Delayed postoperative bleeding from polytetrafluoroethylene carotid artery patches R o b e r t A. M c C r e a d y , M D , H a r r y Siderys, M D , J o h n N. P i t t m a n , M D , Gilbert T. H e r o d , M D , H a r o l d G. H a l b r o o k , M D , J o h n W. Fehrenbacher, M D , D~miel J. Beckman, M D , and David A. H o r m u t h , M D , Indianapolis, Ind. Pwtch angioplasty of the internal carotid artery after endarterectomy has been advocated as a means of decreasing early postoperative carotid artery thrombosis, as well as reducing the incidence of recurrent carotid artery stenosis. Noninfectious rupture ofsaphenous vein patches in the early postoperative period has been reported by several authors, leading others to advocate the use of prosthetic patches. This report describes three patients in whom delayed bleeding through needle holes along the suture lines in polytetrafluoroethylene cardiovascular patches occurred between 1.5 and 4 days after operation. All patents required reexploration to control bleeding, and acute respiratory distress from tracheal compression developed in one patient. Although delayed bleeding through needle holes in polytetrafluoroethylene cardiovascular patches appears to be rare, a word of caution may be in order before advocating routine patching of the carotid artery with this particular type of patch. (J VAsc SURG 1992;15:661-3.)
Routine patching o f the carotid artery after endarterectomy has been recommended by some authors, whereas others perform patch angioplasty in selected patients in w h o m a high incidence o f recurrent carotid artery stenosis might be anticipated or in w h o m a extended arteriotomy is necessary. 19 Patch angioplasty o f the carotid artery is not without complications, however. "Blowout" or rupture o f saphenous vein patches has been well described) ,4,H-~3 Postoperative rupture o f polytetrafluoroethylene (PTFE) patches has also been reported.12 Adthough it is an infrequent complication, rupture o f a patch can be devastating because o f the potential for acute tracheal obstruction, stroke, and exsanguinating hemorrhage. This report describes three patients in w h o m delayed postoperative bleeding occurred through needle holes along the suture lines o f cardiovascular patches; all patients required reoperation. CASE REPORTS Case 1. A 61-year-old woman underwent a left carotid endarterectomy for an asymptomatic 90% stenosis of the internal carotid artery on Oct. 31, 1989. The patient was systemically heparinized (100 units/kg) before the arteri-
From Cardiovascular Surgical Associates, Methodist Hospital, Indianapolis. Reprint requests: Robert A. McCready,MD, 1801 North Senate Blvd., Suite 755, Indianapolis, IN 46202. 24/4/32981
otomy. The patient had been given 325 mg of aspirin the evening before the operation. After completion of the endarterectomy, a 0.4 mm PTFE patch (W. L. Gore & Assoc., Elkton, Md.) was used as a patch angioplasty. A 6-0 Prolene (Ethicon Inc., Somerville, N.J.) suture was used to sew the patch in place. After flow had been reestablished, the heparin was reversed with protamine. Activated clotting time (ACT) was measured to be certain that the heparin had been completely neutralized. The patient did well initially, and she remained normotensive after operation. No hematoma was noted the following morning. She was restarted on 325 mg per day of aspirin. Thirty-sL-(hours after operation, however, an expanding hematoma associated with respiratory distress developed. She was normotensive before the acute bleeding episode. The patient was returned immediately to the operating room where two needle holes in the suture line were found to be actively bleeding. The bleeding was controlled with Gelfoam (Parke-Davis, Morris Plains, N.J.) and thrombin and gentle compression. After this episode, the patient recovered uneventfully. The patient was on 325 mg of aspirin after operation, but no other anticoagulants had been used. Extensive coagulation tests were done after this bleeding episode, but results were all normal. Case 2. A 70-year-old woman underwent a left carotid endarterectomy for a preocclusive stenosis of the carotid artery 6 weeks after suffering a left hemispheric stroke. The patient had hypertension, which was well controlled. She was also taking 325 mg of aspirin daily. On Feb. 12, 1990 a left carotid endarterectomy was performed. Before the arteriotomy, the patient was given 661
662 McCready et aL
