Antithrombotic Therapy for Arterial Dissection Flaps

Pre-Procedure Preparation

• The American College of Neurosurgery recommends administering aspirin in conjunction with ticlopidine or clopidogrel for 3 days before any planned intervention to allow ticlopidine to achieve full functional activity 1

Initial Heparin Dosing

• An initial intravenous bolus of 100 units/kg heparin followed by continuous infusion with supplemental doses to maintain ACT between 300-350 seconds is recommended 1

Monitoring and Adjustment

• Monitor ACT hourly and target ACT: 300-350 seconds, administering supplemental heparin as needed to maintain target ACT 1

Post-Procedure Heparin

• Continue heparin for 24 hours post-procedure with a target APTT: 1.5-2.3 times control values 1
• Discontinue heparin after the procedure if no complications 1

Alternative Options

• Subcutaneous enoxaparin 1 mg/kg twice daily can be used as an alternative 1

Consider Abciximab

• When using abciximab, reduce heparin dose to 70 units/kg to maintain ACT around 200 seconds 1

Thrombotic Complications

• Intramural thrombosis can occur in >90% of deeply injured arteries even with ACT elevated to 4-5 times control 1

Bleeding Complications

• Regular platelet count monitoring for heparin-induced thrombocytopenia is recommended 2

Long-Term Management

• Continue aspirin (325 mg daily) and ticlopidine (250 mg twice daily) or clopidogrel (75 mg daily) for at least 4 weeks 1