Mauney M C, Buchanan S A, Lawrence W A, Bishop A, Sinclair K, Daniel T M, Tribble C G, Kron I L
University of Virginia School of Medicine, Section of Vascular Surgery, Charlottesville 22908, USA.
J Vasc Surg. 1995 Sep;22(3):264-9; discussion 269-70. doi: 10.1016/s0741-5214(95)70140-0.
Postoperative neurologic injury remains a significant risk of carotid endarterectomy. Mechanisms include embolization of debris and formation of thrombus on the newly endarterectomized surface. We hypothesized that the risk of postoperative neurologic injury would be lower in those patients who did not receive protamine for reversal of heparin anticoagulation.
We reviewed 348 consecutive primary carotid endarterectomies performed since January 1, 1986, to determine the relationship between surgical outcomes and reversal of heparin anticoagulation. Patients undergoing additional simultaneous cardiovascular procedures were excluded. One hundred ninety-three patients received protamine after completion of the endarterectomy. The remaining 155 patients did not receive any protamine.
All patients in both groups survived to discharge. There were no strokes in those patients who did not receive any protamine; however, the stroke rate in the protamine group was 2.6% (5 of 193), p < 0.045. The incidence of hematoma requiring reexploration was 1.0% (2 of 193) and 1.9% (3 of 155) in the protamine and no-protamine groups, respectively (p = NS). Intraoperative shunting was used more frequently in the no-protamine group (84% vs 67%, p < 0.001), and patch angioplasty was performed more frequently in the protamine group (35% vs 15%, p < 0.001). However, neither shunting nor patching significantly influenced stroke rates.
We conclude that carotid endarterectomy without reversal of heparin anticoagulation is associated with a reduced postoperative stroke rate without a significant increase in morbidity rates.
术后神经损伤仍然是颈动脉内膜切除术的一项重大风险。其机制包括碎片栓塞以及在新内膜切除的表面形成血栓。我们推测，未接受鱼精蛋白来逆转肝素抗凝作用的患者术后发生神经损伤的风险会更低。
我们回顾了自1986年1月1日起连续进行的348例原发性颈动脉内膜切除术，以确定手术结果与肝素抗凝逆转之间的关系。排除同时接受其他心血管手术的患者。193例患者在完成内膜切除术后接受了鱼精蛋白。其余155例患者未接受任何鱼精蛋白。
两组所有患者均存活至出院。未接受任何鱼精蛋白的患者中无一例发生中风；然而，鱼精蛋白组的中风发生率为2.6%（193例中有5例），p<0.045。鱼精蛋白组和未用鱼精蛋白组中需要再次探查的血肿发生率分别为1.0%（193例中有2例）和1.9%（155例中有3例）（p=无显著性差异）。未用鱼精蛋白组更频繁地使用术中分流术（84%对67%，p<0.001），而鱼精蛋白组更频繁地进行补片血管成形术（35%对15%，p<0.001）。然而，分流术和补片血管成形术均未对中风发生率产生显著影响。
我们得出结论，不逆转肝素抗凝作用的颈动脉内膜切除术与术后中风发生率降低相关，且发病率无显著增加。
