Clinical Hemorheology and Microcirculation 58 (2014) 271–279 DOI 10.3233/CH-141901 IOS Press

271

Influence of local hemostatic and antiplatelet agents on the incidence of bleeding complications in carotid endarterectomies M. Weinricha,∗ , P. Schindlera , G. Kundtb , E. Klara and C.M. B¨ungera,c a

Department of General, Thoracic, Vascular and Transplantation Surgery, University Medicine Rostock, Rostock, Germany b Institute for Biostatistics and Informatics in Medicine and Ageing Research, University Medicine Rostock, Rostock, Germany c Department of Vascular Medicine, Vivantes Humboldt-Klinikum, Berlin, Germany

Abstract. BACKGROUND: For the reduction of cardio- and cerebrovascular events in carotid endarterectomies continuation of antiplatelet medication is recommended perioperatively. As a result, this patient population is at increased risk for postoperative bleeding complications. Intraoperative application of local hemostatic agents might reduce the incidence of bleeding complications. MATERIAL AND METHODS: All 565 patients undergoing carotid endarterectomy between January 2005 and January 2011 were analysed retrospectively. Most patients in the earlier cohort years of the study had no perioperative antiplatelet medication. In contrast antiplatelet medication was usually continued perioperatively in the later cohort years. To reduce the risk of perioperative bleeding local hemostatic agents were applied increasingly. RESULTS: Revision surgery, due to postoperative bleeding or massive hematoma, was necessary in 20 cases (3.5%). Overall, 383 carotid endarterectomies (67.8%) were performed with perioperative antiplatelet medication. Local hemostatic agents were applied in 259 cases (45.8%) intraoperatively. Initially, operations performed in patients taking antiplatelet medication resulted in an increased need for surgical revision. Following an accelerated practice of using local hemostatic agents, the need for revision surgeries fell. Nevertheless, when patients from all years were analysed together there was no significant benefit from the application of local hemostatic agents. CONCLUSION: Application of local hemostatic agents might have contributed to a reduction of bleeding complications in carotid endarterectomies. However, this could not be shown of statistical significance. Other confounding factors such as different operative techniques or forms of anesthesia might also have influenced this decline. Keywords: Hemostatic agents, carotid endarterectomy, antiplatelet medication, bleeding complication

1. Introduction Severely narrowed carotid arteries or unstable ulcerous plaques within the carotid arteries bare the risk for embolization causing stroke or loss of vision. Surgical desobliteration (carotid endarterectomy) or carotid artery stenting are indicated in these patients as a primary or secondary prophylaxis [7]. For the ∗

Corresponding author: Malte Weinrich, Department of General, Thoracic, Vascular and Transplantation Surgery, University Medicine Rostock, Rostock, Germany. Tel.: +49 381 494 6001; Fax: +49 381 494 6002; E-mail: [email protected]. 1386-0291/14/$27.50 © 2014 – IOS Press and the authors. All rights reserved

272

M. Weinrich et al. / Local hemostatic and antiplatelet agents in carotid endarterectomies

reduction of cardio- and cerebrovascular events in carotid endarterectomies continuation of antiplatelet medication is recommended perioperatively for years [1, 5, 14, 15]. As a result, this patient population is at increased risk for postoperative bleeding complications [8, 9, 12]. Postoperative bleeding or extended hematoma can cause life threatening respiratory insufficiency within a short period of time and might even become an obstacle for intubation due to the close localisation of the surgical site to the airway. Intraoperative application of fibrin-coated sealants onto the suture lines might enhance safety through a surplus of fibrin in order to avoid bleeding complications [3, 11, 18]. Aim of this study was the evaluation of the influence of perioperative continuation of antiplatelet agents as well as of intraoperative application of local hemostatic agents on the incidence of bleeding complications. 2. Materials and methods All patients undergoing carotid endarterectomy at the university medicine Rostock (department of general, thoracic, vascular and transplantation surgery) between January 2005 and January 2011 were analysed retrospectively. Patients were surgically treated due to symptomatic or severely narrowing asymptomatic stenoses of the internal carotid artery. Patients undergoing simultaneous carotid endarterectomy within another operation such as cardiac surgery were excluded from the study. Within the observation period 565 carotid endarterectomies were performed on 528 patients. An overview on the epidemiologic patient criteria is given in Table 1. To evaluate an impact of patient age on the incidence of revision surgeries all patients were divided into four subgroups of approximately equal numbers (subgroup 1:32–65; subgroup 2:66–70; subgroup 3:71–75 and subgroup 4:76–95 years of age). All carotid endarterectomies were performed in a standardized manner: General or locoregional anesthesia, beach chair positioning of the patient, skin incision along the anterior line of the sternocleidomastoid muscle, ventral to the muscle opening of the middle collar fascia, systemic application of Table 1 Epidemiologic patient criteria (n = 565 carotid endarterectomies) Patients’ age (years, mean ± standard deviation) Range (years) Sex Male Female Asymptomatic lesion Grade of stenosis∗ (%, mean ± standard deviation) Range of stenosis∗ (%) Symptomatic lesion Grade of stenosis∗ (%, mean ± standard deviation) Range of stenosis∗ (%) Perioperative antiplatelet medication ∗

