From the Guidelines
Not using heparin during repair of blunt aortic injury significantly increases the risk of thromboembolic complications, particularly distal embolization, stroke, and spinal cord ischemia. The use of heparin in this context is supported by the 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS guideline for the management of lower extremity peripheral artery disease, which recommends therapeutic doses of intravenous unfractionated heparin in patients with acute limb ischemia (ALI) on diagnosis, in the absence of contraindication 1. Although this guideline does not specifically address blunt aortic injury, the principle of preventing thrombus propagation and distal embolization applies to both conditions. Key considerations for heparin use in blunt aortic injury repair include:
- Weighing the risk of bleeding against the risk of thromboembolism
- Using reduced heparin doses or regional heparinization in patients with contraindications to full heparinization
- Minimizing clamp time and maintaining adequate blood pressure to reduce thromboembolic risk
- Considering alternative strategies, such as partial bypass techniques and vigilant monitoring for thromboembolic complications, if heparin must be avoided. The goal of systemic anticoagulation with heparin is to limit the propagation of existing thrombus and distal embolization, and heparin may also provide an anti-inflammatory effect that lessens ischemia, as noted in the guideline 1.
From the Research
Risk of Complications without Heparin in Blunt Aortic Injury Repair
- The risk of complications when not using heparin during repair of blunt aortic injury is a topic of interest in vascular surgery 2, 3.
- A study published in the Journal of Vascular Surgery in 2019 found that the outcomes of patients who underwent thoracic endovascular aortic repair (TEVAR) without heparinization were comparable to those who received full-dose or low-dose heparinization 2.
- The study analyzed 77 cases of confirmed blunt thoracic aortic injury (BTAI) and found no significant difference in thromboembolic and bleeding outcomes, and mortality rates between the heparinized and nonheparinized groups 2.
- However, another study published in the Journal of Vascular Surgery in 2021 found that intraoperative heparin use was associated with reduced inpatient mortality without increasing hemorrhagic complications after TEVAR for BTAI 3.
- The study analyzed 655 patients and found that heparin use was associated with a lower incidence of inpatient death and a reduced risk of lower extremity embolic events in patients with grade III BTAI 3.
Heparin Use and Complications
- Heparin is an anticoagulant that is commonly used to prevent thrombosis and embolism during surgical procedures 4, 5.
- However, heparin use can be associated with complications such as bleeding, heparin-induced thrombocytopenia, and osteoporosis 6, 4.
- The use of heparin requires careful monitoring and dosing to minimize the risk of complications and achieve therapeutic anticoagulation 5.
- Alternative anticoagulants such as argatroban and bivalirudin may be used in patients with suspected heparin-induced thrombocytopenia or other contraindications to heparin use 6.