Key Lab of Applied Chemistry of Zhejiang Province, Department of Chemistry, Zhejiang University, Hangzhou 310027, China. .,Department of Gastroenterology, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, China
| | - Lisha Yu
- Key Lab of Applied Chemistry of Zhejiang Province, Department of Chemistry, Zhejiang University, Hangzhou 310027, China. .,Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Liping Xiao
- Key Lab of Applied Chemistry of Zhejiang Province, Department of Chemistry, Zhejiang University, Hangzhou 310027, China.
| | - Jie Fan
- Key Lab of Applied Chemistry of Zhejiang Province, Department of Chemistry, Zhejiang University, Hangzhou 310027, China.
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Jiang Y, Liu Y, Jia X, Xin W, Wang H. The emerging role of adopting protamine for reducing the risk of bleeding complications during the percutaneous coronary intervention: A meta-analysis. J Card Surg 2022; 37:5341-5350. [PMID: 36352811 DOI: 10.1111/jocs.17139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 10/27/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND The safety and the benefits of reducing the risk of bleeding complications via protamine administration during the percutaneous coronary intervention (PCI) remains unclear. This study aimed to systematically assessed the efficacy and safety of using protamine in PCI. METHOD Potential academic studies were identified from PubMed, Cochrane Library, EMBASE, and Web of Science. The time range we retrieved from was that from the inception of electronic databases to March 31, 2022. Gray studies were identified from the references of included literature reports. Stata version 12.0 statistical software (StataCorp LP) was used to analyze the pooled data. RESULTS A total of seven studies were involved in our study. The overall participants of the protamine group were 4983, whereas it was 1953 in the nonprotamine group. This meta-analysis indicated that protamine was preferable for PCI as its lower value of major bleeding (odds ratio [OR] = 0.489, 95% confidence interval [CI]: 0.362-0.661, p < .001) and minor bleeding (OR = 0.281, 95% CI: 0.123-0.643, p = .003). Additionally, the protamine did not tend to be related a higher incidence of mortality (p = .143), myocardial infarction (p = .990), and stent thrombosis (p = .698). CONCLUSIONS Based on available evidence, use of protamine may reduce the risk of bleeding complications without increasing the risk of mortality, myocardial infarction, and stent thrombosis. Given the relevant possible biases in our study, adequately powered and better-designed studies with long-term follow-up are required to reach a firmer conclusion.
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Affiliation(s)
- Yunshan Jiang
- Department of Cardiology, Liaocheng People's Hospital, Liaocheng, People's Republic of China
| | - Yuzhi Liu
- Department of Cardiology, Liaocheng People's Hospital, Liaocheng, People's Republic of China
| | - Xiaoli Jia
- Department of Pharmacy, Liaocheng People's Hospital, Liaocheng, People's Republic of China
| | - Wenqiang Xin
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Hongyan Wang
- Department of Pharmacy, Liaocheng People's Hospital, Liaocheng, People's Republic of China
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Bevilacqua S, Ticozzelli G, Orso M, Alba G, Capoccia L, Cappelli A, Cernetti C, Diomedi M, Dorigo W, Faggioli G, Giannace G, Giannandrea D, Giannetta M, Lessiani G, Marone EM, Mazzaccaro D, Migliacci R, Nano G, Pagliariccio G, Petruzzellis M, Plutino A, Pomatto S, Pulli R, Sirignano P, Vacirca A, Visco E, Moghadam SP, Lanza G, Lanza J. Anesthetic management of carotid endarterectomy: an update from Italian guidelines. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE (ONLINE) 2022; 2:24. [PMID: 37386522 PMCID: PMC10245611 DOI: 10.1186/s44158-022-00052-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 05/12/2022] [Indexed: 07/01/2023]
Abstract
BACKGROUND AND AIMS In order to systematically review the latest evidence on anesthesia, intraoperative neurologic monitoring, postoperative heparin reversal, and postoperative blood pressure management for carotid endarterectomy. The present review is based on a single chapter of the Italian Health Institute Guidelines for diagnosis and treatment of extracranial carotid stenosis and stroke prevention. METHODS AND RESULTS A systematic article review focused on the previously cited topics published between January 2016 and October 2020 has been performed; we looked for both primary and secondary studies in the extensive archive of Medline/PubMed and Cochrane library databases. We selected 14 systematic reviews and meta-analyses, 13 randomized controlled trials, 8 observational studies, and 1 narrative review. Based on this analysis, syntheses of the available evidence were shared and recommendations were indicated complying with the GRADE-SIGN version methodology. CONCLUSIONS From this up-to-date analysis, it has emerged that any type of anesthesia and neurological monitoring method is related to a better outcome after carotid endarterectomy. In addition, insufficient evidence was found to justify reversal or no-reversal of heparin at the end of surgery. Furthermore, despite a low evidence level, a suggestion for blood pressure monitoring in the postoperative period was formulated.
