Acute hemodynamic changes during carotid artery stenting

doi:10.1016/S0002-9149(98)00562-1

The American Journal of Cardiology

Volume 82, Issue 9, 1 November 1998, Pages 1077-1081

https://doi.org/10.1016/S0002-9149(98)00562-1 Get rights and content

Abstract

To determine the clinical significance of acute hemodynamic disturbances during stenting in the carotid sinus region, we assessed the relation between intraprocedural changes in heart rate (HR) and blood pressure (BP) and adverse neurologic and cardiac outcomes. Eighteen patients underwent carotid stenting with the Wallstent (Schneider Inc). Suitable candidates had at least 60% diameter stenosis of the carotid artery by angiography. Initial and nadir HR and BP were recorded during the predilatation, stent delivery, and postdilatation periods. Bradycardia was defined as HR ≤60 beats/min and hypotension as systolic BP ≤100 mm Hg. Nineteen Wallstents were successfully deployed in all 19 carotid arteries. Some degree of bradycardia or hypotension occurred in 68% of carotid stent procedures, but administration of vasoactive medications was necessary in only 7 patients (37%) with more persistent hemodynamic disturbances. Hypotension or the need for continuous vasopressor therapy was significantly more common during postdilatation (32%) than in the predilatation period (5%) (p = 0.02). Bradycardia was not reduced by prophylactic atropine. In 1 patient the hemodynamic response to stenting may have contributed to an adverse neurologic and cardiac outcome. Thus, despite frequent fluctuations in HR and BP, most carotid stenting procedures were performed with excellent overall results, even in patients at high risk.

Section snippets

Patients

Between June 1996 and October 1997, 24 patients underwent carotid stenting at Duke University Medical Center. Patients were eligible for carotid stenting if they had at least 60% diameter stenosis of the carotid artery by angiography.1 Patients were excluded from the present hemodynamic study if (1) the stent did not completely cover the carotid sinus (n = 4) or (2) stenting was performed under general anesthesia (n = 2). Eighteen patients treated with 19 Wallstents (Schneider Inc.,

Clinical characteristics

Mean age of the carotid stent patients was 69 ± 10 years, and 61% were men. Study patients included both those with symptoms of transient ischemic attacks or recent stroke (n = 14) and asymptomatic patients (n = 4). One patient had undergone a prior ipsilateral carotid endarterectomy. Atherosclerotic risk factors included hypertension (67%), hypercholesterolemia (61%), diabetes mellitus (28%), and tobacco abuse (94%). A subset of patients were taking β blockers (33%) and/or calcium channel

Discussion

Although bradycardia or hypotension occurred in 68% of carotid stent procedures, vasoactive medications were necessary in only 7 cases (37%) with more persistent hemodynamic disturbances. Significant hemodynamic alterations, when they did develop, occurred predominantly during the postdilatation period. Hypotension after predilatation, even with relatively small diameter (4 mm) balloons, foreshadowed subsequent hemodynamic compromise. Both patients whose systolic BP fell below 105 mm Hg during

Acknowledgements

We wish to acknowledge the excellent technical assistance of Mark W. Urtz, Thomas J. Hoffman, and Worth Miller. The assistance of Stan M. Coffman, Jansen D. Wellendorf, and Hugh A. Wells in acquiring and organizing data was invaluable. We are especially grateful for the helpful critique of the manuscript by Joseph C. Greenfield, Jr., MD.

