From the Research
The target Activated Clotting Time (ACT) during carotid endarterectomy should be maintained at a range of 250-300 seconds. This level of anticoagulation is typically achieved by administering intravenous unfractionated heparin, usually at a dose of 100-150 units/kg, prior to carotid cross-clamping 1. The ACT should be measured 5 minutes after heparin administration to confirm adequate anticoagulation, and additional heparin may be given if the target ACT is not reached.
Key Considerations
- The use of heparin in carotid endarterectomy is well-established, with studies demonstrating its efficacy in preventing thrombus formation and reducing the risk of perioperative stroke 2.
- Monitoring of ACT during the procedure is essential to maintain the target range and ensure patient safety, as it helps to balance the risk of thrombosis and bleeding 3.
- In patients with heparin-induced thrombocytopenia, alternative anticoagulants such as argatroban or bivalirudin may be used, with careful monitoring of their anticoagulant effect 4.
Clinical Implications
- Regular monitoring of ACT throughout the procedure is crucial to maintain the target range and ensure patient safety.
- The use of low-dose heparin (30 U/kg) has been shown to be safe and effective in carotid endarterectomy, eliminating the need for protamine and its potentially deleterious effects 5.
- The choice of anticoagulant and monitoring strategy should be individualized based on the patient's risk factors and medical history.
Recommendations
- Maintain an ACT range of 250-300 seconds during carotid endarterectomy to balance the risk of thrombosis and bleeding.
- Use intravenous unfractionated heparin at a dose of 100-150 units/kg prior to carotid cross-clamping.
- Monitor ACT regularly throughout the procedure to ensure patient safety.