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Affiliation(s)
- Sergio Bevilacqua
- Department of Anesthesia, Azienda Ospedaliera Universitaria Careggi, Firenze, Italy
| | - Giulia Ticozzelli
- Anesthesiology and Intensive Care Unit, Fondazione I.R.C.C.S. Policlinico San Matteo, Pavia, Italy.
| | - Massimiliano Orso
- Società Italiana di Chirurgia Vascolare ed Endovascolare (SICVE), Roma, Italy
| | - Giuseppe Alba
- Department of Vascular Surgery, University of Siena, Siena, Italy
| | - Laura Capoccia
- Vascular and Endovascular Surgery Division, Policlinico Umberto I La Sapienza University of Rome, Rome, Italy
| | - Alessandro Cappelli
- Vascular Surgery Unit, Policlinico Le Scotte Hospital University of Siena, Siena, Italy
| | - Carlo Cernetti
- Division of Cardiology and and Interventional Hemodynamics, Ca' Foncello Hospital, Azienda USLL2 Marca Trevigiana, Treviso, Italy
| | - Marina Diomedi
- Stroke Unit, Department of Systems Medicine, Tor Vergata University Hospital, Rome, Italy
| | - Walter Dorigo
- Vascular Surgery Unit, University of Florence, Florence, Italy
| | - Gianluca Faggioli
- Vascular Surgery Unit, Policlinico Sant'Orsola, Alma Mater Studiorum University, Bologna, Italy
| | - Giovanni Giannace
- Vascular Surgery Unit, Arcispedale Snata Maria Nuova, Reggio Emilia, Italy
| | - David Giannandrea
- Stroke Unit, Neurology Department, USL Umbria 1, Cittá di Castello, Perugia, Italy
| | - Matteo Giannetta
- Vascular Surgery Unit, IRCCS Policlinico San Donato Hospital University, San Donato Milanese, Italy
| | | | - Enrico Maria Marone
- Vascular Surgery Unit, Department of Policlinico Monaza, Monza, Italy
- Pavia University, Pavia, Italy
| | - Daniela Mazzaccaro
- Vascular Surgery Unit, IRCCS Policlinico San Donato Hospital University, San Donato Milanese, Italy
| | - Rino Migliacci
- Angiology and Internal Medicine, Valdichiana S.Margherita Hospital, Cortona, Italy
| | - Giovanni Nano
- Vascular Surgery Unit, IRCCS Policlinico San Donato Hospital University, San Donato Milanese, Italy
| | | | | | | | - Sara Pomatto
- Vascular Surgery Unit, Policlinico Sant'Orsola, Alma Mater Studiorum University, Bologna, Italy
| | - Raffaele Pulli
- Vascular Surgery Unit, Policlinico Careggi Hospital University, Florence, Italy
| | - Pasqualino Sirignano
- Vascular and Endovascular Surgery Division, Sant'andrea Hospital , "La sapienza" University of Rome, Rome, Italy
| | - Andrea Vacirca
- Vascular Surgery Unit, Policlinico San'Orsola-Alma Mater Studiorum University, Bologna, Italy
| | - Emanuele Visco
- Division of Cardiology and Interventional Hemodynamic, San Giacomo Apostolo Hospital, Azienda ULSS2 Marca Trevigiana, Castelfranco Veneto, Italy
| | | | - Gaetano Lanza
- Vascular Surgery Department, Multimedica Hospital-IRCCS, Castellanza, Italy
| | - Jessica Lanza
- Vascular Surgery Department, IRCSS Ospedale Policlinico, San Martino Genova, Italy
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Pan Y, Zhao Z, Yang T, Jiao Q, Wei W, Ji J, Xin W. A Meta-Analysis of Using Protamine for Reducing the Risk of Hemorrhage During Carotid Recanalization: Direct Comparisons of Post-operative Complications. Front Pharmacol 2022; 13:796329. [PMID: 35281915 PMCID: PMC8914204 DOI: 10.3389/fphar.2022.796329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Accepted: 01/24/2022] [Indexed: 11/13/2022] Open
Abstract
Background: Protamine can decrease the risk of hemorrhage during carotid recanalization. However, it may cause severe side effects. There is no consensus on the safety and efficacy of protamine during surgery. Thus, we conduct a comprehensive review and meta-analysis to compare the differences between the protamine and the no-protamine group.Method: We systematically obtained literature from Medline, Google Scholar, Cochrane Library, and PubMed electronic databases. All four databases were scanned from 1937 when protamine was first adopted as a heparin antagonist until February 2021. The reference lists of identified studies were manually checked to determine other eligible studies that qualify. The articles were included in this meta-analysis as long as they met the criteria of PICOS; conference or commentary articles, letters, case report or series, and animal observation were excluded from this study. The Newcastle-Ottawa Quality Assessment Scale and Cochrane Collaboration’s tool are used to assess the risk of bias of each included observational study and RCT, respectively. Stata version 12.0 statistical software (StataCorp LP, College Station, Texas) was adopted as statistical software. When I2 < 50%, we consider that the data have no obvious heterogeneity, and we conduct a meta-analysis using the fixed-effect model. Otherwise, the random-effect model was performed.Result: A total of 11 studies, consisting of 94,618 participants, are included in this study. Our analysis found that the rate of wound hematoma had a significant difference among protamine and no-protamine patients (OR = 0.268, 95% CI = 0.093 to 0.774, p = 0.015). Furthermore, the incidence of hematoma requiring re-operation (0.7%) was significantly lower than that of patients without protamine (1.8%). However, there was no significant difference in the incidence of stroke, wound hematoma with hypertension, transient ischemic attacks (TIA), myocardial infarction (MI), and death.Conclusion: Among included participants undergoing recanalization, the use of protamine is effective in reducing hematoma without increasing the risk of having other complications. Besides, more evidence-based performance is needed to supplement this opinion due to inherent limitations.