References (19)

F.A Shawl et al.
Combined percutaneous carotid stenting and coronary angioplasty during acute ischemic neurologic and coronary syndromes
Am J Cardiol
(1996)
D O’Mahony
Pathophysiology of carotid sinus hypersensitivity in elderly patients
Lancet
(1995)
Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis
N Engl J Med
(1991)
Endarterectomy for asymptomatic carotid artery stenosis
JAMA
(1995)
J.G Theron et al.
Carotid artery stenosistreatment with balloon angioplasty and stent placement
Radiology
(1996)
P Bergeron et al.
Cervical carotid artery stenosiswhich technique, balloon angioplasty or surgery?
J Cardiovasc Surg
(1996)
E.B Diethrich et al.
Stenting in the carotid arteryinitial experience in 110 patients
J Endovasc Surg
(1996)
J.S Yadav et al.
Elective stenting of the extracranial carotid arteries
Circulation
(1997)
J.R Laird et al.
Procedural results and early clinical outcomes after carotid stent-supported angioplasty in high-risk patients (abstr)
J Am Coll Cardiol
(1997)

There are more references available in the full text version of this article.

Cited by (110)

Hemodynamic instability predicts in-hospital and 1-year mortality after transcarotid artery revascularization and transfemoral carotid stenting
2023, Journal of Vascular Surgery
Blood pressure fluctuations are a common hemodynamic alteration following carotid artery stenting either with transfemoral (TFCAS) or transcarotid (TCAR) approach and are thought to be related to alteration in baroreceptor function due to angioplasty and stent expansion. These fluctuations are particularly worrisome in the high-risk patient population referred for CAS. This study aims to evaluate the outcomes of patients who required the administration of intravenous blood pressure medication (IVBPmed) for hypotension or hypertension after CAS.
All patients undergoing carotid revascularization in the Vascular Quality Initiative (VQI) database between 2016 and 2021 were included. We compared outcomes of patients who required postoperative IVBPmed to treat hyper- or hypotension with normotensive patients. In-hospital outcomes were compared using multivariable logistic regression. One-year outcomes were assessed using Kaplan-Meier survival and multivariable Cox proportional hazard regression analyses.
We identified 38,510 patients undergoing CAS (57.7% TCAR and 42.3% TFCAS), of which, 30% received IVBPmed for treatment of either postoperative hypertension (12.6%) or hypotension (16.4%). In multivariable analysis, postoperative hypotension was associated with a higher risk of stroke, death, or myocardial infarction (MI) (odds ratio [OR], 3.1; 95% confidence interval [CI], 2.6-3.6; P < .001), stroke or death (OR, 2.9; 95% CI, 2.4-3.5; P < .001), stroke (OR, 2.6; 95% CI, 2.1-3.2; P < .001), death (OR, 3.5; 95% CI, 2.6-4.8; P < .001), MI (OR, 4.7; 95% CI, 3.3-6.7; P < .001), and bleeding (OR, 1.96; 95% CI, 1.4-2.7; P < .001) compared with normotensive patients. Postoperative hypertension was associated with a higher risk of stroke, death, or MI (OR, 3.6; 95% CI, 3-4.4; P < .001), stroke or death (OR, 3.3; 95% CI, 2.7-4.1; P < .001), stroke (OR, 3.7; 95% CI, 3-4.7; P < .001), death (OR, 2.7; 95% CI, 1.9-3.9; P < .001), MI (OR, 5.7; 95% CI, 3.9-8.3; P < .001), and bleeding (OR, 1.9; 95% CI, 1.4-2.7; P < .001) compared with normotensive patients.
Postoperative hypertension or hypotension requiring IVBPmed after CAS is associated with an increased risk of in-hospital stroke, death, MI, and bleeding. Postoperative hypertension is associated with worse survival at 1 year. This study indicates that the need for IVBPmed after CAS is not benign; therefore, these patients necessitate aggressive perioperative medical management and safe techniques to avoid hypo and hypertension. Close follow-up and continue medical management are needed to maximize these patients’ survival.
Overlapped Stenting Is Associated with Postoperative Hypotension after Carotid Artery Stenting
2018, Journal of Stroke and Cerebrovascular Diseases
Hypotension (HT) is well recognized to frequently occur during and after carotid artery stenting (CAS), which sometimes causes postoperative complications such as stroke or myocardial infarction. This study aimed to examine the risk factors associated with HT after CAS based on the hypothesis that overlapped stenting may affect postoperative HT.
