SHOULD HEPARIN BE REVERSED AFTER CAROTID ENDARTERECTOMY - A RANDOMIZED PROSPECTIVE TRIAL

Objective: To investigate whether heparin reversal after carotid endar terectomy reduces the incidence of haemorrhagic complications. Design: A randomised prospective trial. Methods: Sixty-four patients randomis ed to reversal of heparin or no reversal, of whom 31 received protamin e titrated to the residual circulating heparin at closure of arterioto my. Measurements included serial activated clotting times (ACTs), woun d drainage, neck swelling using duplex Doppler imaging to measure the depth from skin to carotid bifurcation, and the recording of all compl ications. Results: Wound drainage volumes were significantly reduced b y protamine reversal (68.5 ml compared to 35 ml, p<0.0001), but neck s welling was not (72 mm compared to 70 mm, p=0.77). Two patients who we re not reversed developed neck haematomas requiring evacuation. More i mportantly, two patients receiving protamine, thrombosed the operated internal carotid artery (ICA) postoperatively and died despite urgent thrombectomy. A further patient who was not randomised in this study w ho received protamine also developed ICA thrombosis within the same 3 month period. Conclusions: Reversing heparin with protamine reduces po stoperative wound drainage after carotid surgery but may predispose to ICA thrombosis and stroke. This is in keeping with a previous retrosp ective study published during our trial.(7)