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Affiliation(s)
- Yongli Pan
- Department of Neurology, Weifang Medical University, Weifang, China
| | - Zhiqiang Zhao
- Department of Neurosurgery, Heji Hospital Affiliated Changzhi Medical College, Changzhi, China
| | - Tao Yang
- Department of Neurosurgery, Heji Hospital Affiliated Changzhi Medical College, Changzhi, China
| | - Qingzheng Jiao
- Second Department of Internal Medicine, Gucheng Country Hospital, Shijiazhuang, China
| | - Wei Wei
- Department of Neurology, Mianyang Central Hospital, Mianyang, China
| | - Jianyong Ji
- Department of Neurosurgery, Liaocheng People’s Hospital, Liaocheng, China
- *Correspondence: Jianyong Ji, ; Wenqiang Xin,
| | - Wenqiang Xin
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- *Correspondence: Jianyong Ji, ; Wenqiang Xin,
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9
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Singh AA, Boyle JR, Chetter I, Falter F. Protamine for Heparin Reversal After Carotid Endarterectomy is Significantly Underutilised: Results from a UK National Survey. Eur J Vasc Endovasc Surg 2022; 63:657-658. [DOI: 10.1016/j.ejvs.2022.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 01/07/2022] [Accepted: 01/09/2022] [Indexed: 11/28/2022]
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Zagzoog N, Elgheriani A, Attar A, Takroni R, Aljoghaiman M, Klotz L, Vandervelde C, Darling C, Farrokhyar F, Martyniuk A, Algird A. Comprehensive comparison of carotid endarterectomy primary closure and patch angioplasty: A single-institution experience. Surg Neurol Int 2022; 13:1. [PMID: 35127201 PMCID: PMC8813614 DOI: 10.25259/sni_1013_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 12/18/2021] [Indexed: 11/15/2022] Open
Abstract
Background: Carotid endarterectomy (CEA) is an effective intervention for the treatment of high-grade carotid stenosis. Technical preferences exist in the operative steps including the use patch for arteriotomy closure. The goals of this study are to compare the rate of postoperative complications and the rate of recurrent stenosis between patients undergoing primary versus patch closure during CEA. Methods: Retrospective chart review was conducted for patients who underwent CEA at single institution. Vascular surgeons mainly performed patch closure technique while neurosurgeons used primary closure. Patients’ baseline characteristics as well as intraprocedural data, periprocedural complications, and postprocedural follow-up outcomes were captured. Results: Seven hundred and thirteen charts were included for review with mean age of 70.5 years (SD = 10.4) and males representing 64.2% of the cohort. About 49% of patients underwent primary closure while 364 (51%) patients underwent patch closure. Severe stenosis was more prevalent in patients receiving patch closure (94.5% vs. 89.4%; P = 0.013). The incidence of overall complications did not differ between the two procedures (odds ratio = 1.23, 95% confidence intervals = 0.82–1.85; P = 0.353) with the most common complications being neck hematoma, strokes, and TIA. Doppler ultrasound imaging at 6 months postoperative follow-up showed evidence of recurrent stenosis in 15.7% of the primary closure patients compared to 16% in patch closure cohort. Conclusion: Both primary closure and patch closure techniques seem to have similar risk profiles and are equally robust techniques to utilize for CEA procedures.
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Affiliation(s)
- Nirmeen Zagzoog
- Department of Neurosurgery, McMaster University, Hamilton, Ontario, Canada
| | - Ali Elgheriani
- Department of Internal Medicine, University of Manitoba, Manitoba, Canada
| | - Ahmed Attar
- Department of Neurology, McMaster University, Hamilton, Canada,
- King Abdullah International Medical Research Center, Jeddeah, Saudi Arabia,
| | - Radwan Takroni
- Department of Neurosurgery, McMaster University, Hamilton, Ontario, Canada
| | - Majid Aljoghaiman
- Department of Neurosurgery, McMaster University, Hamilton, Ontario, Canada
| | - Lisa Klotz
- Faculty of Medicine, University of Toronto, Toronto, Canada
| | | | - Chloe Darling
- Fleming School of Nursing, Trent University, Peterborough, Ontario, Canada
| | - Forrough Farrokhyar
- Department of Health, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Amanda Martyniuk
- Department of Neurosurgery, McMaster University, Hamilton, Ontario, Canada
| | - Almunder Algird
- Department of Neurosurgery, McMaster University, Hamilton, Ontario, Canada
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11
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AbuRahma AF, Avgerinos ED, Chang RW, Darling RC, Duncan AA, Forbes TL, Malas MB, Perler BA, Powell RJ, Rockman CB, Zhou W. The Society for Vascular Surgery implementation document for management of extracranial cerebrovascular disease. J Vasc Surg 2021; 75:26S-98S. [PMID: 34153349 DOI: 10.1016/j.jvs.2021.04.074] [Citation(s) in RCA: 61] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 04/28/2021] [Indexed: 12/24/2022]
Affiliation(s)
- Ali F AbuRahma
- Department of Surgery, West Virginia University-Charleston Division, Charleston, WV.
