Doganer Orkun, Jongkind Vincent, Blankensteijn Jan D, Yeung Kak Khee, Wiersema Arno M
Department of Vascular Surgery, Dijklander Ziekenhuis, Hoorn, the Netherlands; Department of Vascular Surgery, Amsterdam University Medical Centers location VU Medical Center, Amsterdam, the Netherlands.
Department of Vascular Surgery, Dijklander Ziekenhuis, Hoorn, the Netherlands; Department of Vascular Surgery, Amsterdam University Medical Centers location VU Medical Center, Amsterdam, the Netherlands.
Ann Vasc Surg. 2021 Feb;71:280-287. doi: 10.1016/j.avsg.2020.07.035. Epub 2020 Aug 6.
In non-cardiac arterial procedures (NCAP), heparin is administered to prevent arterial thromboembolic complications (ATEC). Heparin has a nonpredictable effect in the individual patient, also known as variation in heparin sensitivity. Various dosing protocols are in use, but the optimal dose is currently still unknown. A standardized bolus of 5 000 IU heparin is most frequently used by vascular surgeons and interventional radiologists. The activated clotting time (ACT) is an established method to measure the level of anticoagulation, but has, until now, not gained widespread use in NCAP. The purpose of this study was to evaluate the anticoagulant effect during NCAP of a standardized bolus of 5 000 IU heparin by measuring the ACT.
In this prospective study, 190 patients undergoing NCAP were enrolled between December 2016 and September 2018. The ACT was measured during open and endovascular/hybrid procedures. All patients received a standardized bolus of 5 000 IU heparin. The ACT was measured by the Hemostasis Management System Plus (HMS Plus, Medtronic®), before, 5 minutes after administration of heparin, and every 30 minutes thereafter. The primary outcome was periprocedural ACT values measured. Secondary outcomes were ATEC and hemorrhagic complications.
A large individual patient variability in the response to heparin was found. The mean baseline ACT in all patients was 129 ± 18 s., and the mean ACT 5 minutes after the initial bolus of heparin was 191 ± 36 s. After the initial dose of 5 000 IU heparin 60 (33%) and 10 (6%) patients reached an ACT of 200 and 250 s., respectively. Despite the use of heparin, ATEC occurred in 17 patients (9%). The lowest number of ATEC occurred in the group of patients with an ACT between 200 and 250 s.
A standardized bolus of 5 000 IU heparin does not lead to adequate and safe heparinization in non-cardiac arterial procedures. Patient response to heparin shows a large individual variability. Therefore, routine ACT measurements are necessary to ascertain adequate anticoagulation. Further research is needed to investigate if heparin dosing based on the ACT could result in less arterial thromboembolic complications, without increasing hemorrhagic complications.
在非心脏动脉手术（NCAP）中，使用肝素以预防动脉血栓栓塞并发症（ATEC）。肝素在个体患者中的作用不可预测，即肝素敏感性存在差异。目前有多种给药方案在使用，但最佳剂量仍未知。血管外科医生和介入放射科医生最常使用5000国际单位肝素的标准化推注剂量。活化凝血时间（ACT）是一种已确立的测量抗凝水平的方法，但迄今为止在NCAP中尚未广泛应用。本研究的目的是通过测量ACT来评估5000国际单位肝素标准化推注剂量在NCAP期间的抗凝效果。
在这项前瞻性研究中，2016年12月至2018年9月期间纳入了190例行NCAP的患者。在开放手术以及血管内/杂交手术期间测量ACT。所有患者均接受5000国际单位肝素的标准化推注剂量。在给予肝素前、给药后5分钟以及此后每30分钟，使用止血管理系统升级版（HMS Plus，美敦力公司）测量ACT。主要结局是测量围手术期ACT值。次要结局是ATEC和出血并发症。
发现患者对肝素的反应存在很大的个体差异。所有患者的平均基线ACT为129±18秒，首次推注肝素后5分钟的平均ACT为191±36秒。给予初始剂量5000国际单位肝素后，分别有60例（33%）和10例（6%）患者的ACT达到200秒和250秒。尽管使用了肝素，仍有17例患者（9%）发生了ATEC。ACT在200至250秒之间的患者组中发生ATEC的数量最少。
在非心脏动脉手术中，5000国际单位肝素的标准化推注剂量不能实现充分且安全的肝素化。患者对肝素的反应存在很大的个体差异。因此，需要常规测量ACT以确定充分的抗凝效果。是否基于ACT调整肝素剂量能够减少动脉血栓栓塞并发症且不增加出血并发症，这需要进一步研究。