heparin (100 units/kg). Because the plaque extended up in the internal carotid artery for approximately 3 cm, a 0.4 mm PTFE patch was used for closure of the arteriotomy. A 7-0 PTFE cardiovascular suture (W.L. Gore & Assoc., Elkton, Md.) was used for closure of the patch angioplasty. The heparin was reversed with protamine. The ACT was normal after the heparin was reversed. The patient was normotensive after operation and was neurologically intact. On the first postoperative day she was restarted on 325 mg of aspirin daily. On the fourth postoperative day a large hematoma suddenly developed in the wound, and the patient was returned to the operating room. At exploration, the bleeding was found to be coming through a single needle hole in the suture line and was controlled with Gelfoam and thrombin. Once again, extensive coagulation tests were normal. After operation the patient did well and was dismissed 3 days later. Case 3. A 62-year-old man with a history of wellcontrolled hypertension underwent a right carotid endarterectomy on Sept. 11, 1990, for a symptomatic 90% stenosis of the internal carotid artery. The plaque extended into the carotid artery for approximately 3 cm. The patient was taking 325 mg of aspirin per day. The patient was heparinized (100 units/kg) before the arteriography. Because of the distal extent of the plaque in the internal carotid artery, a 0.6 mm PTFE patch was used to close the arteriotomy in the internal carotid artery. A 7-0 PTFE suture was used for closure of the patch angioplasty. The heparin was reversed with protamine. An ACT measurement was normal. Low molecular weight dextran at 30 mt per hour was begun during the operation and continued after operation for 24 hours. The patient did well and no hematoma was noted the following morning. The dextran was stopped. However, 12 hours later (36 hours after the operation), a rapidly expanding hematoma developed and the patient was returned immediately to the operating room. There was significant bleeding through two needle holes in the patch. The bleeding was controlled with Gelfoam and thrombin. No additional sutures were needed. The patient recovered uneventfully. During the 12-month time interval of this study (October 1989 through September 1990) during which these three cases occurred, 87 patients underwent carotid endarterectomy. Prosthetic PTFE patches were used in 18 patients. Most patients received the 0.4 mm PTFE patches. DISCUSSION
Advocates of routine patch angioplasty after carotid endarterectomy cite the following advantages of patch angioplasty: (1) A decreased incidence of postoperative carotid artery thrombosis with a subsequent reduction in the incidence of early postoperative neurologic deficits, a n d (2) a lower incidence of recurrent carotid artery stenosis. 1-6,9,10In addition, it has been suggested that the flow characteristics of patched internal carotid arteries may be superior to
lournal of VASCULAR ~. SURGEP,.Y
unpatched carotid arteries in terms of preventing early thrombus formation. (2) Dirrenberger and Sundt 14 have demonstrated that an endarterectomized carotid artery is extraordinarily thrombogenic for the first several hours after endarterectomy, during which time the carotid artery is most vulnerable to acute occlusion, leading these authors to recommend closure of the arteriotomy with a saphenous vein patch. An infrequent but devastating complication associated with saphenous vein patches has been "blowout" or rupture of vein patches in the early postoperative period3 ,4,11-13 In addition to the propensity toward rupture of saphenous vein patches harvested from the anlde. Lord et al.~s reported a significant incidence of aneurysmal expansion of saphenous vein patches, as demonstrated by posto: erative arteriograms. Accordingly, they recommended use of PTFE patches preferentially, Postoperative disruption of a PTFE carotid patch has also been reported, with the patient suffering a stroke as a result of disruption of the patch. 