title: Using protamine can significantly reduce the incidence of bleeding complications after carotid endarterectomy without increasing the risk of ischemic cerebral events.
abstract: BACKGROUND
  Controversy persists regarding the use of protamine sulfate (PS) during carotid endarterectomy (CEA), chiefly because of conflicting experiences reporting both less bleeding and a higher stroke risk. The goal of the present study was to test the hypothesis that reversing heparin with PS after CEA significantly reduces the incidence of bleeding complications without increasing the risk of postoperative stroke.
  
  
  METHODS
  From January 2010 to December 2012 all consecutive patients undergoing CEA under general anesthesia at our institution received 5,000 U of heparin prior to carotid clamping, which was partially (half-dose) reversed with PS 25 mg immediately after declamping (group I). Heparinization had never been reversed with PS in earlier CEAs performed from 1998 to 2009 at the same institution (group II). All patients were assessed preoperatively and postoperatively by a neurologist, and cerebral magnetic resonance imaging was performed in all group I patients to exclude any silent cerebral infarction. End points of the study were bleeding complications, perioperative (30-day) stroke, and death.
  
  
  RESULTS
  Overall, 219 CEAs (201 patients) were performed in group I, and 1,458 CEAs (1,294 patients) in group II. Demographics, risk factors, and preoperative antiplatelet medication were comparable in the two groups. The incidence of adverse events (group I vs group II) was as follows: stroke (0 vs 0.5 % [8/1,458], p = 0.27); death (0 vs 0 %); neck bleeding (0 vs 8.2 % [120/1,458], p < 0.001).
  
  
  CONCLUSIONS
  The results of the present study demonstrate that (1) partially neutralizing heparin with PS after CEA can significantly reduce the risk of bleeding complications, and (2) there is no association between the administration of PS and the incidence of postoperative stroke.
authors.affiliation: Vascular Surgery Group, 2nd Surgical Clinic, Department of Surgical, Oncological, and Gastroenterological Sciences, School of Medicine, University of Padua, Ospedale Giustinianeo, 2nd Floor, Via N. Giustiniani, 2, 35128, Padua, Italy.
authors.forename: Franco
authors.initials: F
authors.lastname: Mazzalai
authors.forename: Giacomo
authors.initials: G
authors.lastname: Piatto
authors.forename: Antonio
authors.initials: A
authors.lastname: Toniato
authors.forename: Renata
authors.initials: R
authors.lastname: Lorenzetti
authors.forename: Claudio
authors.initials: C
authors.lastname: Baracchini
authors.forename: Enzo
authors.initials: E
authors.lastname: Ballotta
mesh_terms: D000368:Aged; D002545:Brain Ischemia / Q000453:epidemiology*; D016894:Endarterectomy, Carotid; D005260:Female; D006494:Heparin Antagonists / Q000627:therapeutic use*; D006801:Humans; D015994:Incidence; D008297:Male; D019106:Postoperative Hemorrhage / Q000453:epidemiology* / Q000517:prevention & control*; D011479:Protamines / Q000627:therapeutic use*; D012189:Retrospective Studies; D018570:Risk Assessment; D020521:Stroke / Q000453:epidemiology*
chemical_list: D006494:Heparin Antagonists; D011479:Protamines