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Protamine use in transcarotid arterial revascularization.

John J Kanitra1, Rebekah L Bjorklund2, David J Clausen1

  • 1Department of Surgery, 21928Ascension St John Hospital, Detroit, MI, USA.

Vascular
|January 18, 2022
PubMed
Summary

In transcarotid arterial revascularization (TCAR), a near 1:1 protamine to heparin ratio was used for reversal. Lower protamine doses did not increase bleeding complications, suggesting potential for reduced use during shortages.

Keywords:
Carotid stenosiscarotid stentendovascular proceduresprotaminetranscarotid arterial revascularization

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Area of Science:

  • Vascular Surgery
  • Anesthesiology
  • Pharmacology

Background:

  • Heparin reversal with protamine is standard in transcarotid arterial revascularization (TCAR).
  • Optimal protamine dosing for heparin reversal in TCAR remains unevaluated.
  • Previous literature suggests reduced bleeding without increased stroke or death.

Purpose of the Study:

  • To evaluate the institutional experience with intraoperative heparin reversal using protamine in TCAR procedures.
  • To assess the protamine to heparin dose ratio utilized in TCAR.
  • To investigate the association between protamine/heparin ratio and postoperative complications.

Main Methods:

  • Single-center, retrospective, observational study.
  • Inclusion of adult patients undergoing TCAR between September 2019 and April 2021.
  • Data collection from Vascular Quality Initiative and chart review for heparin/protamine doses.
  • Multivariate logistic regression to analyze protamine/heparin ratio associations.

Main Results:

  • Sixty-two patients were analyzed with an average protamine/heparin ratio of 0.96 ± 0.12 mg/U.
  • No postoperative bleeding occurred in patients with a protamine/heparin ratio > 0.8 mg/U.
  • Incidence of bradycardia (32.3%) and hypotension (35%) was observed, with no correlation to the protamine/heparin ratio.
  • Zero 30-day myocardial infarction, stroke, or death events were recorded.

Conclusions:

  • A near 1:1 protamine/heparin ratio is commonly used for heparin reversal in TCAR.
  • Lower protamine doses (ratio > 0.8 mg/U) were not associated with increased bleeding complications.
  • Further large-scale studies are warranted to explore reduced protamine dosing, especially during shortages.