POSTOPERATIVE ANTICOAGULANT AND ANTIAGGREGANT STRATEGY FOR THE PATIENTS WITH ATRIAL FIBRILLATION FOLLOWING CAROTID ENDARTERECTOMY - SINGLE CENTER EXPERIENCE

Yıl 2019, Cilt: 82 Sayı: 4, 174 - 179, 21.10.2019

Didem Melis Öztaş Murat Uğurlucan Hakkı Tankut Akay İbrahim Erdinç Kubilay Aydın Ufuk Alpagut

Öz

Objective: Literature does not contain a standard procedure about anticoagulant therapy aimed at patients with atrial fibrillation and carotid artery stenosis following carotid endarterectomy. In this paper, we present our therapy modality at these patients in our clinic. Material and Method: The study includes 424 patients and 498 carotid endarterectomy operations performed by two surgeons with the same technique between June 2010 and December 2017. Fourty-five patients had chronic or paroxysmal atrial fibrillation. Therefore, the patients were receiving Coumadin and aspirin. The median age was 63.4±7.9. There were 27 female and 18 male patients. Thirty seven patients were hypertensive and 17 patients were diabetic. Nine patients underwent bilateral carotid endarterectomy operations. Thirty three patients were symptomatic. Eleven patients had coronary artery disease and 5 patients had cardiac valvular pathologies. Results: The whole carotid endarterectomy operations were performed under locoregional anesthesia. Early mortality occured in one patient because of hypertensive intracranial bleeding. The median follow up period was 68.4±19.2 months. One patient was lost due to aging and co-morbid factors and one patient was lost due to malignancy in late follow up period. Three patients required revisions for hematoma at incision region but an active bleeding focus could not be detected. There was no re-stenosis in any patient during follow-up. Conclusion: The large and multi-centered studies are needed for the anticoagulant therapy protocol for the patients with atrial fibrillation following carotid endarterectomy. We prefer combination of warfarin, providing INR value between 2-3, and 100 mg aspirin per day at our patients as therapy modality. 

Anahtar Kelimeler

Carotid artery stenosis, atrial fibrillation, carotid endarterectomy

ATRİAL FİBRİLASYONU OLAN VE KAROTİS ENDARTEREKTOMİSİ GEÇİREN HASTALARDA POSTOPERATİF ANTİKOAGÜLAN VE ANTİAGREGAN STRATEJİSİ – TEK MERKEZ TECRÜBESİ

Öz

Amaç: Karotis arter stenozu ve atriyal fibrilasyonun birarada görüldüğü hasta grubunda karotis endarterektomi sonrası antikoagülan tedavi protokolü ile ilgili standart bir prosedür bulunmamaktadır. Bu hasta grubunda kliniğimizde uyguladığımız tedavi stratejimizi sunmaktayız. Gereç ve Yöntem: Çalışma Haziran 2010 - Aralık 2017 arasında karotis endarterektomisi operasyonunu gerçekleştiren 2 cerrahın verilerinin toplandığı 424 hastayı ve 498 karotis endarterektomisi işlemini içermektedir. Bu hastaların 45’inde kronik veya paroksismal atriyal fibrilasyon mevcuttu. Hastalar warfarin ve aspirin tedavisi almaktaydı. Ortalama yaş 63,4±7,9 idi. Hastalardan 27’si kadın 18’i erkekti. 37 hastada hipertansiyon, 17 hastada diyabetes mellitus mevcuttu. Hastaların 9’una bilateral karotis arter stenozu nedeniyle cerrahi işlem uygulandı. 33 hasta semptomatikti. 11 hastada koroner arter hastalığı, 5 hastada kardiyak valvuler patoloji mevcuttu. Bulgular: Hastaların tamamında lokorejyonel anestezi ile karotis endarterektomisi yapıldı. Erken mortalite 1 hastada hipertansif intrakraniyal kanama sebebiyle gerçekleşti. Hastaları ortalama takip süresi 68,4±19,2 ay idi. Takiplerde 1 hastada komorbid faktörlere bağlı sebepler, 1 hastada malignite nedeniyle geç dönemde mortalite gerçekleşti. Hastaların 3’ünde insizyon böl gesinde hematom nedeniyle revizyon gerekti; fakat eksplorasyonda aktif kanama odağı tespit edilemedi. Hiçbir hastada takipleri sırasında restenoz saptanmadı. Tartışma: Atriyal fibrilasyonu olan hastalarda karotis endarterektomi sonrası antikoagülan tedavi protokolü açısından daha geniş ve çok merkezli çalışmalara gereksinim vardır. Biz hastalarımızda INR değerini 2-3 arasında tutacak şekilde warfarin tedavisi ile günlük 100 mg aspirin kombinasyonunu tedavi stratejisi olarak uygulamayı tercih ettik. 

