Hakkı Tankut AKAY, Murat UĞURLUCAN, İbrahim ERDİNÇ, Çağla CANBAY, Didem Melis ÖZTAŞ, Erdal ASLIM

KAROTİS ENDARTEREKTOMİSİ GEÇİREN ATRİAL FİBRİLASYONLU HASTALARDA ANTİKOAGÜLASYONU NASIL YAPIYORUM? ANKARA BAŞKENT ÜNİVERSİTESİ HASTANESİ TECRÜBESİ

Amaç: Günümüzde, karotis arter stenozu ve atriyal fibrilasyon hastalıklarının izole tedavisinde belirli standartlar bulunmaktadır. İleri yaş grubunun çoğalması ile birlikte bu hastalıkların görülme sıklığı artmıştır ve aynı hastada birlikte bulunabilirler. Ancak literatürde atriyal fibrilasyonu olan hastalarda karotis endarterektomi sonrası kesin antikoagülan tedavi protokolleri bulunmamaktadır. Biz bu yazıda kendi merkezimizde uyguladığımız antikoagülan tedavi stratejileri ile ilgili deneyimlerimizi sunuyoruz. Gereç ve Yöntem: Kliniğimizde 2003-2017 yılları arasında karotis arter stenozu nedeniyle toplam 392 endarterektomi, 165 stent olmak üzere toplamda 557 revaskülarizasyon işlemi uygulanmıştır. Atriyal fibrilasyonu olan 36 hasta retrospektif olarak incelendi. Hastaların 23 tanesi Coumadin ve aspirin, 9 tanesi rivaroksaban ve 4 tanesi dabigartan tedavisi almaktaydı. Ortalama yaş 61.3 ± 5.9 yıl idi. Kadın/erkek oranı 17/19’du. Tüm hastalara kardiyoversiyon uygulandı ve hastaların %22.1 (8 hasta)’inde kalıcı sinüs ritmi elde edildi. İdiopatik atrial fibrilasyon 23 hastada mevcutken, atrial fibrilasyon için risk faktörü olarak 9 hastada koroner arter hastalığı, 4 hastada ise valvüler patoloji vardı. Bulgular: Atrial fibrilasyonu olup endarterektomi uygulanan 1 hasta myokard infarktüsü nedeniyle kaybedildi. Majör inme 1 hastada gözlendi ve kalıcı oldu. Minör nörolojik defisit 1 hastada izlenirken 2 hastada hipoglossus siniri ile alakalı fasial belirtiler görüldü. Endarterektomi sonrası sırasıyla 39 ve 43 aylık takiplerinde restenoz gelişen iki hastaya revaskülarizasyon için başarılı stent uygulaması yapıldı. Ortalama 48.2 ± 11.5 aylık takipler sırasında hiç bir hastada majör ya da minör kanama ile karşılaşılmadı. Sonuç: Literatürde karotis enrdarterektomisi uygulanan atrial fibrilasyonlu hastaların medikal tedavileri için belirlenmiş protokol yoktur. Bizim hastalarımızda uyguladığımız tedavi protokolü aspirin ve warfarin ya da aspirin ve direk oral antikoagülan kombinasyonunu içermektedir. Her ne kadar hasta sayımız düşük olsa da uyguladığımız tedavi ile başarılı tedavi elde edilmiştir. Ancak konu ile ilgili kesin bir tedavi protokolü oluşturabilmek için çok merkezli yüksek hasta sayıları içeren çalışmalara ihtiyaç vardır.

HOW DO I MANAGE ANTICOAGULATION IN PATIENTS WITH ATRIAL FIBRILLATION FOLLOWING CAROTID ENDARTERECTOMY? ANKARA BAŞKENT UNIVERSITY EXPERIENCE

Introduction:There are standard teatment protocols for isolated carotid artery disease and atrial fibrillation in the current era. With the increasing number of the aging population, the frequency of these pathologies is also increased and both may coexist in the same patient. Theliterature lacks established anticoagulation therapy protocols for patients with atrial fibrillation after following carotid endarterectomy. In this report, we present our anticoagulation therapy strategies and experiences. Material and Method: Between 2003-2017,a total of 557 carotid artery revascularization procedures; 392 being endarterectomy and 165 being stent implantation, at our institution. Thirty-six patients with atrial fibrillation were examined, retrospectively. Twenty-three patients received Coumadin and aspirin, 9 received rivaroxaban and 4 received dabigatran. Mean age was 61.3 ± 5.9 years. Female/male raito was 17/19. All patients underwent cardioversion and in 8 patients (22.1 %) permanent sinus rhythm could be achieved. Idiopathic atrial fibrillation was present in 23 patients; however, 9 patients had coronary artery disease and 4 patients had valvular pathologies as a risk factor for atrial fibrillation. Results: One patient with atrial fibrillation who underwent carotid endarterectomy was lost due to myocardial infarction. Major stroke occured in one patient and had been permanent. Minor neurologic defisit occured in 1 patient and facial symptoms related to hypoglossus nerve was observed in 2 patients. Re-stenosis occured in two patients 39 and 43 months after endarterectomy and they underwent successful stent implantation for revascularization. During a mean of 48.2 ± 11.5 months follow up, major or minor bleeding was not observed in any patients. Conclusion: Literature lacks an accepted medical treatment protocol in patients with atrial fibrillation whom underwent carotid endarterectomy. Our treatment protocol includes combination of aspirin and warfarin or aspirin and direct oral anticoagulants. Although we have a small number patient cohort, our treatment protocol has been succesful.Multicenter studies with increased number of patients are warranted In order to establish certain treatment protocols for the treatment of this particular patient population.

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