Intraoperative Management of Peripheral Arterial Disease

[Kumar Madassery]
I actually have a question for Sabeen. What is your intraprocedural anticoagulation and do you have issues with Heparin versus Angiomax? Let me know what you think.

[Sabeen Dhand]
Surprisingly we don't really use Angiomax or anything. I was thinking about it, but we use Heparin. Typically once I get access, say I'm going up and over, I'll first access with a six french short sheath and I'll use an Omni Flush catheter and then get up and over. I'll do my whole diagnostic run and then once I switch over to my up and over sheath, that's when I end up anticoagulating the patient. And typically I used to start off a standard 5,000 unit of bolus. And now I've been just doing 100 units per kilogram. Which is now, on average, it's about 7,000 or 8,000 units to start the case.

And really as the case is going, if I'm doing a lot of intervention, then I'll typically, every 45 minutes of so, bolus about 2 to 3 thousand. You know I want to do ACT more, and I feel like our machines are not calibrated right, because they sometimes don't respond appropriately, or maybe they're real. But I haven't done, I don't know, I kind of just do it, and I've been luckily okay. When I have done ACTs I typically try to keep it between 200 to 250. And my typical below the knee, say a pretty long case, like a three hour case, I'll probably end up doing anywhere between 12,000 to 16,000 units of heparin, which is more than when I started. Last year I would say I would average about 5,000 to max 10,000. So I've been more aggressive lately, and I’d be interested to know what you guys do.

[Kumar Madassery]
I think it's interesting. We use heparin primarily. I feel like in the community when we all talk about these things, we're seeing more and more patients that may be heparin resistant or something. When we see all these cases that they're saying they're doing a normal case, and suddenly there's thrombus that just won't kind of stop. So I don't know what's going on, but we primarily use heparin.

I agree with you we typically start at 5,000. If we're letting the fellow kind of get the access and start, and we know it's a disease vessel, we'll get 5,000 after they get access, just because you know they're going to be playing around in the artery, in the aorta.

It's actually really one of the things my partners taught me, if the fellow's in there starting the angio, and you know there’s a lot of disease, just give 5,000 at the start. If we're in there from the start, then we give it after we do our sequential run, like Sabeen does. So it's very operator dependent.

But we typically start with 5,000. And I do agree with you, I think the weight based may be a better way to go. And we do check ACTs. It was painful the last few years because the machine would take a minute to read, but now I think we got some newer machines where they can do it on the spot. So it's kind of sped up how fast the results come.

[Sabeen Dhand]
I have the old machines then, yeah. It takes a little bit.

[Kumar Madassery]
There's a point of care style one or something now that's available and that’s what we use. Where they can instantly, in every room, just check it for us quickly.

[Michael Barraza]
Yeah, at Penn it would take one or two minutes, and it's just like time would stop. It's just like how it is when you're holding pressure. It's like time slows down to a halt.

[Kumar Madassery]
Yeah. Yeah, the newer machines are pretty fast.

[Sabeen Dhand]
Maybe it's more a fact of being inpatient or a little bit of laziness that I don't do it, and I should. Because I think it would gear and titrate my heparin better. Luckily, knock on wood, I haven't seen too many thrombi forming after intervention. I've been lucky in that. It's happened once or twice, but when you go to these meetings and they talk about Angiomax, I feel like they're saying it happened 10% or 15% of the time, which I don't see that in my patient population.

[Kumar Madassery]
Yeah, we see it every now and then rarely, but I know some people who are just showing it out there on Twitter, but again, I agree with you. I don't see it that often.