Winkler M S, Larena-Avellaneda A, Diener H, Kölbel T, Debus E S
Department for Vascular Medicine, University Heart Center at University Medical Center, Hamburg-Eppendorf, Germany.
J Cardiovasc Surg (Torino). 2013 Feb;54(1 Suppl 1):183-92.
In vascular surgery postoperative thrombosis prophylaxis must sufficiently prevent arterial thrombosis. This cohort study examines different therapeutic approaches of unfractionated heparin (UFH) or low molecular weight heparin (LMWH) after vascular reconstruction.
Four hundred seventy-five patients entered the study between 2005 and 2008. Our clinical routine made a differentiation between low-risk patients (N.=375) and patients with peripheral bypass, which were grouped as high-risk (N.=148). We changed our postoperative anticoagulation management after 24 months in the low-risk and after each 16 months in the high-risk group. The anticoagulation of low-risk patients consisted of either two applications of 7.500 IU UFH subcutaneously (N.=158) or one daily application of 40 mg LMWH each up to discharge (N.=169). High-risk patients received either 25.000 IU UFH i.v. over 24 hours and 4 days (N.=48), 2-times (N.=51) or one-time weight-adjusted LMWH (N.=49) up to discharge (1 mg/kg body weight). Minor complications (bleedings) were differentiated from major early graft occlusion during the postoperative course. Further follow-up was not done for this study.
Low risk: under LMWH, complications could be significantly reduced (P=0.001). Under LMWH significantly fewer occlusion complications occurred (P=0.01) and operation-induced hemorrhages were less frequently observed (P=0.05), this was significant in the complete low-risk group. High-risk: the one-time weight-adjusted LMWH group similarly exhibited many occlusions, like the unfractionated group (NS). The two-time LMWH treatment was significantly superior to the one-time application with respect to occlusion followed by amputations (P=0.03). Minor complications could be minimized overall by administration of LMWH and its dose reduction (NS).
The differentiation between patients with high and low risk seems reasonable. An improvement could be achieved by differentiated LMWH application. Synthetic specific antifactor Xa substances (fondaparinux) or other medications could lead in future to other changes in the management of vascular surgery patients and should be further evaluated.
在血管外科手术中，术后血栓预防必须充分预防动脉血栓形成。这项队列研究探讨了血管重建术后普通肝素（UFH）或低分子量肝素（LMWH）的不同治疗方法。
2005年至2008年间，475名患者进入该研究。我们的临床常规将低风险患者（n = 375）与外周旁路手术患者区分开来，后者被归类为高风险患者（n = 148）。低风险组在24个月后改变术后抗凝管理，高风险组每16个月改变一次。低风险患者的抗凝治疗包括皮下注射两次7500 IU普通肝素（n = 158）或直至出院每天注射一次40 mg低分子量肝素（n = 169）。高风险患者接受25000 IU普通肝素静脉滴注24小时并持续4天（n = 48）、两次（n = 51）或直至出院一次按体重调整剂量的低分子量肝素（n = 49）（1 mg/kg体重）。在术后过程中区分轻微并发症（出血）与主要早期移植物闭塞。本研究未进行进一步随访。
低风险：在低分子量肝素治疗下，并发症可显著减少（P = 0.001）。在低分子量肝素治疗下，闭塞并发症显著减少（P = 0.01），手术引起的出血较少见（P = 0.05），在整个低风险组中这具有显著性。高风险：一次性按体重调整剂量的低分子量肝素组与普通肝素组一样，出现许多闭塞情况（无显著性差异）。就闭塞后继发截肢而言，两次低分子量肝素治疗明显优于一次性应用（P = 0.03）。通过给予低分子量肝素及其剂量减少，总体上可将轻微并发症降至最低（无显著性差异）。
区分高风险和低风险患者似乎是合理的。通过差异化应用低分子量肝素可实现改善。合成特异性抗Xa因子物质（磺达肝癸钠）或其他药物未来可能会导致血管外科手术患者管理的其他变化，应进一步评估。