| | - Efthymios D Avgerinos
- Division of Vascular Surgery, University of Pittsburgh School of Medicine, UPMC Hearrt & Vascular Institute, Pittsburgh, Pa
| | - Robert W Chang
- Vascular Surgery, Permanente Medical Group, San Francisco, Calif
| | | | - Audra A Duncan
- Division of Vascular & Endovascular Surgery, University of Western Ontario, London, Ontario, Canada
| | - Thomas L Forbes
- Division of Vascular & Endovascular Surgery, University of Western Ontario, London, Ontario, Canada
| | - Mahmoud B Malas
- Vascular & Endovascular Surgery, University of California San Diego, La Jolla, Calif
| | - Bruce Alan Perler
- Division of Vascular Surgery & Endovascular Therapy, Johns Hopkins, Baltimore, Md
| | | | - Caron B Rockman
- Division of Vascular Surgery, New York University Langone, New York, NY
| | - Wei Zhou
- Division of Vascular Surgery, University of Arizona, Tucson, Ariz
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12
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Álvarez Marcos F. Protamine and Myocardial Infarction Risk after Carotid Endarterectomy: A New Finding. Eur J Vasc Endovasc Surg 2021; 61:707-708. [PMID: 33640281 DOI: 10.1016/j.ejvs.2021.01.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Accepted: 01/21/2021] [Indexed: 10/22/2022]
Affiliation(s)
- Francisco Álvarez Marcos
- Department of Vascular and Endovascular Surgery, Asturias University Central Hospital (HUCA), Oviedo, Spain; Principles and Practice of Clinical Research program, Harvard T. H. Chan School of Public Health, Boston, MA, USA.
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13
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Stone DH, Giles KA, Kubilis P, Suckow BD, Goodney PP, Huber TS, Powell RJ, Cronenwett JL, Scali ST. Editor's Choice – Protamine Reduces Serious Bleeding Complications Associated with Carotid Endarterectomy in Asymptomatic Patients without Increasing the Risk of Stroke, Myocardial Infarction, or Death in a Large National Analysis. Eur J Vasc Endovasc Surg 2020; 60:800-807. [DOI: 10.1016/j.ejvs.2020.08.047] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 08/16/2020] [Accepted: 08/25/2020] [Indexed: 10/23/2022]
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14
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Protamine use in transcarotid artery revascularization is associated with lower risk of bleeding complications without higher risk of thromboembolic events. J Vasc Surg 2020; 72:2079-2087. [DOI: 10.1016/j.jvs.2020.02.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Accepted: 02/08/2020] [Indexed: 11/21/2022]
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15
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The Vascular Implant Surveillance and Interventional Outcomes (VISION) Coordinated Registry Network: An effort to advance evidence evaluation for vascular devices. J Vasc Surg 2020; 72:2153-2160. [DOI: 10.1016/j.jvs.2020.04.507] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 04/16/2020] [Indexed: 11/18/2022]
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16
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Uno M, Takai H, Yagi K, Matsubara S. Surgical Technique for Carotid Endarterectomy: Current Methods and Problems. Neurol Med Chir (Tokyo) 2020; 60:419-428. [PMID: 32801277 PMCID: PMC7490601 DOI: 10.2176/nmc.ra.2020-0111] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Over the last 60 years, many reports have investigated carotid endarterectomy (CEA) and techniques have thus changed and improved. In this paper, we review the recent literature regarding operational maneuvers for CEA and discuss future problems for CEA. Longitudinal skin incision is common, but the transverse incision has been reported to offer minimal invasiveness and better cosmetic effects for CEA. Most surgeons currently use microscopy for dissection of the artery and plaque. Although no monitoring technique during CEA has been proven superior, multiple monitors offer better sensitivity for predicting postoperative neurological deficit. To date, data are lacking regarding whether routine shunt or selective shunt is better. Individual surgeons thus need to select the method with which they are more comfortable. Many surgical techniques have been reported to obtain distal control of the internal carotid artery in patients with high cervical carotid bifurcation or high plaque, and minimally invasive techniques should be considered. Multiple studies have shown that patch angioplasty reduces the risks of stroke and restenosis compared with primary closure, but few surgeons in Japan have been performing patch angioplasty. Most surgeons thus experience only a small volume of CEAs in Japan, so training programs and development of in vivo training models are important.
