Utilization Of Thromboelastography With Platelet Mapping Assay To Predict Graft Thrombosis In Lower Extremity Revascularization
Monica Majumdar, MD MPH1, Srihari Lella, MD1, Davis Waller, MD1, Zach M. Feldman, MD1, Brandon J. Sumpio, MD1, Young Kim, MD1, Charles S. Decarlo, MD1, Jessica C. Cardenas, MD2, Ryan P. Hall, MD3, Kathryn Nuzzolo, BS1, Amanda Kirshkaln, MS1, Anahita Dua, MD MS MBA1.
1Massachusetts General Hospital / Harvard Medical School, Boston, MA, USA, 2Center for Translational Injury Research / University of Texas Houston, Houston, TX, USA, 3Tufts Medical Center / Tufts University School of Medicine, Boston, MA, USA.
Objectives Hypercoaguability is one of the most commonly implicated causes of graft/stent thrombosis and current strategies for prevention after revascularization rely on antiplatelet/anticoagulation medications. Existing coagulation tests may not reflect in vivo coagulation and do not measure parameters such as platelet function. Thromboelastography with platelet mapping (TEG-PM) aims to assay clot strength while taking into account inherent platelet resistance to medications and may provide an integral key to the next stage of patient-centered, personalized thrombophrophylaxis. This prospective observational study aimed to determine if TEG-PM could identify patients that were more like to have thrombotic events after extremity revascularization. Methods All patients undergoing named vessel revascularization during December 2020-August 2021 at a large tertiary institution were prospectively included. TEG-PM assays were performed on patients immediately pre-operatively and at serial intervals postoperatively up to six months. Results Fifty-eight patients met enrollment criteria and were included in this analysis. Ten (17.2%) patients had thrombosis of their graft/stent requiring reintervention and/or amputation. TEG-PM results at the timepoint just prior to the thrombotic event were compared to results from “last known well” in the nonevent group. Platelet aggregation was significantly higher in the thrombotic event group as compared to the nonevent group, [80.3%±22.2 vs 63.1%±22.7, p<0.05] (Figure 1A). The percent of platelet inhibition was significantly lower in the thrombotic event group as compared to the nonevent group, [19.7%±22.2 vs 35.9%±23.1, p< 0.05] (Figure 1B). Other TEG values reflecting time to clot formation, strength and breakdown did not differ. There was no significant difference in the proportion of patients taking antiplatelet/anticoagulation medications nor in routine coagulation study values between groups. Conclusions TEG-PM revealed a significantly higher level of platelet aggregation with a diminished platelet inhibition prior to thrombotic events in post-revascularization patients. Thromboprophylaxis and traditional coagulation studies did not differ significantly between groups. Our results indicate that current antiplatelet/anticoagulant management may be insufficient in protecting patients from thrombosis of their graft/stent. TEG-PM may be useful in identifying those at risk for thrombosis and establishing the role of personalized medicine in peripheral vascular surgery. 
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