Objectives
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.
Methods
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.
Results
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.
Conclusions
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.