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Affiliation(s)
- Masaaki Uno
- Department of Neurosurgery, Kawasaki Medical School
| | - Hiroki Takai
- Department of Neurosurgery, Kawasaki Medical School
| | - Kenji Yagi
- Department of Neurosurgery, Kawasaki Medical School
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17
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Protamine in Patients Undergoing Transcatheter Aortic Valve Replacement: Why Not? JACC Cardiovasc Interv 2020; 13:1481-1483. [PMID: 32553338 DOI: 10.1016/j.jcin.2020.04.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 04/30/2020] [Indexed: 11/24/2022]
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18
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Peeters M, Yilmaz A, Vandekerkhof J, Kaya A. Protamine Induced Anaphylactic Shock after Peripheral Vascular Surgery. Ann Vasc Surg 2020; 69:450.e13-450.e15. [PMID: 32554194 DOI: 10.1016/j.avsg.2020.06.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 05/27/2020] [Accepted: 06/01/2020] [Indexed: 10/24/2022]
Abstract
Anaphylactic reactions to protamine are quite rare and almost exclusively reported during cardiac surgery. In this report, we illustrate a rare case of protamine reaction after peripheral vascular surgery a couple of months after cardiac surgery and how the patient survived this critical complication.
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Affiliation(s)
- Maxim Peeters
- Department of Vascular Surgery, Jessa Hospital, Hasselt, Belgium.
| | - Alaaddin Yilmaz
- Department of Cardiothoracic Surgery, Jessa Hospital, Hasselt, Belgium
| | - Jos Vandekerkhof
- Department of Vascular Surgery, Jessa Hospital, Hasselt, Belgium
| | - Abdullah Kaya
- Department of Cardiothoracic Surgery, Jessa Hospital, Hasselt, Belgium
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19
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Mukherjee D, Collins DT, Liu C, Ha N, Jim J. The study of transcarotid artery revascularization under local versus general anesthesia with results from the Society for Vascular Surgery Vascular Quality Initiative. Vascular 2020; 28:784-793. [DOI: 10.1177/1708538120924158] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective The primary purpose of this study was to examine any potential difference in clinical outcomes between transcarotid artery revascularization performed under local anesthesia compared with general anesthesia by utilizing a large national database. Methods The primary outcome of the study was a composite endpoint of postoperative in-hospital stroke, myocardial infarction and mortality following transcarotid artery revascularization for the index procedure. Secondary outcomes included a composite outcome of postoperative in-hospital stroke, transient ischemic attack, myocardial infarction and mortality along with several subsets of its components and each individual component, flow reversal time (min), radiation dose (GY/cm2), contrast volume utilized (mL), total procedure time (min), extended total length of stay (>1 day) and extended postoperative length of stay (>1 day). Statistical analyses employed both descriptive measures to characterize the study population and analytic measures such as multivariable mixed-effect linear and logistic regressions using both unmatched and propensity-score matched cohorts. Results A total of 2609 patients undergoing transcarotid artery revascularization between the years 2016 and 2018 in the US were identified, with 82.3% performed under general anesthesia and 17.7% under local anesthesia. The primary composite outcome was observed in 2.3% of general anesthesia patients versus 2.6% of local anesthesia patients ( p = 0.808). The rate of postoperative transient ischemic attack and/or myocardial infarction was 1.6% with general anesthesia versus 1.1% with local anesthesia ( p = 0.511). For adjusted regression analysis, general anesthesia and local anesthesia were comparable in terms of primary outcome (OR: 0.72; 95% CI: 0.27–1.93, p = 0.515). As for the secondary outcomes, no significant differences were found except for contrast, where the results demonstrated significantly less need for contrast with procedures performed under general anesthesia (coefficient: 4.94; 95% CI: 1.34–8.54, p = 0.007). A trend towards significance was observed for lower rate of postoperative transient ischemic attack and/or myocardial infarction (OR: 0.33; 95% CI: 0.09–1.18, p = 0.088) and lower flow reversal time under local anesthesia (coefficient: –0.94: 95% CI: –2.1–0.22, p = 0.111). Conclusions Excellent outcomes from transcarotid artery revascularization for carotid stenosis were observed in the VQI database between the years 2016 and 2018, under both local anesthesia and general anesthesia. The data demonstrate the choice of anesthesia for transcarotid artery revascularization does not appear to have any effect on clinical outcomes. Surgical teams should perform transcarotid artery revascularization under the anesthesia type they are most comfortable with.