12 In addition to the complications reported herein with the PTFE patches after carotid endarterectomy, we have noted excessive intraoperative bleeding from needle holes in the PTFE cardiovascular patches, especially those in whom the 0.4 m m patch has been used. Although postoperative bleeding or "blowout" of PTFE cardiovascular patches after carotid endarterectomy would seem to be quite rare, such a complication could result in serious morbidity, such as stroke and acute respiratory embarrassment. Surgeons using PTFE patches should be aware of the possibility of delayed postoperative bleeding from these patches. In these days of ever increasing pressure for early hospital discharge of patients after carotid endarterectomy, delayed bleeding from a PTFE carotid patch could result in disastrous consequences. All three patients in this study received 325 mg of aspirin before operation, and this was restarted on the first postoperative day. Aspirin produces irreversible acetylation of cyclooxygenase, inhibiting the production of thromboxane, thereby inhibiting platelet aggregation. This effect lasts for the full 7-day life span of the platelet. We do not think the aspirin was responsible for the delayed postoperative bleeding seen in these patients. Although bleeding times were not done on these patients, we did not have excessive intraoperative bleeding except through the needle holes in the PTFE patches. In addition, we have not encountered
Volume 15 "Tumber 4 ~~pril 1992
delayed postoperative bleeding in patients receiving Dacron or saphenous vein patches, and all of these patients were receiving aspirin. Dextran also has a direct antiplatelet effect.16 Although large doses of higher molecular weight dextran can produce diffuse intravascular coagulation, the use of low molecular weight dextran is not associated with increased surgical bleeding. 16Patient three in our series did receive low molecular weight dextran for the first 24 hours after operation, but it had been discontinued 12 hours before his bleeding episode began. We do not think the dextran was the cause of the clelayed postoperative bleeding. The authors thank Bert Neu for her excellentassistance in the preparation of this manuscript. RL2ERENCES 1. Katz MM, Jones GT, Degenhardt J, Gunn B, Wilson J, Katz S. The use of patch angioplasty to alter the incidence of carotid restenosis fbllowing thromboendatterectomy. ~ Cardiovasc Surg (Torino) 1987;28:2-8. 2. Archie JP. Prevention of early restenosis and thrombosisocclusion after carotid endarterectomy by saphenous vein patch angioplasty. Stroke 1986;17:901-5. 3. Das MB, Hertzer NB, Ratliff NB, O'Hara P1, Beven EG. Recurrent carotid stenosis. Ann Surg 1985;202:28-35. 4. Hertzer NR, Beven EG, O'Hara PF, Krajewski LP. A prospective study of vein patch angioplasty during carotid endarterectomy. Ann Surg 1987;206:628-35. 5. LeGrand DR, Linehan RL. The suitability of expanded PTFE for carotid patch angioplasty. Ann Vasc Surg 1990;4: 209-12. 6. Deriu GP, BaUotta E, Bonavina L, et al. The rationale for
Delayed bleedingfrom PTFE carotid arterypatches 663
patch-graft angioplasty after carotid endarterecmmy: early and long-term follow-up. Stroke 1984;15:972-9. 7. Fode NC, Sundt TM, Robertson JT, Peerless SI, Shields CB. Multicenter retrospective review of results and complications of carotid endarterectomy in 1981. Stroke 1986;17:370-6. 8. Clagett GP, Patterson CB, Fisher DF lr, et al. Vein patch versus primary closure for carotid endarterectomy. J VASC SURG 1989;9:218-23. 9. Eikelboom BC, AckerstaffRGA, Hoenevdd H, et al. Benefits of carotid patching~ a randomized study. I VASC SURG 1988;7:240-7. 10. Riles TS, Lamparello PJ, Giangola G, Imparato AM. Rupture of the vein patch: a rare complication of carotid endarterectomy. Surgery 1990;107:10-12. 11. Bartlett FE, Rapp JH, Goldstone J, Ehrenfeld WK, Stoney RJ. Recurrent carotid stenosis: operative strategy and late results. J VASC SURG 1987;5:452-6. 12. Rosenthal D, Archie JP, Garcia-Rinald R, et aL Carotid patch angioplasty: immediate and long-term results, l VAsc SURG 1990;12:326-33. 13. Tawes RL, Treiman RL. Vein patch rupture after carotid endarterectomy: a survey of the Western Vascular Society Members. Ann Vasc Surg 1991;5:71-3. 14. Dirrenberger RA, Sun& TM Jr. Carotid endarterectomy: temporal profile of the healing process and effects of anticoagulation therapy. J Neurosurg 1978;48:201-19. 15. Lord RSA, Raj TB, Stary DL, Nash PA, Graham AR, Goh KH. Comparison of saphenous vein patch, polytetrafluoroethylene patch, and direct arteriotomy closure after carotid endarterectomy. Part i. Perioperative results. J VASC SURG 1989;9:521-9. 16. Shoenfeld NA, Eldmp-Jorgensen J, Connally R, et al. The effect of low molecular weight dextran on platetet deposition onto prosthetic materials. J VASC SUnG 1987;5:76-82. Submitted May 13, 1991; accepted Aug. 6, 1991.
