Editor's Choice - Benefits and Harms of Protamine Use during Carotid Endarterectomy: An Updated Systematic Review and...

Despite all the advances in endovascular techniques, carotid endarterectomy (CEA) remains the standard intervention for carotid stenosis. The refinement of intra- and post-operative care increasingly aims to increasingly minimize the risks associated with this procedure, especially neurological and cardiovascular events. This study aimed to summarise the literature on the benefits and harms of protamine use during CEA.

PubMed (MEDLINE), Embase, and Cochrane databases.

MEDLINE, Embase, and Cochrane databases were systematically searched for studies of patients undergoing CEA whose population was partially given protamine. Outcomes included cervical haematomas, stroke, myocardial infarction, and overall mortality rate. Statistical analysis was performed using R Studio version 5.3. Heterogeneity was assessed with the I² statistic.

Twelve studies, including over 87 000 CEAs, were analysed. Protamine administration significantly reduced the rate of any cervical haematoma (odds ratio [OR] 0.49, 95% confidence interval [CI] 0.39 - 0.60; p < .001) as well as haematomas requiring re-operation (OR 0.48, 95% CI 0.35 - 0.67; p < .001). There was an association with a lower stroke rate after protamine use (OR 0.85, 95% CI 0.74 - 0.97; p = .018). Finally, no difference was identified in terms of mortality (OR 0.95, 95% CI 0.69 - 1.31; p = .77). The GRADE certainty of evidence was rated as very low across all outcomes analysed.

Protamine may reduce the risks of CEA without increasing adverse outcomes. However, further research is needed given the very low certainty of the available evidence.