Argatroban Anticoagulation for Transcarotid TAVR Under Conscious Sedation in a Patient With Heparin-Induced Thrombocytopenia.

OBJECTIVES

To describe argatroban anticoagulation in a patient with heparin-induced thrombocytopenia undergoing transcarotid transcatheter aortic valve replacement under conscious sedation.

KEY STEPS: Vitamin K antagonist therapy was discontinued and intravenous argatroban initiated, with anti-factor IIa monitoring. Procedural anticoagulation consisted of an argatroban bolus followed by continuous infusion guided by activated clotting time. An ultrasound-guided intermediate cervical plexus block with remifentanil sedation maintained consciousness for neurological assessment. Argatroban was resumed postoperatively before transition to vitamin K antagonist therapy.

POTENTIAL PITFALLS: Surgical carotid access under argatroban requires careful balancing of thrombotic and bleeding risks. Maintaining consciousness for neurological monitoring adds an anesthetic challenge, requiring adequate anesthesia for carotid exposure while avoiding excessive sedation; an intermediate cervical plexus block may cause dysphagia.

TAKE-HOME MESSAGE: Integrating argatroban anticoagulation with locoregional anesthesia may address the competing requirements of surgical carotid access and continuous neurological monitoring in patients with heparin-induced thrombocytopenia undergoing transcarotid transcatheter aortic valve implantation.