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Affiliation(s)
| | - Devon T Collins
- Department of Community and Global Health, Inova Heart and Vascular Institute, Inova Fairfax Hospital, College of Health and Human Services, George Mason University, Fairfax, VA, USA
| | - Chang Liu
- Department of Surgery, Inova Fairfax Hospital, Falls Church, VA, USA
| | - Neul Ha
- Department of Surgery, Inova Fairfax Hospital, Falls Church, VA, USA
| | - Jeffrey Jim
- Section of Vascular Surgery, School of Medicine, Washington University, St. Louis, MO, USA
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20
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Phair J, Futchko J, Trestman EB, Carnevale M, Friedmann P, Shukla H, Garg K, Koleilat I. Protamine sulfate use during tibial bypass does not appear to increase thrombotic events or affect short-term graft patency. Vascular 2020; 28:708-714. [PMID: 32393108 DOI: 10.1177/1708538120924149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES While the use of protamine sulfate as a heparin reversal agent has been extensively reviewed in patients undergoing carotid endarterectomy and coronary artery bypass grafting, there is a lack of literature on protamine's effects on lower extremity bypasses. The purpose of this study was to determine the risk of protamine sulfate dosing after tibial bypass on thrombotic or bleeding events, including early bypass failure. METHODS We performed a retrospective review of our institutional database for patients undergoing primary distal peripheral bypass from January 2009 through December 2015 (contralateral bypass was considered to be a new primary bypass). Primary endpoints include composite thrombotic events (myocardial infarction, stroke, amputation at 30 days and patency less than 30 days) and composite bleeding events (bleeding or transfusion). RESULTS A total of 152 tibial or peroneal bypasses in 136 patients with critical limb ischemia were identified. Of these, 78 (57.4%) patients received protamine sulfate intraoperatively and 58 (42.6%) did not. There were no differences in composite thrombotic or hemorrhagic outcomes. Protamine use had no effect on the rates of perioperative MI (9.0% versus 3.5%, p = 0.20), stroke (1.3% versus 1.7%, p = 0.83), or perioperative mortality (5.1% versus 3.5%, p = 0.64). There was no significant difference in composite post-operative bleeding events (20.7% versus 14.1%, p = 0.31) or composite thrombotic events (17.2% versus 18.0%, p = 0.91). Patients who received protamine undergoing bypass with non-autogenous conduit had significantly higher-recorded median operative blood loss (250 mL versus 150 mL, p = 0.0097) and median procedure lengths (265 min versus 201 min, p = 0.0229). No difference in 30-day amputation-free survival was noted (91.0% versus 91.4%, p = 0.94). Follow-up Kaplan-Meier estimation did not demonstrate a difference in 30-day patency (91.7% versus 88.5%, p = 0.52). CONCLUSIONS Heparin reversal with protamine sulfate after tibial or peroneal bypass grafting is not associated with higher cardiovascular morbidity, bypass thrombosis, amputation, or mortality. Additionally, there was no statistically significant difference in post-operative bleeding or thrombosis complications for patients who did not receive protamine, although the findings are suggestive of a potential difference in a more adequately powered study. Our results suggest that protamine sulfate is safe for intraoperative use without increased risk of thrombotic complications or early tibial bypass graft failure.
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Affiliation(s)
- John Phair
- Division of Vascular Surgery, Mount Sinai Medical Center, New York, NY, USA
| | - John Futchko
- Division of Vascular Surgery, Montefiore Medical Center, New York, NY, USA
| | - Eric B Trestman
- Division of Vascular Surgery, Columbia University Medical Center, New York, NY, USA
| | - Matthew Carnevale
- Division of Vascular Surgery, Montefiore Medical Center, New York, NY, USA
| | - Patricia Friedmann
- Division of Vascular Surgery, Montefiore Medical Center, New York, NY, USA
| | - Harshal Shukla
- Department of Pharmacy, Montefiore Medical Center, New York, NY, USA
| | - Karan Garg
- Division of Vascular Surgery, New York University Langone Health, New York, NY, USA
| | - Issam Koleilat
- Division of Vascular Surgery, Montefiore Medical Center, New York, NY, USA
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21
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Ranasinghe T, Mays T, Quedado J, Adcock A. Thrombolysis Following Heparin Reversal With Protamine Sulfate in Acute Ischemic Stroke: Case Series and Literature Review. J Stroke Cerebrovasc Dis 2019; 28:104283. [PMID: 31324409 PMCID: PMC6800047 DOI: 10.1016/j.jstrokecerebrovasdis.2019.06.041] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 06/23/2019] [Accepted: 06/27/2019] [Indexed: 01/01/2023] Open
Abstract
INTRODUCTION Administering intravenous IV tissue plasminogen activator (tPA) is the recommended standard of care in acute ischemic stroke (AIS), although it is not recommended to administer intravenous thrombolysis with tPA following heparin reversal with protamine sulfate in patients with AIS. METHODS We describe a case series of three patients and the most comprehensive literature review published to date in this specific subset of AIS patients undergoing thrombolysis following heparin reversal with protamine sulfate. The literature review was based on a scoping review methodology performed on four databases; PubMed, CINAHL, Web of Science, and Cochrane Library. All sources were searched from the inauguration of the database until February 2019. A total of six articles involving eight patients were identified. RESULTS The primary safety outcome of no symptomatic intracranial hemorrhage (sICH) was met in all eleven patients, although only seven cases had a good functional outcome at 3 months. CONCLUSIONS In appropriately selected AIS patients, coagulopathy correction appears to be safe from an sICH standpoint and may be beneficial. However, given the potential for bias with observational databases, case reports and case series, extreme caution is warranted in applying these results to routine clinical practice.