70.3 ± 9.1 32–95 387 (68.5%) 178 (31.5%) 323 (57.2%) 67 ± 14 40–95 242 (42.8%) 67 ± 16 20–95 383 (67.8%)

Grades of stenosis according to NASCET. Grades of stenosis were transferred from ECST to NASCET using the formula of Rothwell et al. [20] or from DEGUM to NASCET according to the German S3-guideline (Table 1, p. 26) [7].

M. Weinrich et al. / Local hemostatic and antiplatelet agents in carotid endarterectomies

273

heparin (5000 IE, 3000 IE when surgery was performed under antiplatelet medication), exposure of common carotid, external carotid, internal carotid and superior thyroid arteries medial of the internal jugular vein, temporary clamping of the carotid bifurcation, incision of the carotid artery and shunt insertion (routinely in general anesthesia, in locoregional anesthesia only when indicated due to a deficit in neurologic monitoring), dissection of the arteriosclerotic plaque depending on the chosen operative technique (thrombendarterectomy and patch angioplasty or eversion endarterectomy), closure of the carotid artery after extraction of the shunt if used, verification of hemostasis of the suture line and the operation site, insertion of a wound drainage and closure of the wound in layers. To reduce the risk of postoperative bleeding fibrin-coated sealants (TachoSil® , Takeda Austria GmbH, Linz, Austria) were applied more frequently onto the suture line since 2007. In some cases other hemostatic agents such as TachoComb® (Nycomed Deutschland GmbH, Konstanz, Germany) or Tissucol® (Baxter Deutschland GmbH, Unterschleißheim, Germany) were applied. An overview of all performed carotid endarterectomies is given in Table 2. Until 2006 all carotid endarterectomies were performed in general anesthesia. Starting in 2008, carotid endarterectomies were performed mainly in locoregional anesthesia. Within the last year of the observation period 39% of the patients were treated in locoregional anesthesia. The operative technique of eversion endarterectomy was used increasingly starting in 2008 (2% of the procedures) reaching 42% of the carotid endarterectomies in 2010. To evaluate an impact of the different surgical techniques applied as well as types of patches used on the incidence of surgical revisions the following subgroups were created and compared: Table 2 Overview of chosen anesthesiologic and surgical treatment forms, intraoperative surgical data (n = 565 carotid endarterectomies) Type of anesthesia General anesthesia∗ Locoregional anesthesia Shunt insertion With shunt insertion Without shunt insertion Thrombendarterectomy with patch angioplasty Dacron (% of patches) Bovine pericard (% of patches) Saphenous vein (% of patches) PTFE (% of patches) Polyurethane (% of patches) Eversion endarterectomy Other surgical treatment (1 Dacron and 1 PTFE graft interposition, 1 external carotid angioplasty) Side of surgery Right internal carotid artery Left internal carotid artery Duration of surgery (min.) Mean ± standard deviation Range ∗

In 7 cases anesthesia was switched from locoregional to general anesthesia during surgery.

