Introduction Carotid endarterectomy (CEA) for symptomatic stenosis reduces further stroke risk. Post-CEA haematoma increases the risk of complications including stroke. There are few studies considering protocols aimed at reducing post-CEA haematoma rates. Presented are the outcomes of a protocol developed to reduce this surgical complication. Method The protocol was implemented in 112 consecutive CEA. It involves stepwise additional measures to ensure haemostasis before wound closure. Attention to bleeding points is followed by light compression for 10 min. Protamine is then given if haemostasis has not been achieved. If after 20 min the problem persists Tranexamic acid is given. Following a further 20 min if haemostasis is not yet achieved a platelet transfusion is undertaken. Haematoma rates, return to theatre for post-operative haematoma and other complications were compared with 100 consecutive pre-protocol introduction CEA cases. Results Of 112 CEA patients, 19 received protamine, 8 protamine and tranexamic acid. One case required platelet transfusion. Neck haematoma rate fell from 10 to 3 cases ( P = .02, OR: 0.25 [95% CI .07-.94]), of which returned to theatre for haematoma evacuation fell from 6 to 1 case ( P = .03, OR: 0.14 [95% CI .02-1.19]). 30 day stroke and death rate reduced from 5% to 1.8% ( P = .11, OR: 0.35 [95% CI .07-1.82]). Conclusion The stepwise haemostasis intraoperative protocol can reduce post-CEA haematoma rates.

Aim Stroke is the third leading cause of death in developed nations and the leading cause of long-term disability. Carotid artery stenosis accounts for 20 to 30% of ischaemic strokes. Carotid Endarterectomy, has proven highly effective in preventing the development of strokes, TIAs and reducing death among patients with symptomatic carotid artery stenosis of 50–99%. The most common complication of CEA is wound haematomas. This study evaluates a protocol driven haemostasis pathway aimed to address the findings of a recent QI project that identified a significantly high neck haematoma rate as well as a high return to theatre rate for the complication. Method A prospective cohort outcome study between June 2019 and June 2020 was conducted, with the introduction of this stepwise pathway introduced as a quality improvement measure. This was implemented at the end of successful patch closure, for each CEA. Results Post-CEA haematoma rates decreased from 7% to 3.6%. Return to theatre rates reduced from 6% to 0.9% with no increase in peri-operative stroke rates. Conclusion Our protocol appears to reduce post-CEA haematoma rates. Return to theatre rates had also dropped without an increase in peri-operative stroke rates despite using protamine and tranexemic acid when needed.

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