Predictors of neck bleeding after eversion carotid endarterectomy

Baracchini, Claudio; Gruppo, Mario; Mazzalai, Franco; Lorenzetti, Renata; Meneghetti, Giorgio; Ballotta, Enzo

doi:10.1016/j.jvs.2011.03.262

Cited by 27 publications

(38 citation statements)

References 34 publications

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“…17 Of interest was the fact that the risk of severe neck bleeding after CEA requiring reoperation was higher in patients who received clopidogrel as a single chronic antiplatelet agent (7.8%) and also in patients who received clopidogrel 24 hours before surgery (9.5% vs. 4.7%) in our series. This finding is not new, and demonstrates the relationship previously reported, as in Baracchini et al, 11 where the risk of reoperation in patients treated with clopidogrel until the day before surgery was 15 times higher. Contrary to our results, the double antiplatelet treatment was associated with an increased incidence of bleeding in Rosenbaum et al 14 and reported the highest rate of bleeding in the group of patients who received clopidogrel over ASA.…”

Section: Discussionsupporting

confidence: 89%

“…Also, the relationship found in the univariate analysis between postoperative hypertension and cervical bleeding supported the results of previous publications, where postoperative hypertension nonresponding to therapy is associated with a higher rate of reoperation because of bleeding. 11,17 In our experience the cervical bleeding and early reoperation did not result in increased morbidity and mortality, according to other publications, 11,17 but this is a potentially serious complication. In other studies, this complication increase not only the risk of mortality 8,13,16 but also of stroke 13,16 and myocardial infarction.…”

Section: Discussionsupporting

confidence: 63%

“…The absence of relationship with the anticoagulation and bleeding events after carotid surgery have been reported in some previous retrospective studies. 11,14 Other interesting factors to discuss are those related to the procedure. The surgical technique itself has some potential bleeding causes, the closure method being one of the most relevant.…”

Section: Discussionmentioning

confidence: 99%

See 2 more Smart Citations

Predictors of Cervical Bleeding after Carotid Endarterectomy

Gisbert

Almonacil

García

et al. 2014

Annals of Vascular Surgery

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Section: Discussionsupporting

confidence: 89%

Section: Discussionsupporting

confidence: 63%

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

Predictors of Cervical Bleeding after Carotid Endarterectomy

Gisbert

Almonacil

García

et al. 2014

Annals of Vascular Surgery

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“…1 Drs Stone, Goodney, and Nolan believe that the number of our patients continuing clopidogrel (n ϭ 110) or aspirin (n ϭ 95) or both (n ϭ 10) to the day before carotid endarterectomy (CEA) is too small to draw any definite conclusions about the risk of neck bleeding after CEA. Since our preoperative protocol includes the discontinuation of any type of preoperative antiplatelet therapy for 1 week before surgery, it was already expected that only a small percentage of patients would violate this protocol, mainly for their own omission.…”

Section: Replymentioning

confidence: 95%

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mentioning

confidence: 99%

Regarding “Predictors of neck bleeding after eversion carotid endarterectomy”

Stone

Goodney

Nolan

2012

Journal of Vascular Surgery

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We noted with interest the recent study by Baracchini et al,1 which reports a single-center, single-surgeon experience of eversion carotid endarterectomies (CEA) and factors associated with increased perioperative bleeding complications, including re-exploration for bleeding. The study concludes that preoperative treatment with clopidogrel, when used either alone or combined with aspirin was associated with an increased incidence of bleeding. The authors additionally conclude that aspirin and ticlopidine, when used alone preoperatively were also associated with an increased incidence of neck hemorrhage following CEA. Review of the study sample, however, reveals that only 110 patients were taking clopidogrel alone within 1 day of surgery and that only an additional 10 patients were taking combined therapy (clopidogrel ϩ aspirin). Furthermore, only 95 patients were taking aspirin alone at the time of CEA, making definitive conclusions regarding these commonly used antiplatelet agents more difficult.By comparison, in a recent study by the Vascular Study Group of New England, 2 we evaluated 5264 carotid endarterectomies, performed by 66 surgeons treated at 15 academic and community centers. We found that preoperative aspirin (asa; n ϭ 3823), clopidogrel (n ϭ 147), or dual antiplatelet therapy (asa ϩ clopidogrel; n ϭ 708) use was not associated with any increase in re-exploration for bleeding after CEA (asa 1.2%, clopidogrel 0.7%, asa ϩ clopidogrel 1.4%; P ϭ .84). 2 Based on this data, we do not believe that aspirin or clopidogrel increases serious bleeding complications and it remains our practice to routinely perform CEA in patients taking antiplatelet therapy at the time of surgery, for which there is sufficient evidence from both randomized controlled trials and our study group to justify therapy given their impact on reducing stroke. [3][4][5][6] The different conclusion reached by Baracchini et al could also relate to their nonuse of protamine to reverse heparin during CEA, potentially amplifying bleeding risk if antiplatelet agents are also being used. Our data has previously shown a significant decrease in re-exploration for bleeding after CEA (n ϭ 4587) when protamine is used, independent of antiplatelet agents (protamine 0.64% vs no protamine 1.66%; P ϭ .001). 7 Accordingly, we believe that recent studies support the safe use of both antiplatelet therapy at the time of CEA and the use of protamine to reverse heparin intraoperatively.

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