474 (83.9%) 91 (16.1%) 465 (82.3%) 100 (17.7%) 467 (82.7%) 408 (87.4%) 24 (5.1%) 20 (4.3%) 12 (2.6%) 3 (0.6%) 95 (16.8%) 3 (0.5%)

285 (50.4%) 280 (49.6%) 98.9 ± 24.9 54–215

274

M. Weinrich et al. / Local hemostatic and antiplatelet agents in carotid endarterectomies

1. Eversion endarterectomy versus thrombendarterectomy (all kinds of patches) 2. Eversion endarterectomy/thrombendarterectomy (saphenous vein) versus thrombendarterectomy (artificial/bovine patches) 3. Eversion endarterectomy/thrombendarterectomy (saphenous vein/bovine patches) versus thrombendarterectomy (artificial patches) Most patients in the earlier cohort years of the study had no perioperative antiplatelet medication. In contrast antiplatelet medication was usually continued perioperatively in the later cohort years. Starting in 2006, more carotid endarterectomies were performed in patients taking antiplatelet medication than in patients without antiplatelet medication. Overall, 383 carotid endarterectomies (67.8%) were performed in patients taking an antiplatelet medication. Of these, acetyl salicylic acid (ASA) monotherapy was the most common with 75%. A different monotherapy than ASS – mainly clopidrogel – was given in 18%, and 7% of the patients had a combination therapy including ASA and a second antiplatelet drug. Only one patient was treated with a combination of two antiplatelet drugs other than ASA. A detailed breakdown is given in Table 3. To reduce the risk of perioperative bleeding local hemostatic agents were applied intraoperatively in 259 (45.8%) of all carotid endarterectomies. The most common was TachoSil® in 95% of the procedures. In 5% of the cases other hemostatic agents or a combination were used. These data are also demonstrated in Table 3. All cases requiring surgical revision due to postoperative bleeding or massive hematoma following carotid endarterectomy were counted as postoperative bleeding complications. Acquisition of data was carried out retrospectively from the clinical information system of our hospital, the patients’ charts and the documentary books for intraoperatively applied materials from the operation theatre. Additionally, compiled data records for the mandatory quality assurance (module 10/2, specification 11.0 SR3) by the Bundesgesch¨aftsstelle f¨ur Qualit¨atssicherung (BQS, D¨usseldorf, Germany) were used. All data were stored in Microsoft Office Excel 2010 (Microsoft Corporation, Redmond, Washington/USA) and analysed using the SPSS statistical package 21.0 (SPSS Inc. Chicago, Illinois/USA). Descriptive statistics were computed for continuous and categorical variables. The statistics computed included mean and standard deviations of continuous variables, frequencies and relative frequencies of categorical factors. Table 3 Overview of perioperative antiplatelet medications and intraoperative application of local hemostatic agents (n = 565 carotid endarterectomies) Antiplatelet medication ASA∗ (% of antiplatelet agents) Monotherapy other than ASA∗ (% of antiplatelet agents) Combination therapy including ASA∗ (% of antiplatelet agents) Combination therapy without ASA∗ (% of antiplatelet agents) Application of hemostatic agents Fibrin-coated sealant (TachoSil® ,% of hemostatic agents) Other than fibrin-coated sealants (% of hemostatic agents) Combination of 2 hemostatic agents (% of hemostatic agents) ∗

ASA = acetyl salicylic acid.

383 (67.8%) 287 (74.9%) 67 (17.5%) 28 (7.3%) 1 (0.3%) 259 (45.8%) 245 (94.6%) 10 (3.9%) 4 (1.5%)