Routine patching o f the carotid artery after endarterectomy has been recommended by some authors, whereas others perform patch angioplasty in selected patients in w h o m a high incidence o f recurrent carotid artery stenosis might be anticipated or in w h o m a extended arteriotomy is necessary. 19 Patch angioplasty o f the carotid artery is not without complications, however. "Blowout" or rupture o f saphenous vein patches has been well described) ,4,H-~3 Postoperative rupture o f polytetrafluoroethylene (PTFE) patches has also been reported.12 Adthough it is an infrequent complication, rupture o f a patch can be devastating because o f the potential for acute tracheal obstruction, stroke, and exsanguinating hemorrhage. This report describes three patients in w h o m delayed postoperative bleeding occurred through needle holes along the suture lines o f cardiovascular patches; all patients required reoperation. CASE REPORTS Case 1. A 61-year-old woman underwent a left carotid endarterectomy for an asymptomatic 90% stenosis of the internal carotid artery on Oct. 31, 1989. The patient was systemically heparinized (100 units/kg) before the arteri-
From Cardiovascular Surgical Associates, Methodist Hospital, Indianapolis. Reprint requests: Robert A. McCready,MD, 1801 North Senate Blvd., Suite 755, Indianapolis, IN 46202. 24/4/32981
otomy. The patient had been given 325 mg of aspirin the evening before the operation. After completion of the endarterectomy, a 0.4 mm PTFE patch (W. L. Gore & Assoc., Elkton, Md.) was used as a patch angioplasty. A 6-0 Prolene (Ethicon Inc., Somerville, N.J.) suture was used to sew the patch in place. After flow had been reestablished, the heparin was reversed with protamine. Activated clotting time (ACT) was measured to be certain that the heparin had been completely neutralized. The patient did well initially, and she remained normotensive after operation. No hematoma was noted the following morning. She was restarted on 325 mg per day of aspirin. Thirty-sL-(hours after operation, however, an expanding hematoma associated with respiratory distress developed. She was normotensive before the acute bleeding episode. The patient was returned immediately to the operating room where two needle holes in the suture line were found to be actively bleeding. The bleeding was controlled with Gelfoam (Parke-Davis, Morris Plains, N.J.) and thrombin and gentle compression. After this episode, the patient recovered uneventfully. The patient was on 325 mg of aspirin after operation, but no other anticoagulants had been used. Extensive coagulation tests were done after this bleeding episode, but results were all normal. Case 2. A 70-year-old woman underwent a left carotid endarterectomy for a preocclusive stenosis of the carotid artery 6 weeks after suffering a left hemispheric stroke. The patient had hypertension, which was well controlled. She was also taking 325 mg of aspirin daily. On Feb. 12, 1990 a left carotid endarterectomy was performed. Before the arteriotomy, the patient was given 661
662 McCready et aL
heparin (100 units/kg). Because the plaque extended up in the internal carotid artery for approximately 3 cm, a 0.4 mm PTFE patch was used for closure of the arteriotomy. A 7-0 PTFE cardiovascular suture (W.L. Gore & Assoc., Elkton, Md.) was used for closure of the patch angioplasty. The heparin was reversed with protamine. The ACT was normal after the heparin was reversed. The patient was normotensive after operation and was neurologically intact. On the first postoperative day she was restarted on 325 mg of aspirin daily. On the fourth postoperative day a large hematoma suddenly developed in the wound, and the patient was returned to the operating room. At exploration, the bleeding was found to be coming through a single needle hole in the suture line and was controlled with Gelfoam and thrombin. Once again, extensive coagulation tests were normal. After operation the patient did well and was dismissed 