Review of the use of parenteral direct thrombin inhibitors in carotid endarterectomy in patients with a history of heparin-induced thrombocytopenia

Background

Carotid endarterectomy reduces the risk of recurrent stroke in symptomatic carotid stenosis. In patients with a history of heparin-induced thrombocytopenia, heparin is contraindicated, and these patients require an alternative parenteral anticoagulant during carotid endarterectomy. The aim of this review was to review the literature for evidence of the use of parenteral direct thrombin inhibitors (DTIs) (hirudin, hirudin derivatives [lepirudin, desirudin, and bivalirudin], and argatroban) in carotid endarterectomy.

Methods

A literature search was conducted using MEDLINE through PubMed on October 14, 2023. All reports that described treatment with parenteral direct thrombin inhibitors in carotid endarterectomy were included. Two authors independently screened abstract and titles according to the predefined criteria, and nonagreement was discussed with a third author for the final decision.

Results

46 publications were identified, and 39 were excluded based on predefined criteria. Seven case reports were included, identifying seven patients who underwent carotid endarterectomy with intraoperative parenteral DTI use. There were four reports of the use of argatroban, two of bivalirudin, and one report of hirudin in a case of concurrent carotid endarterectomy and coronary artery bypass grafting. Argatroban was the preferred agent in patients with renal insufficiency. DTIs were administered parenterally through bolus and infusion and were monitored through activated clotting times or plasma-modified activated clotting times. There were no significant bleeding events, and all procedures were successfully performed. The pharmacology of DTIs and the use of DTIs in other peripheral vascular and cardiac procedures will also be reviewed.

Conclusions

Overall, the use of DTIs for anticoagulation in vascular surgery appears to be safe and effective. The DTIs with the most evidence supporting their use in carotid endarterectomy are bivalirudin and argatroban.