Anahtar Kelimeler

Karotis arter stenozu, atrial fibrilasyon, karotis endarterektomisi

Kaynakça

• 1. Hıdıroğlu M, Çetin L, Kunt A, Karakişi O, Küçüker A, Şener E. Karotis arter hastalıklarında karotis endarterektomi erken sonuçları. Turkish J Thorac Cardiovasc Surg 2010;18(3):1905.
• 2. Harthun NL, Stukenborg GJ. Atrial fibrillation is associated with increased risk of perioperative stroke and death from carotid endarterectomy. J Vasc Surg 2010;51(2):330-6.
• 3. Akanksha WG, Paramdeep K, Gagandeep S, Rajinder B, Birinder SP, Monika S, et al. Clinical Features, Risk Factors, and Short-term Outcome of Ischemic Stroke, in Patients with Atrial Fibrillation: Data from a Population-based Study. Ann Indian Acad Neurol 2017;20(3):289-93.
• 4. Ugurlucan M, Filik ME, Caglar IM, Zencirci E, Sayin OA, Aydiner O, Yildiz Y, Basaran M, Cicek S. Carotid endarterectomy using a “home-constructed” shunt for patients intolerant to cross-clamping. Surg Today 2015;45(3):284-9.
• 5. Lehtola H, Airaksinen KEJ, Hartikainen P, Hartikainen JEK, Palomäki A, Nuotio I, Ylitalo A, Kiviniemi T, Mustonen P. Stroke recurrence in patients with atrial fibrillation: concomitant carotid artery stenosis doubles the risk. Eur J Neurol 2017;24(5):719-25.
• 6. Gu Y, Feng L, Xu Y, Zhao Y. Co-prevalence of carotid stenosis and coronary artery disease in Chinese patients with paroxysmal atrial fibrillation. J Int Med Res 2014;42(6):1294300.
• 7. Sakamoto Y, Sato S, Kuronuma Y, Nagatsuka K, Minematsu K, Toyoda K. Factors associated with proximal carotid axis occlusion in patients with acute stroke and atrial fibrillation. J Stroke Cerebrovasc Dis 2014;23(5):799-804.
• 8. Watanabe M, Chaudhry SA, Adil MM, Alqadri SL, Majidi S, Semaan E, Qureshi AI. The effect of atrial fibrillation on outcomes in patients undergoing carotid endarterectomy or stent placement in general practice. J Vasc Surg 2015;61(4):927-32.
• 9. Déglise S, Dubuis C, Mosimann P, Saucy F, Engelberger S, Hirt L, et al. Management of the carotid artery stenosis. Rev Med Suisse 2013;9(391):1305-11.
• 10. Kernan WN, Ovbiagele B, Black HR, Bravata DM, Chimowitz MI, et al. American Heart Association Stroke Council, Council on Cardiovascular and Stroke Nursing, Council on Clinical Cardiology, and Council on Peripheral Vascular Disease. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2014;45(7):2160-236.
• 11. Bischof G, Pratschner T, Kail M, Mittlböck M, Turkof E, Puig S, Polterauer P, Kretschmer G. Anticoagulants, antiaggregants or nothing following carotid endarterectomy?. Eur J Vasc Surg 1993;7(4):364-9.
• 12. Cvjetko I, Dovžak Bajs I, Bezjak M. Carotid Endarterectomy in Patients with Antiaggregation Therapy. Acta Med Croatica 2016;70(2):131-8.
• 13. Steinberg BA, Piccini JP. Anticoagulation in atrial fibrillation. BMJ 2014;348:g2116.
• 14. Lip GY, Lim HS. Atrial fibrillation and stroke prevention. Lancet Neurol 2007;6:981-93.
• 15. Paciaroni M, Bogousslavsky J. Antithrombotic therapy in carotid artery stenosis: an update. Eur Neurol 2015;73(12):51-6.
• 16. Arnao V, Agnelli G, Paciaroni M. Direct oral anticoagulants in the secondary prevention of stroke and transient ischemic attack in patients with atrial fibrillation. Intern Emerg Med 2015;10(5):555-60.
• 17. Pullicino PM, Qian M, Sacco RL, Freudenberger R, Graham S, Teerlink JR, et al. WARCEF Investigators. Recurrent stroke in the warfarin versus aspirin in reduced cardiac ejection fraction (WARCEF) trial. Cerebrovasc Dis 2014;38(3):176-81.
• 18. Nanda MM, Kauflin MJ, Jain PG, Yannetta JC 3rd. Use of argatroban as a procedural and bridging anticoagulant in a patient undergoing carotid endarterectomy with concomitant atrial fibrillation. Ann Pharmacother 2011;45(3):e16.