title: Protamine Reduces Bleeding Complications without Increasing the Risk of Stroke after Carotid Endarterectomy: A Meta-analysis.
abstract: The aim was to evaluate the safety and efficacy of heparin reversal with protamine after completion of carotid endarterectomy (CEA), summarising the available data from both randomised and non-randomised studies.
  
  
  
  The study was a meta-analysis. Pooled odds ratios (ORs) with 95% confidence intervals (95% CIs) were calculated for the outcomes of stroke and wound haematoma among patients receiving or not receiving protamine after CEA. Meta-regression analysis was performed to examine whether the documented differences were modified by potentially meaningful patient related or procedure related predictors, namely publication year, general anesthesia used, number of patients treated, mean age (years), males, neurological symptoms, use of patch, and use of shunt.
  
  
  
  Seven studies were included in the meta-analysis reporting on 3,817 patients receiving protamine after CEA and 6,070 patients not receiving protamine for heparin reversal. Only one study was randomised. A statistically significant reduction in wound haematoma requiring re-operation was recorded after heparin reversal with protamine in patients undergoing CEA (OR, 0.42, 95% CI, 0.22-0.80, p = .008). In contrast, no significant difference was observed in stroke rates between groups of patients that received and did not receive protamine (OR, 0.71, 95% CI, 0.49-1.03, p = .07). Meta-regression analysis did not reveal any significant effect mediated by the modifiers examined.
  
  
  
  On the basis of the available data, heparin reversal with protamine seems to reduce the risk of wound haematoma, without increasing the risk of procedural stroke. However, taking into account the limitations of the analysis, further studies are needed to increase the level of evidence provided by the current meta-analysis.
authors.affiliation: Department of Vascular Surgery, "Attikon" Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece. Electronic address: kakisis@med.uoa.gr.
authors.forename: J D
authors.initials: JD
authors.lastname: Kakisis
authors.affiliation: Department of Vascular Surgery, "Attikon" Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece.
authors.forename: C N
authors.initials: CN
authors.lastname: Antonopoulos
authors.affiliation: Department of Vascular Surgery, "Attikon" Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece.
authors.forename: K G
authors.initials: KG
authors.lastname: Moulakakis
authors.affiliation: Department of Vascular Surgery, Jean-Bernard Hospital, University of Poitiers, Poitiers, France.
authors.forename: F
authors.initials: F
authors.lastname: Schneider
authors.affiliation: Department of Vascular Surgery, "Attikon" Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece.
authors.forename: G
authors.initials: G
authors.lastname: Geroulakos
authors.affiliation: Department of Vascular Surgery, Jean-Bernard Hospital, University of Poitiers, Poitiers, France.
authors.forename: J B
authors.initials: JB
authors.lastname: Ricco
mesh_terms: D016894:Endarterectomy, Carotid / Q000009:adverse effects / Q000379:methods*; D006494:Heparin Antagonists / Q000627:therapeutic use*; D006801:Humans; D019106:Postoperative Hemorrhage / Q000517:prevention & control*; D011479:Protamines / Q000627:therapeutic use*; D020521:Stroke / Q000139:chemically induced* / Q000209:etiology
chemical_list: D006494:Heparin Antagonists; D011479:Protamines
keywords: Carotid endarterectomy; Haematoma; Heparin; Meta-analysis; Protamine; Stroke