Department of Neurosurgery, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 56, Dongsu-ro, Bupyeong-gu, Incheon, 21431, Republic of Korea.
Acta Neurochir (Wien). 2023 Dec;165(12):3743-3757. doi: 10.1007/s00701-023-05869-z. Epub 2023 Nov 20.
This study aimed to evaluate the feasibility and safety values of activated clotting time (ACT)-guided systemic heparinization in reducing periprocedural thrombosis and bleeding complications during coil embolization of unruptured intracranial aneurysms.
A total of 228 procedures performed on 213 patients between 2016 and 2021 were included in the retrospective analysis. The target ACT was set at 250 s. Logistic regression was performed to assess predictors for the occurrence of thrombosis and bleeding. Receiver operating characteristic (ROC) analyses were employed to determine the optimal cut-off values for ACT, heparinization, and procedure time.
Most (85.1%) of procedures were stent-assisted embolization. The mean baseline ACT was 128.8 ± 45.7 s. The mean ACT at 20 min after the initial intravenous heparin loading of 78.2 ± 18.8 IU/kg was 185 ± 46.4 s. The mean peak ACT was 255.6 ± 63.8 s with 51.3% (117 cases) achieving the target ACT level. Peak ACT was associated with symptomatic thrombosis (OR per second, 1.008; 95% CI, 1.000-1.016; P = 0.035) (cut-off value, 275 s; area under ROC (AUROC), 0.7624). Total administered heparin dose per body weight was negatively associated with symptomatic thrombosis (OR per IU/kg, 0.972; 95% CI, 0.949-0995; P = 0.018) (cut-off value, 294 IU/kg; AUROC, 0.7426) but positively associated with significant bleeding (OR, 1.008 per IU/kg; 95% CI, 1.005-1.012; P <0 .001) (cut-off value, 242 IU/kg; AUROC, 0.7391). Procedure time was significantly associated with symptomatic thrombosis (OR per minute, 1.05; 95% CI, 1.017-1.084; P value = 0.002) (cut-off value, 158 min; area under ROC, 0.8338).
This study demonstrated that ACT-guided systemic heparinization was feasible to achieve the target ACT value and proposes probable safety thresholds to prevent periprocedural complications through reducing procedure time during coil embolization of unruptured intracranial aneurysms in the stent era.
本研究旨在评估激活凝血时间（ACT）指导的全身肝素化在减少未破裂颅内动脉瘤线圈栓塞术中围手术期血栓形成和出血并发症方面的可行性和安全性价值。
回顾性分析了 2016 年至 2021 年间 213 例患者的 228 例手术。目标 ACT 设置为 250s。采用逻辑回归评估血栓形成和出血发生的预测因素。采用受试者工作特征（ROC）分析确定 ACT、肝素化和手术时间的最佳截断值。
大多数（85.1%）手术为支架辅助栓塞。基线时 ACT 的平均值为 128.8±45.7s。初始静脉推注 78.2±18.8IU/kg 肝素后 20min 的平均 ACT 为 185±46.4s。平均峰值 ACT 为 255.6±63.8s，其中 51.3%（117 例）达到目标 ACT 水平。峰值 ACT 与症状性血栓形成相关（每增加 1 秒的比值比，1.008；95%可信区间，1.000-1.016；P=0.035）（截断值，275s；ROC 曲线下面积（AUROC），0.7624）。每公斤体重给予的肝素总剂量与症状性血栓形成呈负相关（每增加 1IU/kg 的比值比，0.972；95%可信区间，0.949-0.995；P=0.018）（截断值，294IU/kg；AUROC，0.7426），但与显著出血呈正相关（比值比，每增加 1IU/kg，1.008；95%可信区间，1.005-1.012；P<0.001）（截断值，242IU/kg；AUROC，0.7391）。手术时间与症状性血栓形成显著相关（每增加 1 分钟的比值比，1.05；95%可信区间，1.017-1.084；P 值=0.002）（截断值，158min；AUROC，0.8338）。
本研究表明，ACT 指导的全身肝素化是可行的，可以达到目标 ACT 值，并通过减少支架时代未破裂颅内动脉瘤线圈栓塞术中的手术时间，提出预防围手术期并发症的可能安全阈值。