M. Weinrich et al. / Local hemostatic and antiplatelet agents in carotid endarterectomies

275

The statistical technique of matching in the proportion 1:4 was used to find for every patient with revision surgery due to bleeding/massive hematoma four controls with the similar observable characteristics age and sex. The Logistic Regression model was used to assess the independence of postsurgical neck bleeding after carotid endarterectomy from prognostic factors. First, univariate analyses were performed to reveal unadjusted significant associations between prognostic variables and postsurgical neck bleeding. Thereafter, variables yielding p-values ≤0.05 in the univariate analyses were entered in the multivariate model to highlight some adjusted associations between the outcome and covariates, which were of significant impact in univariate analyses. All p-values resulted from two-sided statistical tests and values of p < 0.05 were considered to be statistically significant. 3. Results Within the observation period revision surgeries, due to postoperative bleeding or massive hematoma, were necessary in 20 cases (3.5%). Initially, carotid endarterectomies performed in patients taking antiplatelet medication resulted in an increased need for surgical revision reaching a maximum of 8.7% in 2007. This trend was declining with an increasing use of hemostatic agents. In 2006 hemostatic agents were applied in only 1% of all procedures performed. Following an accelerated practice of using local hemostatic agents (86% in 2011), the need for revision surgeries fell to 0% at the end of the observation period. Time courses and frequencies of perioperative antiplatelet medication, application of hemostatic agents and need for revision surgery are depicted in Fig. 1. When patients from all years were analysed together there was almost no change in the incidence of surgical revisions in patients taking ASA monotherapy (p = 0.677; OR 1.32; CI 95%) and only a slight increase in patients taking a combination therapy with ASA and a different antiplatelet drug – commonly clopidrogel – (p = 0.158; OR 3.50; CI 95%) in comparison to patients without antiplatelet medication. Solely a monotherapy with an antiplatelet drug other than ASA (almost always clopidrogel) showed a statistically significant increase of surgical revisions (p = 0.040; OR 4.67; CI 95%). Nevertheless, when patients from all years were analysed together there was no significant benefit from the application of local hemostatic agents (p = 0.369; CI 95%).

Fig. 1. Time courses and frequencies of perioperative antiplatelet medication, application of local hemostatic agents and need for revision surgery (2005 3.1%, 2006 2.7%, 2007 8.7%, 2008 6.1%, 2009 1.8% and 2010 0%).

276

M. Weinrich et al. / Local hemostatic and antiplatelet agents in carotid endarterectomies

Table 4 Overview of the influence of performed surgical treatment forms/types of patches on the risk for revision surgery (CI: 95%) Surgical treatment/type of patch ∗

Eversion vs. thrombendarterectomy (all kinds of patches) Eversion endarterectomy/autologous vein vs. artificial/bovine patch∗ Biologic (eversion endarterectomy, autolog/bovine) vs. artificial patch∗ ∗

Odds-ratio

p-value

1.09 1.23 1.99

0.915 0.799 0.389

Reference category.

Table 5 Evaluation of risk factors within the subgroup of patients requiring revision surgery and with preceding application of local hemostatic agents (n = 11 out of 565 carotid endarterectomies) (CI: 95%) Surgical treatment/type of patch Eversion vs. thrombendarterectomy (all kinds of patches)∗ Eversion endarterectomy/autologous vein vs. artificial/bovine patch∗ Biologic (eversion endarterectomy, autolog/bovine) vs. artificial patch∗ Antiplatelet agents ASA∗∗ monotherapy vs. others∗ ASA∗∗ monotherapy vs. ASA∗∗ plus others∗ ∗

Odds-ratio

p-value

2.19 1.95 1.22

0.364 0.437 0.815

2.64 6.51

0.191 0.014

Reference category; ∗∗ ASA = acetyl salicylic acid.

Neither an advanced age (subgroup 4 versus 1: p = 0.378; OR 0.36/subgroup 4 versus 2: p = 0.759; OR 1.24/subgroup 4 versus 3: p = 0.916; OR 1.09) nor the gender of the patients (p = 0.112; OR 2.65) showed a significant influence on the need for surgical revision. There was also no influence of the side of the surgical procedure (p = 0.761; OR: 1.17). Within the subgroup of patients treated in locoregional anesthesia no revision surgery was required. Therefore a statistical evaluation was not appropriate. Subgroup analyses of the different surgical techniques applied as well as of the types of patches used revealed no statistical differences on the incidence of surgical revisions (p > 0.05). An overview on these data is given in Table 4. Patients requiring revision surgery following carotid endarterectomy with intraoperative application of local hemostatic agents were analysed in different subgroups for separate risk factors. The results are stated in Table 5. 4. Discussion The rate of bleeding complications requiring revision surgery was 3.5% in 565 carotid endarterectomies comparing well with the literature [7]. The time course of the occurrence of these bleedings suggested a causal relationship with perioperative antiplatelet therapy and the use of local hemostatic agents as shown in Fig. 1. In general, it was the surgeon’s decision to apply local hemostatic agents in each individual patient. During 2005 and 2006 local hemostatic agents were used very infrequently. Of the four patients requiring revision surgery in these two years two were taking antiplatelet medication and in one patient a local hemostatic agent (TachoSil® ) was applied. In 2007 a rapid increase of carotid endarterectomies under