3 days later. Case 3. A 62-year-old man with a history of wellcontrolled hypertension underwent a right carotid endarterectomy on Sept. 11, 1990, for a symptomatic 90% stenosis of the internal carotid artery. The plaque extended into the carotid artery for approximately 3 cm. The patient was taking 325 mg of aspirin per day. The patient was heparinized (100 units/kg) before the arteriography. Because of the distal extent of the plaque in the internal carotid artery, a 0.6 mm PTFE patch was used to close the arteriotomy in the internal carotid artery. A 7-0 PTFE suture was used for closure of the patch angioplasty. The heparin was reversed with protamine. An ACT measurement was normal. Low molecular weight dextran at 30 mt per hour was begun during the operation and continued after operation for 24 hours. The patient did well and no hematoma was noted the following morning. The dextran was stopped. However, 12 hours later (36 hours after the operation), a rapidly expanding hematoma developed and the patient was returned immediately to the operating room. There was significant bleeding through two needle holes in the patch. The bleeding was controlled with Gelfoam and thrombin. No additional sutures were needed. The patient recovered uneventfully. During the 12-month time interval of this study (October 1989 through September 1990) during which these three cases occurred, 87 patients underwent carotid endarterectomy. Prosthetic PTFE patches were used in 18 patients. Most patients received the 0.4 mm PTFE patches. DISCUSSION
Advocates of routine patch angioplasty after carotid endarterectomy cite the following advantages of patch angioplasty: (1) A decreased incidence of postoperative carotid artery thrombosis with a subsequent reduction in the incidence of early postoperative neurologic deficits, a n d (2) a lower incidence of recurrent carotid artery stenosis. 1-6,9,10In addition, it has been suggested that the flow characteristics of patched internal carotid arteries may be superior to
lournal of VASCULAR ~. SURGEP,.Y
unpatched carotid arteries in terms of preventing early thrombus formation. (2) Dirrenberger and Sundt 14 have demonstrated that an endarterectomized carotid artery is extraordinarily thrombogenic for the first several hours after endarterectomy, during which time the carotid artery is most vulnerable to acute occlusion, leading these authors to recommend closure of the arteriotomy with a saphenous vein patch. An infrequent but devastating complication associated with saphenous vein patches has been "blowout" or rupture of vein patches in the early postoperative period3 ,4,11-13 In addition to the propensity toward rupture of saphenous vein patches harvested from the anlde. Lord et al.~s reported a significant incidence of aneurysmal expansion of saphenous vein patches, as demonstrated by posto: erative arteriograms. Accordingly, they recommended use of PTFE patches preferentially, Postoperative disruption of a PTFE carotid patch has also been reported, with the patient suffering a stroke as a result of disruption of the patch. 12 In addition to the complications reported herein with the PTFE patches after carotid endarterectomy, we have noted excessive intraoperative bleeding from needle holes in the PTFE cardiovascular patches, especially those in whom the 0.4 m m patch has been used. Although postoperative bleeding or "blowout" of PTFE cardiovascular patches after carotid endarterectomy would seem to be quite rare, such a complication could result in serious morbidity, such as stroke and acute respiratory embarrassment. Surgeons using PTFE patches should be aware of the possibility of delayed postoperative bleeding from these patches. In these days of ever increasing pressure for early hospital discharge of patients after carotid endarterectomy, delayed bleeding from a PTFE carotid patch could result in disastrous consequences. All three patients in this study received 325 mg of aspirin before operation, and this was restarted on the first postoperative day. Aspirin produces irreversible acetylation of cyclooxygenase, inhibiting the production of thromboxane, thereby inhibiting platelet aggregation. This effect lasts for the full 7-day life span of the platelet. We do not think the aspirin was responsible for the delayed postoperative bleeding seen in these patients. Although bleeding times were not done on these patients, we did not have excessive intraoperative bleeding except through the needle holes in the PTFE patches. In addition, we have not encountered
