Accepted Manuscript The sticky platelet syndrome during carotid endarterectomy Ahmad A. Alsheekh, MD, Alessandra Puggioni, MD, Anil P. Hingorani, MD, Natalie Marks, MD, Enrico Ascher, MD PII:
S0890-5096(15)00391-X
DOI:
10.1016/j.avsg.2015.02.022
Reference:
AVSG 2375
To appear in:
Annals of Vascular Surgery
Received Date: 21 October 2014 Revised Date:
17 February 2015
Accepted Date: 17 February 2015
Please cite this article as: Alsheekh AA, Puggioni A, Hingorani AP, Marks N, Ascher E, The sticky platelet syndrome during carotid endarterectomy, Annals of Vascular Surgery (2015), doi: 10.1016/ j.avsg.2015.02.022. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
The sticky platelet syndrome during carotid endarterectomy.
2
Ahmad A. Alsheekh MD,
3
Alessandra Puggioni MD, Anil P. Hingorani MD, Natalie Marks MD, Enrico Ascher MD.
4
- Institution: Total vascular care, Brooklyn, NY, USA.
5
- E-mail: [email protected]
6
- NO CONFLICT OF INTEREST.
SC
7
M AN U
8 9
RI PT
1
The sticky platelet syndrome is a congenital disorder, characterized by abnormal platelet aggregation in response to epinephrine and/or adenosine phosphate[1]
11
We present a case of intraoperative carotid artery thrombosis, following patch
12
angioplasty. The successful repair was only feasible upon administration of antiplatelet
13
therapy. Presence of sticky platelet syndrome should be considered during vascular
14
operative interventions and load of antiplatelet agents should be given in patients with
15
unexplained repeated thrombosis of arterial repair, , as we described and reported this
16
case.
18
EP
Case report
AC C
17
TE D
10
A 77 year old male, who presented to our office with asymptomatic high grade, left
19
carotid artery stenosis. His past medical history was significant for hypercholesterolemia,
20
GERD, hypertension, tobacco abuse. His past surgical history was significant for right
21
carotid endarterectomy with patch angioplasty five months prior to presentation and
22
remote craniotomy. Patient was on Clopidogrel therapy only following his right carotid
1
ACCEPTED MANUSCRIPT
endarterectomy, which was discontinued seven days prior to his elective left carotid
24
endarterectomy. However, the when the Clopidogrel was stopped, aspirin was
25
inadvertently not started. Preoperative duplex ultrasound of the left carotid artery
26
demonstrated high grade stenosis >70% confirmed with B-Mode and color flow imaging
27
with peak systolic velocity 325 cm per second, no angiography was done. His
28
preoperative coagulation profile and platelet count were within normal limits. His
29
preoperative echocardiogram demonstrated borderline left ventricular function.
SC
30
RI PT
23
He was taken for elective left carotid endarterectomy. The procedure was performed through standard incision over medial border of sternocleidomastoid muscle. A systemic
32
intravenous heparin was administered prior to carotid cross clamping and ACT was
33
monitored throughout the entire case and was maintained above 280 seconds. An
34
intraoperative carotid shunt was used during the entire procedure. The carotid
35
endarterectomy with Dacron patch angioplasty was performed. A completion
36
intraoperative duplex ultrasound demonstrated the presence of mobile thrombus at the
37
distal extent of carotid repair. The left carotid artery was reclamped and thrombus was
38
evacuated through the patch arteriotomy. The thrombus had a ‘white clot appearance’
39
that made us suspect a reaction to heparin. All usage of heparin was stopped and
40
protamine was used to reverse the effect of heparin. The argatroban was administered
41
prior to the heparin reversal. However, on a repeat duplex ultrasound, performed upon
42
completion of a patch repair, the evidence of recurrent carotid thrombosis was noted. The
43
entire Dacron patch was removed and a carotid artery was repaired with an autologous
44
vein patch. A repeat carotid duplex ultrasound again demonstrated evidence of carotid
45
thrombosis. The patient was given a load of Abciximab and a carotid artery
AC C
EP
TE D
M AN U
31
2
ACCEPTED MANUSCRIPT
thrombectomy with vein patch repair was performed. The completion duplex
47
demonstrated patent lumen without evidence of thrombosis. The patient then was
48
continued on Abciximab for 24 hours and transition to Aspirin and Clopidogrel. A
49
postoperative course was notable for a mild ischemic stroke with mild long-term right
50
hand and leg weakness. A repeat duplex ultrasound was performed on postoperative day
51
six and demonstrated a patent artery without a hemodynamically significant stenosis. At
52
three year follow up the patient remained on dual antiplatelet therapy and without
53
evidence of carotid occlusion. On follow-up at 7 years, patient remains well with no
54
further neurologic events. Hypercoagulable work- up by hematology was negative but
55
aggregometry demonstrated sticky platelet syndrome.