M. Weinrich et al. / Local hemostatic and antiplatelet agents in carotid endarterectomies

277

continuation of antiplatelet agents occurred, which might had an impact on the observed increase in the need for surgical revisions (8.7%) within this year. Out of these eight cases six were taking antiplatelet medication and in four cases local hemostatic agents were applied. At this time point no data were available on a possible protective effect of local hemostatic agents in patients requiring carotid endarterectomy while on antiplatelet medication. The increased awareness of bleeding complications resulting from the high incidence of revision surgeries in 2007 lead to a more frequent use of local hemostatic agents, mostly fibrin-coated sealants, from 49.5% in 2008 to 85.7% in 2010. Parallel the rate of bleeding complications requiring revision surgery decreased from 6.1% in 2008 to 0% in 2010. To evaluate a possible causal relationship of both trends a matched pair analysis was performed showing no significant correlation between the application of local hemostatic agents and the need for revision surgery in our study population. In vascular surgery local hemostatic agents might be applied to stop or avoid secondary bleeding within the suture line through a surplus of fibrin. Of course, a bleeding from a different site such as the mobilized lymph nodes cannot be avoided with application of hemostatic agents at a different anatomical localization. Retrospectively, in many cases the site of secondary bleeding could not be determined. Only in one out of 20 cases bleeding from the suture line was documented at revision surgery. A small arterial vessel within the mobilized lymph nodes was found in one patient and a bleeding from the skin in another patient. In six cases no source of the secondary bleeding could be found, and in two cases diffuse bleeding was mentioned as the site of bleeding. In nine cases no statement was given in the patient’s chart. On the basis of our results it is impossible to determine whether the application of local hemostatic agents had an impact on the incidence of secondary bleeding or the application only lead to a safer feeling of the surgeon. This is attributed to the retrospective setting of the study. We could only analyse patients with the need for revision surgery due to bleeding or massive hematoma whereas the incidence of neck hematomas overall could not be evaluated in this study. Especially the fact that in more than half of the patients with revision surgery the site of bleeding could not be identified, and in only one case a bleeding from the suture line was found – interestingly a fibrin-coated sealant was applied in this patient – make an interpretation difficult. On the other hand we cannot rule out any positive impact of local hemostatic agents/fibrin-coated sealants used in our study population. There is evidence that fibrin-coated sealants such as TachoSil® prevent suture line bleedings [2, 11]. However, in vitro studies demonstrated that this effect could only be shown for smaller defects [3]. In other fields of surgery the potential of TachoSil® to locally control bleeding has already been demonstrated [4, 18]. Although the effect of fibrin-coated sealants is strongly limited to the site of application their use in carotid endarterectomies might still be practical to prevent or shorten suture line bleedings. Different possible sites for secondary bleeding or no evidence for the site of bleeding at revision surgery as well as the size of our study population might explain why we could not identify a benefit from the application of local hemostatic agents in carotid endarterectomies. In 2010 local hemostatic agents were used in 85.7% of the carotid endarterectomies whereas 96.8% of the operations were performed in patients taking antiplatelet medication. In this year no secondary bleeding leading to revision surgery was observed. In accordance with previous studies [21, 22] continuation of antiplatelet agents perioperatively did not enhance the risk of bleeding in our study population overall. An evaluation of subgroups showed that neither ASA alone nor ASA in combination with another antiplatelet drug enhanced the risk for secondary bleeding. A monotherapy with other antiplatelet agents than ASA – mainly clopidrogel – lead to a significantly higher need for revision surgery (p = 0.040, OR 4.67). Five out of 44 patients taking clopidrogel monotherapy (11.4%) and only seven out of 287 patients taking ASA monotherapy