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Affiliation(s)
- Tamra Ranasinghe
- Department of Neurology, West Virginia University, Morgantown, West Virginia.
| | - Traci Mays
- Health Science Library, West Virginia University, Morgantown, West Virginia
| | - Jeff Quedado
- Department of Pharmacy, West Virginia University, Morgantown, West Virginia
| | - Amelia Adcock
- Department of Neurology, West Virginia University, Morgantown, West Virginia
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22
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Taggart NW, Gordon BM, Morgan GJ, Goldstein BH. Variation in Anticoagulation Practices in the Congenital Cardiac Catheterization Lab: Results of a Multinational PICES Survey. Pediatr Cardiol 2019; 40:53-60. [PMID: 30121864 DOI: 10.1007/s00246-018-1960-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 08/09/2018] [Indexed: 11/28/2022]
Abstract
The complex nature of congenital heart disease (CHD) has hindered the establishment of management standards for peri-catheterization anticoagulation. We sought to describe anticoagulation practice variability among providers performing cardiac catheterization in children and adults with CHD. A web-based survey ( http://www.surveymonkey.com ) was distributed to pediatric and congenital interventional cardiologists. Respondents were queried on their training, practice setting, years in practice, and case volume. Clinical questions focused on general anticoagulation strategies and on five common clinical scenarios: two diagnostic (biventricular circulation, single ventricle physiology) and three interventional cardiac catheterizations (atrial septal defect closure, pulmonary artery stenting in Fontan circulation, stent placement for coarctation of aorta). Seventy-seven pediatric and congenital interventional cardiologists responded to the survey (81% in the United States). Twenty-six (36%) worked in a public medical institution; 57% worked in a free-standing children's hospital. Twenty-six percent had been in practice for < 5 years and 32% for > 15 years; 75% completed additional training in interventional congenital cardiology. The median number of cases performed was 200/year (IQR 110); median number of interventional cases was 100/year (IQR 100). Responses to general queries and specific clinical scenarios suggested significant variation in anticoagulation practices, including monitoring of anticoagulation during catheterization, protamine use, and outpatient anticoagulation after catheterization. Practices not only varied between providers but also between different clinical scenarios. Practice patterns did not correlate with provider experience or case volume. Management of anticoagulation in the congenital cardiac catheterization lab varies from operator to operator. Our study may provide some initial insight and context for discussion regarding anticoagulation in a field of increasingly heterogeneous interventional techniques and patient substrates. Future studies would be helpful to better define "best practices" for peri-procedural thromboprophylaxis in patients with congenital heart disease.
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Affiliation(s)
- Nathaniel W Taggart
- Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA.
| | - Brent M Gordon
- Division of Pediatric Cardiology, Loma Linda University Children's Hospital, Loma Linda, CA, USA
| | - Gareth J Morgan
- Department of Paediatric Cardiology, Evelina Children's Hospital, Guy's and St. Thomas' NHS Trust, London, UK
| | - Bryan H Goldstein
- Division of Cardiology, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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Witt DM, Nieuwlaat R, Clark NP, Ansell J, Holbrook A, Skov J, Shehab N, Mock J, Myers T, Dentali F, Crowther MA, Agarwal A, Bhatt M, Khatib R, Riva JJ, Zhang Y, Guyatt G. American Society of Hematology 2018 guidelines for management of venous thromboembolism: optimal management of anticoagulation therapy. Blood Adv 2018; 2:3257-3291. [PMID: 30482765 PMCID: PMC6258922 DOI: 10.1182/bloodadvances.2018024893] [Citation(s) in RCA: 304] [Impact Index Per Article: 50.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 09/24/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Clinicians confront numerous practical issues in optimizing the use of anticoagulants to treat venous thromboembolism (VTE). OBJECTIVE These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians and other health care professionals in their decisions about the use of anticoagulants in the management of VTE. These guidelines assume the choice of anticoagulant has already been made. METHODS ASH formed a multidisciplinary guideline panel balanced to minimize potential bias from conflicts of interest. The McMaster University GRADE Centre supported the guideline development process, including updating or performing systematic evidence reviews. The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess evidence and make recommendations, which were subject to public comment. RESULTS The panel agreed on 25 recommendations and 2 good practice statements to optimize management of patients receiving anticoagulants. CONCLUSIONS Strong recommendations included using patient self-management of international normalized ratio (INR) with home point-of-care INR monitoring for vitamin K antagonist therapy and against using periprocedural low-molecular-weight heparin (LMWH) bridging therapy. Conditional recommendations included basing treatment dosing of LMWH on actual body weight, not using anti-factor Xa monitoring to guide LMWH dosing, using specialized anticoagulation management services, and resuming anticoagulation after episodes of life-threatening bleeding.
