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Thrombin generation in patients undergoing carotid endarterectomy: implications in acute vessel wall closure and
Insights
Significant thrombin generation occurs after carotid endarterectomy surgery, even with heparin. This persistent activation, indicated by elevated F1+2 and TAT levels, may increase the risk of early ischemic events post-surgery.
Area of Science:
- Vascular Surgery
- Hemostasis and Thrombosis
- Biochemistry
Background:
- Carotid endarterectomy is a common procedure to prevent stroke.
- Perioperative coagulation activation is a concern in vascular surgery.
- Heparin is typically used for anticoagulation during carotid endarterectomy.
Purpose of the Study:
- To determine the extent and duration of coagulation activation in the 24 hours following carotid endarterectomy.
- To assess thrombin generation and inhibition during and after the procedure.
- To evaluate the effectiveness of heparin anticoagulation in this context.
Main Methods:
- Serial blood sampling from 10 patients undergoing carotid endarterectomy.
- Measurement of activated prothrombin fragment F1+2 and thrombin-antithrombin III (TAT) levels using ELISA kits.
- Analysis of coagulation markers before, during, and after surgery, including post-heparin neutralization.
Main Results:
- No significant increase in F1+2 or TAT levels was observed during surgery while patients were heparinized.
- Both F1+2 and TAT levels significantly increased within 3 hours after surgery after heparin neutralization (p < 0.01).
- Elevated F1+2 and TAT levels persisted for at least 24 hours in 75% of patients (p < 0.01).
Conclusions:
- Thrombin generation is significant post-carotid endarterectomy, despite intraoperative heparin use.
- Heparin may not be the optimal anticoagulant for this procedure.
- Persistent thrombin generation may contribute to early post-endarterectomy ischemic events.
Abstract:
We determined the extent and duration of activation of coagulation during the first 24 hours after carotid endarterectomy. Serial blood samples were collected before, during and after surgery from 10 patients with severe stenosis (> 70%) undergoing carotid endarterectomy with heparinization. Platelet poor plasmas prepared from these samples, were analysed for activated prothrombin fragment F1 + 2 and thrombin-antithrombin III (TAT) levels, using commercially available ELISA kits. F1 + 2 and TATs were measured as indices of thrombin generation and inhibition respectively. Baseline F1 + 2 and TAT levels were 1.19 +/- 0.27 nMol/ml and 17 +/- 10 pMol/ml, respectively. Neither the F1 + 2 nor TAT level increased during surgery at a time when the patients were heparinized. However, both the F1 + 2 and TAT levels increased significantly within 3 hours after surgery and after the heparin had been neutralized with protamine, (p < 0.01). Moreover, both the F1 + 2 and TAT levels remained elevated in 75% of the patients for at least 24 hours, p < 0.01. We conclude that i) thrombin generation is significant post surgery in patients undergoing carotid endarterectomy despite their receiving heparin during surgery; ii) heparin may not be the ideal anticoagulant for carotid endarterectomy; and iii) persistent thrombin generation may contribute to early post-endarterectomy ischemic events.