56
Figure 1 demonstrates repeated thrombus on posterior wall on completion duplex of
57
carotid endarterectomy after second attempt.
M AN U
SC
RI PT
46
60
Discussion
The sticky platelet syndrome is a congenital autosomal dominant platelet disorder
EP
59
TE D
58
associated with an arterial and venous thromboembolism [1]. It has been characterized in
62
vitro by exaggerated platelet aggregation in response to low dose platelet agonists (e.g.,
63
ADP, epinephrine) and clinically by episodes of otherwise unexplained arterial or venous
64
occlusion. Reports of myocardial infarction or angina pectoris without identifiable
65
coronary artery disease[1], stroke or TIAs in younger patients and children[2], idiopathic
66
ischemic optic neuropathy, bilateral lower extremity ischemia have been published[3].
67
There are no large reported series of patients with this condition, and whether this
68
AC C
61
represents a real clinical syndrome remains uncertain. The underlying defect is not 3
ACCEPTED MANUSCRIPT
known. Anecdotally, treatment with low-dose aspirin (e.g., 81 to 100 mg/day) has been
70
associated with return of the platelet aggregation pattern to normal and relief from the
71
thrombotic symptoms. However, discontinuation of antiplatelet medications leads to
72
abnormal aggregation pattern[4].
RI PT
69
We believe that this is a first report of this condition encountered during operative
74
intervention on carotid artery. The hyperaggregability of the platelets probably was
75
precipitated by discontinuation of the antiplatelet therapy prior to surgical intervention.
76
Besides, the stress of the operation may precipitate release of catecholamines and further
77
increase platelet aggregation.
78
Both heparin induced thrombocytopenia and sticky platelets syndrome will result in
79
white clots, so we treated the first white clot with argatroban which failed. We then
80
stopped the argatroban and used Abciximab with no more white thrombus.
81
Although this patients manifested this disease during this left CEA, but he did not
82
manifested the same during the previous right CEA.
TE D
M AN U
SC
73
In conclusion, the sticky platelet syndrome should be considered during vascular
84
operative interventions and load of antiplatelet agents may be given in patients with
85
unexplained repeated thrombosis of arterial repair. It remains speculation if this patient`s
86
presentation would have been altered if he had received an antiplatelet agent prior to
87
procedure.
AC C
EP
83
88
89
4
ACCEPTED MANUSCRIPT
References
90
RI PT
SC
4.
M AN U
3.
TE D
2.
Mammen, E.F., Sticky platelet syndrome. Semin Thromb Hemost, 1999. 25(4): p. 361-5. Gehoff, A., J.G. Kluge, P. Gehoff, D. Jurisch, D. Pfeifer, J. Hinz, et al., Recurrent strokes under anticoagulation therapy: Sticky platelet syndrome combined with a patent foramen ovale. J Cardiovasc Dis Res. 2(1): p. 68-70. Bojalian, M.O., A.G. Akingba, J.C. Andersen, P.S. Swerdlow, P.G. Bove, O.W. Brown, et al., Sticky platelet syndrome: an unusual presentation of arterial ischemia. Ann Vasc Surg. 24(5): p. 691 e1-6. Frenkel, E.P. and E.F. Mammen, Sticky platelet syndrome and thrombocythemia. Hematol Oncol Clin North Am, 2003. 17(1): p. 63-83.