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Affiliation(s)
- Daniel M Witt
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, UT
| | - Robby Nieuwlaat
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Nathan P Clark
- Clinical Pharmacy Anticoagulation and Anemia Service, Kaiser Permanente Colorado, Aurora, CO
| | - Jack Ansell
- School of Medicine, Hofstra Northwell, Hempstead, NY
| | - Anne Holbrook
- Division of Clinical Pharmacology and Toxicology, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Jane Skov
- Unit for Health Promotion Research, Department of Public Health, University of Southern Denmark, Esbjerg, Denmark
| | - Nadine Shehab
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | | | | | - Francesco Dentali
- Department of Medicine and Surgery, Insubria University, Varese, Italy
| | - Mark A Crowther
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Arnav Agarwal
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Meha Bhatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Rasha Khatib
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL; and
| | - John J Riva
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Family Medicine, McMaster University, Hamilton, ON, Canada
| | - Yuan Zhang
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
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24
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Newhall KA, Stone DH, Goodney PP. Reply. J Vasc Surg 2017; 66:968-969. [DOI: 10.1016/j.jvs.2017.06.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Accepted: 06/06/2017] [Indexed: 11/29/2022]
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25
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Meesters MI, Boer C. A critical note on protamine use in carotid endarterectomy. J Vasc Surg 2017; 66:967-968. [PMID: 28842079 DOI: 10.1016/j.jvs.2017.02.061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 02/17/2017] [Indexed: 11/19/2022]
Affiliation(s)
- Michael I Meesters
- Department of Anesthesiology, Institute for Cardiovascular Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Christa Boer
- Department of Anesthesiology, Institute for Cardiovascular Research, VU University Medical Center, Amsterdam, The Netherlands
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26
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Chan K, Abouzamzam A, Woo K. Carotid Endarterectomy in the Southern California Vascular Outcomes Improvement Collaborative. Ann Vasc Surg 2017; 42:11-15. [PMID: 28323231 PMCID: PMC5559870 DOI: 10.1016/j.avsg.2016.11.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 11/10/2016] [Accepted: 11/21/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND The objective of this study was to examine the variation in practice patterns and associated outcomes for carotid endarterectomy (CEA) within the Southern California Vascular Outcomes Improvement Collaborative (So Cal VOICe), a regional quality group of the Vascular Quality Initiative. METHODS All cases entered in the CEA registry by the So Cal VOICe were included in the study. RESULTS From September 2010 through September 2015, 1,110 CEA cases were entered by 9 centers in the So Cal VOICe. Six hundred seventy-seven patients (61%) were male with mean age of 73 years. Nine hundred eighty-eight (89%) were hypertensive, 655 (59%) were prior or current smokers, 389 (35%) were diabetics, and 233 (21%) had coronary artery disease. Eight hundred twenty-one (74%) patients were asymptomatic (no history of ipsilateral neurologic event). The percentage of asymptomatic patients varied across the 9 centers from 57% to 91%. Preoperatively, 344 (31%) underwent cardiac stress test, center variation 13-75%, 500 (45%) underwent only duplex, center variation 11-72%. Intraoperatively, 600 (54%) underwent routine shunting, whereas 67 (6%) were shunted for an indication, and 444 (40%) were not shunted. Wound drainage was used in 422 (38%) cases, center variation 2-98%. Completion imaging by duplex and/or angiogram was performed in 766 (69%) cases, center variation 0-100%. Postoperatively, 11 (1%) patients had a new ipsilateral postoperative neurologic event, center variation 0-1.3%, 6 (0.5%) had a postoperative myocardial infarction, center variation 0-1.3%, and 8 (0.7%) required return to operating room for bleeding, center variation 0-1.3%. CONCLUSIONS Despite wide variation in practice patterns surrounding CEA in the So Cal VOICe, postoperative complications were uniformly low. Further work will focus on identifying practices that can be modified to improve cost-effectiveness while maintaining excellent outcomes.
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Affiliation(s)
- Kaelan Chan
- Department of Surgery, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA
| | - Ahmed Abouzamzam
- Department of Surgery, Loma Linda University School of Medicine, Loma Linda, CA
| | - Karen Woo
- Department of Surgery, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA.
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Bennett KM, Kent KC, Schumacher J, Greenberg CC, Scarborough JE. Targeting the most important complications in vascular surgery. J Vasc Surg 2017; 65:793-803. [DOI: 10.1016/j.jvs.2016.08.107] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Accepted: 08/18/2016] [Indexed: 11/16/2022]
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Rathenborg LK. Commentary on 'Protamine Reduces Bleeding Complications Without Increasing the Risk of Stroke After Carotid Endarterectomy: A Meta-analysis'. Eur J Vasc Endovasc Surg 2016; 52:308. [PMID: 27424007 DOI: 10.1016/j.ejvs.2016.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2016] [Accepted: 06/16/2016] [Indexed: 11/29/2022]
Affiliation(s)
- L K Rathenborg
- Rigshospitalet, University Hospital of Copenhagen, Denmark.
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