title: Is heparin reversal with protamine after carotid endarterectomy dangerous?
abstract: OBJECTIVE
  Although systemic heparinisation is routine during CEA, reversal with protamine is controversial with 3 studies suggesting increased peri-operative stroke rates and 3 no effect. None included independent peer-review.
  
  
  METHODS
  Non-randomised observational study of data derived from a randomised controlled study of anaesthetic technique for CEA.
  
  
  METHODS
  Data on heparin and protamine use and risk factors potentially influencing CEA outcome were collected prospectively. Stroke, death, MI, wound haematoma and re-operation rates were recorded following independent peer-review.
  
  
  RESULTS
  1513/2107 patients received heparin alone (H) and 594/2107 had heparin reversed with protamine (H+P). Risk factors for outcome were similar in both groups. The frequency of outcome events (H v H+P) were: stroke: 67/1513 (4.4%) v 17/594 (2.9%), p=0.098; non stroke or MI death: 10/1513 (0.7%) v 5/594 (0.8%), p=0.657; MI: 6/1513 (0.4%) v 3/594 (0.5%), p=0.718; haematoma: 157/1513 (10.4%) v 44/594 (7.4%), p=0.037; re-operation: 51/1380 (3.7%) v 18/565 (3.2%), p=0.581.
  
  
  CONCLUSIONS
  These results show a non-significant increase in stroke rate in patients receiving heparin alone refuting suggestions that protamine is harmful. Conversely post-operative haematoma was more frequent when protamine was withheld but re-operation rates were no different. Thus protamine use appears safe and should remain a matter for individual surgeon preference.
authors.affiliation: Leeds Vascular Institute, The General Infirmary at Leeds, United Kingdom.
authors.forename: D
authors.initials: D
authors.lastname: Dellagrammaticas
authors.forename: S C
authors.initials: SC
authors.lastname: Lewis
authors.forename: M J
authors.initials: MJ
authors.lastname: Gough
mesh_terms: D000368:Aged; D000925:Anticoagulants / Q000627:therapeutic use*; D001777:Blood Coagulation / Q000187:drug effects*; D016893:Carotid Stenosis / Q000097:blood / Q000401:mortality / Q000601:surgery*; D016894:Endarterectomy, Carotid; D005060:Europe; D005260:Female; D006406:Hematoma / Q000097:blood / Q000139:chemically induced; D006493:Heparin / Q000627:therapeutic use*; D006494:Heparin Antagonists / Q000009:adverse effects*; D006801:Humans; D008297:Male; D009203:Myocardial Infarction / Q000097:blood / Q000139:chemically induced / Q000401:mortality; D011446:Prospective Studies; D011479:Protamines / Q000009:adverse effects*; D012086:Reoperation; D020521:Stroke / Q000097:blood / Q000139:chemically induced / Q000401:mortality; D016896:Treatment Outcome
chemical_list: D000925:Anticoagulants; D006494:Heparin Antagonists; D011479:Protamines; D006493:Heparin