title: Systemic infusion and local irrigation with argatroban effective in preventing clot formation during carotid endarterectomy in a patient with heparin-induced thrombocytopenia.
abstract: BACKGROUND
  A therapeutic dilemma exists when patients with symptomatic carotid stenosis and concomitant heparin-induced thrombocytopenia (HIT) are advised to urgently undergo carotid endarterectomy (CEA) with heparin therapy.
  
  
  METHODS
  After a 63-year-old man with HIT and multiple medical comorbidities underwent emergent coronary artery bypass grafting, postoperative imaging revealed plaque at the origin of the left internal carotid artery with 80%-99% stenosis and minimal contralateral internal carotid artery disease. During the patient's evaluation to undergo CEA for symptomatic high-grade carotid stenosis, enzyme-linked immunosorbent assay revealed persistent platelet factor 4 antibodies.
  
  
  RESULTS
  The endarterectomy was successfully performed while the patient received argatroban, both as a continuous infusion and intermittent irrigation during dissection of the plaque. Postoperatively, the drip was continued for 24 hours, and the patient was discharged day 2 on a daily dose of 325 mg of aspirin. At the 6-month examination, Doppler ultrasound revealed normal anterograde velocities with no evidence of stenosis, and the patient noted no subsequent ischemic events.
  
  
  CONCLUSIONS
  We now recommend systemic intravenous and local argatroban irrigation to prevent thromboembolic complications in CEA cases with HIT and renal insufficiency. Bivalirudin for both systemic intravenous use and local irrigation may be safer in patients without renal insufficiency because of its shorter half-life.
authors: Department of Neurosurgery, University of Cincinnati College of Medicine and Comprehensive Stroke Center at University of Cincinnati Neuroscience Institute, Cincinnati, Ohio, USA.
authors: Joseph C
authors: JC
authors: Serrone
authors: Norberto
authors: N
authors: Andaluz
authors: Victoria
authors: V
authors: Brink
authors: Mario
authors: M
authors: Zuccarello
authors: Susan L
authors: SL
authors: Ware
mesh_terms: D000368:Aged; D000925:Anticoagulants / Q000008:administration & dosage / Q000009:adverse effects* / Q000627:therapeutic use*; D001120:Arginine / Q000031:analogs & derivatives; D016893:Carotid Stenosis / Q000473:pathology / Q000601:surgery; D002533:Cerebral Angiography; D016894:Endarterectomy, Carotid / Q000379:methods*; D006493:Heparin / Q000009:adverse effects* / Q000276:immunology; D006801:Humans; D020244:Infarction, Middle Cerebral Artery / Q000150:complications; D007262:Infusions, Intravenous; D008279:Magnetic Resonance Imaging; D008297:Male; D010875:Pipecolic Acids / Q000008:administration & dosage / Q000627:therapeutic use*; D011184:Postoperative Period; D013449:Sulfonamides; D007507:Therapeutic Irrigation; D013921:Thrombocytopenia / Q000139:chemically induced* / Q000188:drug therapy*; D016896:Treatment Outcome
chemical_list: D000925:Anticoagulants; D010875:Pipecolic Acids; D013449:Sulfonamides; D006493:Heparin; D001120:Arginine; C031942:argatroban
keywords: Argatroban; CEA; Carotid endarterectomy; HIT; Heparin-induced thrombocytopenia; ICA; Internal carotid artery; MCA; MR; Magnetic resonance; Middle cerebral artery; PF4; Platelet factor 4