EP
1.
AC C
91 92 93 94 95 96 97 98 99 100 101
5
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
S0890-5096(15)00391-X
DOI:
10.1016/j.avsg.2015.02.022
Reference:
AVSG 2375
To appear in:
Annals of Vascular Surgery
Received Date: 21 October 2014 Revised Date:
17 February 2015
Accepted Date: 17 February 2015
Please cite this article as: Alsheekh AA, Puggioni A, Hingorani AP, Marks N, Ascher E, The sticky platelet syndrome during carotid endarterectomy, Annals of Vascular Surgery (2015), doi: 10.1016/ j.avsg.2015.02.022. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
The sticky platelet syndrome during carotid endarterectomy.
2
Ahmad A. Alsheekh MD,
3
Alessandra Puggioni MD, Anil P. Hingorani MD, Natalie Marks MD, Enrico Ascher MD.
4
- Institution: Total vascular care, Brooklyn, NY, USA.
5
- E-mail: [email protected]
6
- NO CONFLICT OF INTEREST.
SC
7
M AN U
8 9
RI PT
1
The sticky platelet syndrome is a congenital disorder, characterized by abnormal platelet aggregation in response to epinephrine and/or adenosine phosphate[1]
11
We present a case of intraoperative carotid artery thrombosis, following patch
12
angioplasty. The successful repair was only feasible upon administration of antiplatelet
13
therapy. Presence of sticky platelet syndrome should be considered during vascular
14
operative interventions and load of antiplatelet agents should be given in patients with
15
unexplained repeated thrombosis of arterial repair, , as we described and reported this
16
case.
18
EP
Case report
AC C
17
TE D
10
A 77 year old male, who presented to our office with asymptomatic high grade, left
19
carotid artery stenosis. His past medical history was significant for hypercholesterolemia,
20
GERD, hypertension, tobacco abuse. His past surgical history was significant for right
21
carotid endarterectomy with patch angioplasty five months prior to presentation and
22
remote craniotomy. Patient was on Clopidogrel therapy only following his right carotid
1
ACCEPTED MANUSCRIPT
endarterectomy, which was discontinued seven days prior to his elective left carotid
24
endarterectomy. However, the when the Clopidogrel was stopped, aspirin was
25
inadvertently not started. Preoperative duplex ultrasound of the left carotid artery
26
demonstrated high grade stenosis >70% confirmed with B-Mode and color flow imaging
27
with peak systolic velocity 325 cm per second, no angiography was done. His
28
preoperative coagulation profile and platelet count were within normal limits. His
29
preoperative echocardiogram demonstrated borderline left ventricular function.
SC
30
RI PT
23
He was taken for elective left carotid endarterectomy. The procedure was performed through standard incision over medial border of sternocleidomastoid muscle. A systemic
32
intravenous heparin was administered prior to carotid cross clamping and ACT was
33
monitored throughout the entire case and was maintained above 280 seconds. An
34
intraoperative carotid shunt was used during the entire procedure. The carotid
35
endarterectomy with Dacron patch angioplasty was performed. A completion
36
intraoperative duplex ultrasound demonstrated the presence of mobile thrombus at the
37
distal extent of carotid repair. The left carotid artery was reclamped and thrombus was
38
evacuated through the patch arteriotomy. The thrombus had a ‘white clot appearance’
39
that made us suspect a reaction to heparin. All usage of heparin was stopped and
40
protamine was used to reverse the effect of heparin. The argatroban was administered
41
prior to the heparin reversal. However, on a repeat duplex ultrasound, performed upon
42
completion of a patch repair, the evidence of recurrent carotid thrombosis was noted. The
43
entire Dacron patch was removed and a carotid artery was repaired with an autologous
44
vein patch. A repeat carotid duplex ultrasound again demonstrated evidence of carotid
45
thrombosis. The patient was given a load of Abciximab and a carotid artery
AC C
EP
TE D
M AN U
31
2
ACCEPTED MANUSCRIPT
thrombectomy with vein patch repair was performed. The completion duplex
47
demonstrated patent lumen without evidence of thrombosis. The patient then was
48
continued on Abciximab for 24 hours and transition to Aspirin and Clopidogrel. A
49
postoperative course was notable for a mild ischemic stroke with mild long-term right
50
hand and leg weakness. A repeat duplex ultrasound was performed on postoperative day
51
six and demonstrated a patent artery without a hemodynamically significant stenosis. At
52
three year follow up the patient remained on dual antiplatelet therapy and without
53
evidence of carotid occlusion. On follow-up at 7 years, patient remains well with no
54
further neurologic events. Hypercoagulable work- up by hematology was negative but
55
aggregometry demonstrated sticky platelet syndrome.
