A Meta-Analysis of Using Protamine for Reducing the Risk of Hemorrhage During Carotid Recanalization: Direct Comparisons of Post-operative Complications

Abstract

Background: Protamine can decrease the risk of hemorrhage during carotid recanalization. However, it may cause severe side effects. There is no consensus on the safety and efficacy of protamine during surgery. Thus, we conduct a comprehensive review and meta-analysis to compare the differences between the protamine and the no-protamine group.Method: We systematically obtained literature from Medline, Google Scholar, Cochrane Library, and PubMed electronic databases. All four databases were scanned from 1937 when protamine was first adopted as a heparin antagonist until February 2021. The reference lists of identified studies were manually checked to determine other eligible studies that qualify. The articles were included in this meta-analysis as long as they met the criteria of PICOS; conference or commentary articles, letters, case report or series, and animal observation were excluded from this study. The Newcastle-Ottawa Quality Assessment Scale and Cochrane Collaboration’s tool are used to assess the risk of bias of each included observational study and RCT, respectively. Stata version 12.0 statistical software (StataCorp LP, College Station, Texas) was adopted as statistical software. When I2 < 50%, we consider that the data have no obvious heterogeneity, and we conduct a meta-analysis using the fixed-effect model. Otherwise, the random-effect model was performed.Result: A total of 11 studies, consisting of 94,618 participants, are included in this study. Our analysis found that the rate of wound hematoma had a significant difference among protamine and no-protamine patients (OR = 0.268, 95% CI = 0.093 to 0.774, p = 0.015). Furthermore, the incidence of hematoma requiring re-operation (0.7%) was significantly lower than that of patients without protamine (1.8%). However, there was no significant difference in the incidence of stroke, wound hematoma with hypertension, transient ischemic attacks (TIA), myocardial infarction (MI), and death.Conclusion: Among included participants undergoing recanalization, the use of protamine is effective in reducing hematoma without increasing the risk of having other complications. Besides, more evidence-based performance is needed to supplement this opinion due to inherent limitations.

Prognostic Factors for Postoperative Bleeding Complications and Prolonged Intensive Care after Percutaneous Hepatic Chemosaturation Procedures with Melphalan

“…As a result of this analysis, we have changed our strategy back to a mandatory reversal while we continue to discuss the correct protamine dose for each case individually after termination of the extracorporeal circulation. Recent studies of other endovascular procedures, particularly percutaneous coronary intervention [11][12][13], transcatheter aortic valve replacement [14], and carotid recanalization [15,16], revealed beneficial effects of protamine for heparin reversal and only low complication rates. However, protamine may cause complex interactions in the coagulation system, including procoagulatory effects, which are not fully explored yet [17,18].…”

Ultra-Early Hemostatic Therapy for Acute Intracerebral Hemorrhage: An Updated Review

“…One meta-analysis validated the use of protamine sulfate for reducing the risk of hemorrhage after carotid recanalization. 44 However, there is little data validating its efficacy in treating ICH. A retrospective study analyzing 18 patients, 14 of whom were actively bleeding, determined that protamine is capable of partially reversing anti-Xa medications.…”