Volume 15 "Tumber 4 ~~pril 1992
delayed postoperative bleeding in patients receiving Dacron or saphenous vein patches, and all of these patients were receiving aspirin. Dextran also has a direct antiplatelet effect.16 Although large doses of higher molecular weight dextran can produce diffuse intravascular coagulation, the use of low molecular weight dextran is not associated with increased surgical bleeding. 16Patient three in our series did receive low molecular weight dextran for the first 24 hours after operation, but it had been discontinued 12 hours before his bleeding episode began. We do not think the dextran was the cause of the clelayed postoperative bleeding. The authors thank Bert Neu for her excellentassistance in the preparation of this manuscript. RL2ERENCES 1. Katz MM, Jones GT, Degenhardt J, Gunn B, Wilson J, Katz S. The use of patch angioplasty to alter the incidence of carotid restenosis fbllowing thromboendatterectomy. ~ Cardiovasc Surg (Torino) 1987;28:2-8. 2. Archie JP. Prevention of early restenosis and thrombosisocclusion after carotid endarterectomy by saphenous vein patch angioplasty. Stroke 1986;17:901-5. 3. Das MB, Hertzer NB, Ratliff NB, O'Hara P1, Beven EG. Recurrent carotid stenosis. Ann Surg 1985;202:28-35. 4. Hertzer NR, Beven EG, O'Hara PF, Krajewski LP. A prospective study of vein patch angioplasty during carotid endarterectomy. Ann Surg 1987;206:628-35. 5. LeGrand DR, Linehan RL. The suitability of expanded PTFE for carotid patch angioplasty. Ann Vasc Surg 1990;4: 209-12. 6. Deriu GP, BaUotta E, Bonavina L, et al. The rationale for
Delayed bleedingfrom PTFE carotid arterypatches 663
patch-graft angioplasty after carotid endarterecmmy: early and long-term follow-up. Stroke 1984;15:972-9. 7. Fode NC, Sundt TM, Robertson JT, Peerless SI, Shields CB. Multicenter retrospective review of results and complications of carotid endarterectomy in 1981. Stroke 1986;17:370-6. 8. Clagett GP, Patterson CB, Fisher DF lr, et al. Vein patch versus primary closure for carotid endarterectomy. J VASC SURG 1989;9:218-23. 9. Eikelboom BC, AckerstaffRGA, Hoenevdd H, et al. Benefits of carotid patching~ a randomized study. I VASC SURG 1988;7:240-7. 10. Riles TS, Lamparello PJ, Giangola G, Imparato AM. Rupture of the vein patch: a rare complication of carotid endarterectomy. Surgery 1990;107:10-12. 11. Bartlett FE, Rapp JH, Goldstone J, Ehrenfeld WK, Stoney RJ. Recurrent carotid stenosis: operative strategy and late results. J VASC SURG 1987;5:452-6. 12. Rosenthal D, Archie JP, Garcia-Rinald R, et aL Carotid patch angioplasty: immediate and long-term results, l VAsc SURG 1990;12:326-33. 13. Tawes RL, Treiman RL. Vein patch rupture after carotid endarterectomy: a survey of the Western Vascular Society Members. Ann Vasc Surg 1991;5:71-3. 14. Dirrenberger RA, Sun& TM Jr. Carotid endarterectomy: temporal profile of the healing process and effects of anticoagulation therapy. J Neurosurg 1978;48:201-19. 15. Lord RSA, Raj TB, Stary DL, Nash PA, Graham AR, Goh KH. Comparison of saphenous vein patch, polytetrafluoroethylene patch, and direct arteriotomy closure after carotid endarterectomy. Part i. Perioperative results. J VASC SURG 1989;9:521-9. 16. Shoenfeld NA, Eldmp-Jorgensen J, Connally R, et al. The effect of low molecular weight dextran on platetet deposition onto prosthetic materials. J VASC SUnG 1987;5:76-82. Submitted May 13, 1991; accepted Aug. 6, 1991.
