title: Predictors of neck bleeding after eversion carotid endarterectomy.
abstract: OBJECTIVE
  The aim of this study was to identify predictors for neck bleeding after eversion carotid endarterectomy (eCEA).
  
  
  METHODS
  A prospectively compiled computerized database of all primary eCEAs performed at a tertiary referral center between September 1998 and December 2009 was analyzed. The end point was any neck bleeding after eCEA. End point predictors were identified by univariate analysis.
  
  
  RESULTS
  Of 1458 eCEAs performed by the same surgeon on 1294 patients under general anesthesia with continuous electroencephalographic monitoring and selective shunting, there were five major and three minor perioperative strokes (0.5%), and no deaths. Neck bleeding after eCEA occurred in 120 cases (8.2%), of which 69 (4.7%) needed re-exploration. Univariate analysis (odds ratio [95% confidence interval]) identified preoperative antiplatelet treatment with clopidogrel (1.77 [1.20-2.62], P = .004), particularly when continued to the day before CEA (3.84 [2.01-7.33], P < .001), and postoperative hypertension (9.44 [6.34-14.06], P < .001) as risk factors for neck bleeding in general and for neck bleeding requiring re-exploration (4.50 [1.85-10.89], P = .001; 15.27 [2.08-104.43], P = .006, and 2.44 [1.12-5.30], P = .02, respectively). An increased risk of neck bleeding in general was associated with clopidogrel plus acetylsalicylic acid (12.00 [2.59-56.78], P = .005), acetylsalicylic acid alone (4.37 [1.99-9.57], P < .001), and ticlopidine (2.49 [1.10-5.63], P = .02) only when they were continued to the day before CEA. No neck bleeding was associated with preoperative treatment with dipyridamole or warfarin, or no medication. No further complications occurred in the patients who underwent re-exploration.
  
  
  CONCLUSIONS
  The results of this single-center university hospital study show that neck bleeding after CEA is relatively common but is not associated with an increased risk of stroke or death. Preoperative treatment with clopidogrel, particularly when it is continued to the day before surgery, and postoperative arterial hypertension seem to be associated with a higher risk of neck bleeding after CEA, requiring re-exploration in most cases. Other antiplatelet agents appear to be associated with an increased risk of postoperative neck bleeding only if they are continued to the day before CEA. Larger studies are warranted to confirm our findings and prevent this feared surgical complication.
authors.affiliation: Department of Neurological Sciences, University of Padua, School of Medicine, Padova, Italy.
authors.forename: Claudio
authors.initials: C
authors.lastname: Baracchini
authors.forename: Mario
authors.initials: M
authors.lastname: Gruppo
authors.forename: Franco
authors.initials: F
authors.lastname: Mazzalai
authors.forename: Renata
authors.initials: R
authors.lastname: Lorenzetti
authors.forename: Giorgio
authors.initials: G
authors.lastname: Meneghetti
authors.forename: Enzo
authors.initials: E
authors.lastname: Ballotta
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002340:Carotid Artery Diseases / Q000150:complications / Q000401:mortality / Q000601:surgery*; D016009:Chi-Square Distribution; D000077144:Clopidogrel; D004334:Drug Administration Schedule; D016894:Endarterectomy, Carotid / Q000009:adverse effects* / Q000401:mortality; D005260:Female; D006785:Hospitals, University; D006801:Humans; D006973:Hypertension / Q000209:etiology; D007558:Italy; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D010975:Platelet Aggregation Inhibitors / Q000008:administration & dosage / Q000009:adverse effects; D019106:Postoperative Hemorrhage / Q000209:etiology* / Q000401:mortality / Q000601:surgery; D012042:Registries; D012086:Reoperation; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D020521:Stroke / Q000209:etiology; D013988:Ticlopidine / Q000008:administration & dosage / Q000009:adverse effects / Q000031:analogs & derivatives; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D010975:Platelet Aggregation Inhibitors; D000077144:Clopidogrel; D013988:Ticlopidine