Protamine administration was shown to reduce bleeding after carotid surgery, but the role of protamine during peripheral vascular interventions (PVI) remains unknown. This study evaluates the trend and outcomes of protamine use in the Vascular Quality Initiative. Our hypothesis is that the use of protamine is associated with decreased bleeding after PVI.
Patients undergoing elective PVI in the Vascular Quality Initiative (2016-2020) for peripheral arterial disease were reviewed and use trend for protamine was derived. The characteristics of patients undergoing PVI with and without protamine were compared. After propensity matching based on patient as well as access site and procedural characteristics, the perioperative outcomes of both groups were compared.
A total of 92,120 PVI procedures were reviewed and 29.6% (n = 27,272) received protamine (Table). Protamine use significantly increased during the study period from 5.2% to 22.9%. (Figure). Patients receiving protamine were more likely to be White (78.9% vs 76.6%; P < .001), Hispanic (6.5% vs 5.9%; P = .003), and smokers (80.5% vs 78.4%; P < .001). Patients treated with protamine were more likely to have congestive heart failure (20.5% vs 19.8%; P = .006), chronic obstructive pulmonary disease (28.2% vs 26.5%; P < .001), diabetes mellitus (53.3% vs 54.4%; P = .002), and were more likely to be on aspirin (73.4% vs 73.6%; P = .596), anticoagulants (19.2% vs 18.4%; P = .005), statins (77.4% vs 76.5%; P = .001), and P2Y12 inhibitors (44.3% vs 45%; P = .013). After propensity matching, there was no significant difference in baseline characteristics. There was a significant decrease in bleeding during procedure where protamine was administered compared with no protamine (2% vs 2.2%; P = .032). Protamine was more likely to be given in procedures complicated by perforation (0.75% vs 0.52%; P < .0001) and less likely to be given during procedures with distal embolization (0.4% vs 0.7%; P < .0001). However, patients receiving protamine had significantly higher myocardial infarction (0.5% vs 0.4%; P = .002) and cardiac complications (1.4% vs 1.1%; P < .001). There was no significant difference in mortality between the two groups.
Protamine use is associated with decreased perioperative bleeding but increased cardiac complications. Protamine should be selectively administered to patients at high risk of bleeding during PVI.
Patients with chronic kidney disease (CKD) who undergo peripheral vascular interventions (PVI) with iodinated contrast are at higher risk of postcontrast acute kidney injury (PC-AKI). CO2 angiography can reduce iodinated contrast volume usage in this patient population, but its impact on PC-AKI has not been studied. This article examines the use of CO2 angiography during PVI in the VQI. We hypothesize that CO2 angiography is associated with a decrease in PC-AKI in patients with advanced CKD.
The Vascular Quality Initiative PVI dataset from 2010 to 2021 was reviewed. Only patients with advanced CKD (estimated glomerular filtration rate of <45 mL/min/1.73 m2) treated for PAD were included. Propensity matching based on demographics, comorbidities, CKD stage, and indications were used to compare the outcomes of patients treated with and without CO2.
There were 20,706 PVIs performed in patients with advanced CKD and only 22% utilized CO2 angiography. Patients who underwent CO2 angiography were younger and less likely to be women or white. However, they were more likely to have more advanced CKD stage, diabetes, and cardiac comorbidities, and be treated for tissue loss compared with patients treated without CO2. Propensity matching yielded 2 well-matched groups with 4396 patients each (Table I). The procedural details after matching demonstrated 50% reduction in the volume of contrast used (32.1 mL vs 63.4 mL; P < .001). PVI with CO2 angiography was associated with lower rates of PC-AKI (3.8% vs 5.1%; P = .01) and cardiac complications (2.1% vs 2.9%; P = .03) without a significant difference in technical failure rates or major/minor amputations (Table II).
CO2 angiography reduces contrast volume usage by 50% during PVI and is associated with decreased cardiac complications and PC-AKI. CO2 angiography is underutilized and should be considered for endovascular treatment of PAD in all patients with advanced CKD.
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