278

M. Weinrich et al. / Local hemostatic and antiplatelet agents in carotid endarterectomies

(2.4%) required revision surgery. In eight cases with revision surgery (40%) the patients were treated with clopidrogel perioperatively, five patients with a monotherapy and three in combination with ASA. Our results on an increased risk for revision surgery under clopidrogel perioperatively are in accordance with some [19, 24] and contrary to some other [6, 22] previous studies. The inconsistent data might be contributory to insufficient numbers of patients and different study design. Focusing on the patients with revision surgery there was no significant difference between patients taking ASA monotherapy and with a monotherapy of other antiplatelet agents than ASA – mainly clopidrogel. Only a combination therapy increased the risk for postoperative bleeding in our study significantly (p = 0.014, OR 6.51) as described previously [9, 13]. During the study period not only the use of local hemostatic agents changed but also an increasing number of carotid endarterectomies was performed in locoregional anesthesia (increasing from 1.1% to 38.9% per year). Within this subgroup no need for revision surgery was observed in 91 carotid endarterectomies. An antiplatelet medication was present in 77 patients (84.6%) within this subgroup and local hemostatic agents were applied in 65 patients (71.4%). Beside the high percentage of applied local hemostatic agents in patients treated in locoregional anesthesia a more gentle preparation by the surgeon and reduced peaks of blood pressure intra- und postoperatively might have contributed to the lack of postoperative bleeding complications. Additional to our observations in non-randomized studies less bleeding complications have been described in locoregional anesthesia compared to general anesthesia [10, 17]. To compare various surgical techniques (thrombendarterectomy with different types of patches as well as eversion endarterectomy) subgroups were formed as mentioned in Table 4. Overall, we could not find any significant difference between these subgroups, which is in accordance to previous studies [16, 23]. The use of synthetic patches might lead to prolonged time to primary hemostasis within the suture line but does not bare an increased risk for secondary bleeding. Application of local hemostatic agents such as fibrin-coated sealants might be appropriate in these cases to shorten operation time, which could not be evaluated within our study due to the retrospective study design. Not unexpectedly, neither the side of surgery nor the patients’ age and sex showed any significant influence on the need for revision surgery. 5. Conclusion We could not find a statistically significant influence of local hemostatic agents in carotid endarterectomies on the need for revision surgery due to secondary bleeding. Despite that fact application of local hemostatic agents might still be helpful to accelerate hemostasis within the suture line and to shorten operation time when artificial patches are used. Our results and previous studies indicate a possible positive effect in patients with clopidrogel or even newer antiplatelet agents perioperatively. References [1] M.J. Armstrong, M.J. Schneck and J. Biller, Discontinuation of perioperative antiplatelet and anticoagulant therapy in stroke patients, Neurol Clinics 24 (2006), 607–630. [2] G. Bajardi, F. Pecoraro and D. Mirabella, Efficacy of TachoSil patches in controlling Dacron suture-hole bleeding after abdominal aortic aneurysm open repair, J Cardiothorac Surg 4 60 (2009), doi: 10.1186/1749-8090-4-60 [3] D. Berdajs, M. B¨urki, A. Michelis, et al., Seal properties of TachoSil: In vitro hemodynamic measurements, Interact Cardiovasc Thorac Surg 10 (2010), 910–913.

