[Carotid Endarterectomy in Patients with Antiaggregation Therapy]

Carotid endarterectomy is a common way of surgical treatment of extracranial carotid artery disease caused by atherosclerosis. Patients are often operated on under local anesthesia with intraoperative application of heparin. Postoperative bleeding occurs in up to 8% of cases, and up to 4.7% of patients need reoperation due to bleeding. TachoSil is a medical sponge consisting of collagen with added human coagulation factors (fibrinogen and thrombin). In contact with water, blood or bodily fluids, it forms a clot that adheres to the surface. The hypothesis and aim of our study was to show that TachoSil could be topically administered during surgery on carotid arteries in order to prevent minor bleeding, without causing any local signs of inflammation or infection. The study included a prospective series of consecutive patients that underwent surgery for extracranial carotid stenosis with concomitant antiplatelet therapy at Department of Vascular Surgery, Merkur University Hospital in Zagreb. All patients received antiplatelet therapy with aspirin or aspirin and clopidogrel until the day before surgery. From April 2, 2012 to February 8, 2013, a total of 24 patients with extracranial carotid artery stenosis were operated on, along with receiving antiplatelet therapy. All patients received 100 mg of acetylsalicylic acid and/or 75 mg of clopidogrel until one day prior to surgery. Patients had been treated with antiplatelet drugs for at least six months prior to carotid endarterectomy. Four patients had been on dual antiplatelet therapy (aspirin 100 mg and clopidogrel 75 mg) because of percutaneous transluminal angioplasty (PTA) and a stent placed in pelvic arteries or superficial femoral artery. Due to speech disturbances following clamping of carotid arteries in two study patients a temporary intraluminal shunt was created. These two patients underwent longitudinal arteriotomy and longitudinal endarterectomy. Arteriotomy was closed by direct suture without a patch. Following arteriotomy and partial conversion of heparin with protamine, six patients needed additional individual sutures. Then, protamine was added again to up to the full dose of conversion (50 mg). In 19 patients, only one TachoSil medical sponge (9.5 cm x 4.8 cm) was placed, whereas in fi ve patients two sponges were placed. None of the patients (24 of them operated on between April 2, 2012 and February 8, 2013) with TachoSil placed intraoperatively had any signs of postoperative wound infection. Carotid artery stenosis is a very common disease the incidence of which increases proportionally with age of the population observed. Bleeding is a relatively common and significant complication following surgical treatment, particularly in case of arterial bleeding. Bleeding and other complications in the neck can be very serious and challenging for surgical treatment. With the present guidelines for the administration of clopidogrel in the evening before surgery, in some circumstances an increased incidence of postoperative hemorrhage or prolonged duration of surgery can be expected. Intraoperative use of hemostatics may reduce the postoperative bleeding complications. Intraoperative application of TachoSil does not increase the rate of postoperative complications such as infection and delayed healing. TachoSil may reduce the rate of postoperative complications in carotid surgery.