56
Figure 1 demonstrates repeated thrombus on posterior wall on completion duplex of
57
carotid endarterectomy after second attempt.
M AN U
SC
RI PT
46
60
Discussion
The sticky platelet syndrome is a congenital autosomal dominant platelet disorder
EP
59
TE D
58
associated with an arterial and venous thromboembolism [1]. It has been characterized in
62
vitro by exaggerated platelet aggregation in response to low dose platelet agonists (e.g.,
63
ADP, epinephrine) and clinically by episodes of otherwise unexplained arterial or venous
64
occlusion. Reports of myocardial infarction or angina pectoris without identifiable
65
coronary artery disease[1], stroke or TIAs in younger patients and children[2], idiopathic
66
ischemic optic neuropathy, bilateral lower extremity ischemia have been published[3].
67
There are no large reported series of patients with this condition, and whether this
68
AC C
61
represents a real clinical syndrome remains uncertain. The underlying defect is not 3
ACCEPTED MANUSCRIPT
known. Anecdotally, treatment with low-dose aspirin (e.g., 81 to 100 mg/day) has been
70
associated with return of the platelet aggregation pattern to normal and relief from the
71
thrombotic symptoms. However, discontinuation of antiplatelet medications leads to
72
abnormal aggregation pattern[4].
RI PT
69
We believe that this is a first report of this condition encountered during operative
74
intervention on carotid artery. The hyperaggregability of the platelets probably was
75
precipitated by discontinuation of the antiplatelet therapy prior to surgical intervention.
76
Besides, the stress of the operation may precipitate release of catecholamines and further
77
increase platelet aggregation.
78
Both heparin induced thrombocytopenia and sticky platelets syndrome will result in
79
white clots, so we treated the first white clot with argatroban which failed. We then
80
stopped the argatroban and used Abciximab with no more white thrombus.
81
Although this patients manifested this disease during this left CEA, but he did not
82
manifested the same during the previous right CEA.
TE D
M AN U
SC
73
In conclusion, the sticky platelet syndrome should be considered during vascular
84
operative interventions and load of antiplatelet agents may be given in patients with
85
unexplained repeated thrombosis of arterial repair. It remains speculation if this patient`s
86
presentation would have been altered if he had received an antiplatelet agent prior to
87
procedure.
AC C
EP
83
88
89
4
ACCEPTED MANUSCRIPT
References
90
RI PT
SC
4.
M AN U
3.
TE D
2.
Mammen, E.F., Sticky platelet syndrome. Semin Thromb Hemost, 1999. 25(4): p. 361-5. Gehoff, A., J.G. Kluge, P. Gehoff, D. Jurisch, D. Pfeifer, J. Hinz, et al., Recurrent strokes under anticoagulation therapy: Sticky platelet syndrome combined with a patent foramen ovale. J Cardiovasc Dis Res. 2(1): p. 68-70. Bojalian, M.O., A.G. Akingba, J.C. Andersen, P.S. Swerdlow, P.G. Bove, O.W. Brown, et al., Sticky platelet syndrome: an unusual presentation of arterial ischemia. Ann Vasc Surg. 24(5): p. 691 e1-6. Frenkel, E.P. and E.F. Mammen, Sticky platelet syndrome and thrombocythemia. Hematol Oncol Clin North Am, 2003. 17(1): p. 63-83.
EP
1.
AC C
91 92 93 94 95 96 97 98 99 100 101
5
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