M. Weinrich et al. / Local hemostatic and antiplatelet agents in carotid endarterectomies

279

[4] J. Brice˜no, A. Naranjo, R. Ciria, et al., A prospective study of the efficacy of clinical application of a new carrier-bound fibrin sealant after liver resection, Arch Surg 145 (2010), 482–488. [5] W. Burger, J.M. Chemnitius, G.D. Kneissl, et al., Low-dose aspirin for secondary cardiovascular prevention - cardiovascular risks after its perioperative withdrawal versus bleeding risks with its continuation - review and meta-analysis, J Intern Med 257 (2005), 399–414. [6] O. Chechik, Y. Goldstein, E. Behrbalk, et al., Blood loss and complications following carotid endarterectomy in patients treated with Clopidogrel, Vascular 20 (2012), 193–197. [7] H.H. Eckstein, A. K¨uhnl, J. Berkefeld, et al., S3-Leitlinie zur Diagnostik, Therapie und Nachsorge der extrakraniellen Carotisstenose, AWMF-Register 004/028 (2012), Epub. [8] P.J. Deveraux, M. Mrkobrada, D.I., Sessler, et al., Aspirin in patients undergoing noncardiac surgery, N Engl J Med 370 (2014), 1494–1503. [9] B. Hale, W. Pan, T.S. Misselbeck, et al., Combined clopidogrel and aspirin therapy in patients undergoing carotid endarterectomy is associated with an increased risk of postoperative bleeding, Vascular (2013), Epub ahead of print. [10] H.J. Lutz, R. Michael, B. Gahl, et al., Local versus general anaesthesia for carotid endarterectomy - improving the gold standard? Eur J Vasc Endovasc 36 (2008), 145–149. [11] F. Maisano, H.K. Kjaerg˚ard, R. Bauernschmitt, et al., TachoSil surgical patch versus conventional haemostatic fleece material for control of bleeding in cardiovascular surgery: A randomised controlled trial, Eur J Cardiothorac Surg 36 (2009), 708–714. [12] S.M. Morales Gisbert, V.A. Sala Almonacil, J.M. Zaragoz´a Garc´ıa, et al., Predictors of Cervical Bleeding after Carotid Endarterectomy, Ann Vasc Surg 28 (2014), 366–374. [13] A. Oldag, S. Schreiber, S. Schreiber, et al., Risk of wound hematoma at carotid endarterectomy under dual antiplatelet therapy, Langenbecks Arch Surg 397 (2012), 1275–1282. [14] J. Papp, P. Kenyeres and K. Toth, Clinical importance of antiplatelet drugs in cardiovascular diseases, Clin Hemorheol Microcirc 53 (2013), 81–96. [15] D. Poldermans, J.J. Bax, E. Boersma, et al., Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery: The Task Force for Preoperative Cardiac Risk Assessment and Perioperative Cardiac Management in Non-cardiac Surgery of the European Society of Cardiology (ESC) and endorsed by the European Society of Anaesthesiology (ESA), Eur J Anaesthesiol 27 (2009), 92–137. [16] S. Ren, X. Li, J. Wen, et al., Systematic review of randomized controlled trials of different types of patch materials during carotid endarterectomy, PLoS One 8 (2013), doi: 10.1371/journal.pone.0055050 [17] K. Rerkasem and P.M. Rothwell, Local versus general anaesthesia for carotid endarterectomy, Cochrane Database Syst Rev 4 (2008), doi: 10.1002/14651858.CD000126.pub3 [18] A. Rickenbacher, S. Breitenstein, M. Lesurtel, et al., Efficacy of TachoSil a fibrin-based haemostat in different fields of surgery–a systematic review, Expert Opin Biol Ther 9 (2009), 897–907. [19] A. Rosenbaum, A.Z. Rizvi, P.B. Alden, et al., Outcomes related to antiplatelet or anticoagulation use in patients undergoing carotid endarterectomy, Ann Vasc Surg 25 (2011), 25–31. [20] P.M. Rothwell, M. Eliasziw, S.A. Gutnikov, et al., Analysis of pooled data from the randomised controlled trials of endarterectomy for symptomatic carotid stenosis, Lancet 361 (2003), 107–116. [21] E. Schoenefeld, K. Donas, A. Radicke, et al., Perioperative use of aspirin for patients undergoing carotid endarterectomy, Vasa 41 (2012), 282–287. [22] D.H. Stone, P.P. Goodney, A. Schanzer, et al., Clopidogrel is not associated with major bleeding complications during peripheral arterial surgery, J Vasc Surg 54 (2011), 779–784. [23] P.A. Stone, A.F. AbuRahma, A.Y. Mousa, et al., Prospective randomized trial of ACUSEAL versus vascu-guard patching in carotid endarterectomy, Ann Vasc Surg 28 (2014), 1530–1538. [24] S.D. Wait, A.A. Abla, B.D. Killory, et al., Safety of carotid endarterectomy while on clopidogrel (Plavix), J Neurosurg 113 (2010), 908–912.

Copyright of Clinical Hemorheology & Microcirculation is the property of IOS Press and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.

Influence of local hemostatic and antiplatelet agents on the incidence of bleeding complications in carotid endarterectomies.

For the reduction of cardio- and cerebrovascular events in carotid endarterectomies continuation of antiplatelet medication is recommended perioperati...
79KB Sizes 2 Downloads 5 Views