PURPOSE To describe the intraoperative use of bivalirudin during lower extremity revascularization in the setting of heparin-induced thrombocytopenia (HIT). CASE SUMMARY A 65 year-old man presented with left common iliac, external iliac, and femoral artery occlusion necessitating revascularization with left femoral endarterectomy and common and external iliac stent angioplasty. Three months before the femoral endarterectomy, the patient was hospitalized for a coronary artery bypass procedure. During this admission, the patient tested positive for the presence of heparin-PF4 antibody complexes. With the patient's recent history of HIT, bivalirudin was selected as the optimal agent for intraoperative anticoagulation. Bivalirudin was administered as a 50 mg bolus, followed by a continuous infusion initiated at 1.75 mg/kg/hr. Repeated bivalirudin boluses were necessary to maintain an activated clotting time (ACT) necessary for the revascularization procedures and recurrent subacute thrombi despite appropriate ACT values. DISCUSSION Bivalirudin has been utilized for cardiopulmonary bypass and carotid endarterectomy (CEA), but data for dosing in lower extremity revascularization are lacking. As the risk for thrombosis with HIT continues for months after diagnosis, it is important to elucidate optimal dosing of non-heparin anticoagulant options, such as the direct thrombin inhibitor, bivalirudin. The absence of validated dosing strategies for bivalirudin can result in prolonged operative times, increased risk of bleeding, and inadequate anticoagulation. CONCLUSION Bivalirudin is an appropriate agent for intraoperative anticoagulation in lower extremity revascularization. However, further investigation into the optimal intraoperative bivalirudin dosing regimen is necessary.

中文翻译：

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接受股动脉内膜切除术并伴有肝素诱导血小板减少症的患者术中使用比伐卢定：病例报告和文献综述。

目的 描述肝素诱导的血小板减少症 (HIT) 下肢血运重建术中比伐卢定的使用情况。病例摘要 一名 65 岁男性因左髂总动脉、髂外动脉和股动脉闭塞，需要通过左股动脉内膜切除术以及髂总动脉和髂外支架血管成形术进行血运重建。股动脉内膜切除术前三个月，患者因冠状动脉搭桥手术住院。入院期间，患者肝素-PF4 抗体复合物检测呈阳性。鉴于患者近期有HIT病史，选择比伐卢定作为术中抗凝的最佳药物。比伐卢定以 50 mg 推注形式给药，然后以 1.75 mg/kg/hr 开始连续输注。尽管 ACT 值适当，但仍需要重复比伐卢定推注，以维持血运重建手术和复发性亚急性血栓所需的活化凝血时间 (ACT)。讨论 比伐卢定已用于体外循环和颈动脉内膜切除术 (CEA)，但缺乏下肢血运重建的剂量数据。由于 HIT 血栓形成的风险在诊断后持续数月，因此阐明非肝素抗凝药物（例如直接凝血酶抑制剂比伐卢定）的最佳剂量非常重要。缺乏经过验证的比伐卢定给药策略可能会导致手术时间延长、出血风险增加和抗凝不足。结论 比伐卢定是下肢血运重建术中抗凝的合适药物。然而，有必要进一步研究最佳的术中比伐卢定给药方案。