A total of 106 lesions in 95 patients with carotid artery stenosis who underwent CAS were reviewed. Bradycardia and HT were defined as a heart rate and a systolic blood pressure less than 60 beats/min and 100 mm Hg, respectively. The patients were categorized by the presence (group H) or the absence (group N) of postoperative HT, respectively, and demographic data, risk factors, conditions of carotid artery stenosis, procedures, and pre- and intraoperative hemodynamics were compared between these 2 groups. Multivariate analysis was performed to evaluate independent factors associated with postoperative HT.
In total, postoperative HT was observed in 30 (28.3%) cases. The incidence of overlapped stenting, the use of an open-cell stent, and intraoperative HT were significantly higher in group H (P = .03, .01 and < .01, respectively). The distance from carotid bifurcation and the maximum stenotic lesion tended to be shorter in group H (P = .09). In the multivariate logistic regression analysis, using all these variables, the overlapped stenting and intraoperative HT were found to be independent predictors for postoperative HT.
The overlapped stenting affected postoperative HT after CAS. Blood pressure should be strictly controlled in cases with overlapped stenting or intraoperative HT after CAS.
Cerebral hyperperfusion syndrome and intracranial hemorrhage after carotid endarterectomy or carotid stenting: A meta-analysis
2017, Journal of the Neurological Sciences
Citation Excerpt :
Due to ischemia/reperfusion injury, reactive oxygen species are produced and cerebral tissue edema is generated, promoting the presentation of CHS [23]. However, literature data suggest an earlier onset of CHS post CAS, possibly due to the prolonged baroreceptor stimulation by the stent that may induce bradycardia, hypotension and ischemic damage [24,25]. Therefore, hemodynamic instability after carotid intervention necessitates an offensive strategy of early management with intravenous antihypertensive medication, in order to prevent adverse sequelae [26].
Cerebral hyperperfusion syndrome (CHS) and intracranial hemorrhage (ICH) after carotid revascularization have been associated with significant morbidity and mortality, although pooled data comparing these outcomes between open and endovascular treatment are lacking. Aim of this meta-analysis is to compare CHS and ICH risk between carotid endarterectomy (CEA) and carotid angioplasty with stenting (CAS).
A systematic literature review was conducted conforming to established criteria, in order to identify eligible articles published prior to February 2017. Eligible studies compared CHS and/or ICH between patients undergoing CEA and CAS. Other outcomes evaluated in this review included stroke and death due to ICH. Outcome risks are presented as odds ratios (OR) and 95% confidence intervals (CI).
Overall, 6 studies (5 studies reporting on CHS and 4 studies reporting on ICH) included 236,537 procedures (218,144 CEA; 18,393 CAS) in total. CEA was associated with a higher risk for CHS compared to CAS (pooled OR = 1.432 [95% CI = 1.078–1901]; P = 0.015), although this difference was generated mainly from older studies (prior to 2012). However, no difference was found regarding ICH risk between the two methods (pooled OR = 0.544 [95% CI = 0.111–2.658]; P = 0.452). Regarding stroke incidence, no difference was found between the two methods as well, although this resulted mainly from studies with a higher volume of CAS procedures (pooled OR = 0.964 [95% CI = 0.741–1.252]; P = 0.833). Finally, death rate was significantly higher among patients with ICH compared to patients without ICH (pooled OR = 386.977 [95% CI = 246.746–606.906]; P < 0.0001). Pooled data were not adequate to calculate potential risk factors for CHS/ICH after CEA compared to CAS.
CEA seems to be associated with a higher risk for CHS compared to CAS, although this difference was generated mainly from older studies. However, there seems to be no difference regarding ICH risk between the two methods, with ICH being associated with a significantly higher risk for death.
Carotid Dissection Complicated by Polymorphic Ventricular Tachycardia
2017, Journal of Stroke and Cerebrovascular Diseases
In this case report, we describe a patient with fibromuscular dysplasia who suffered spontaneous bilateral carotid artery dissections. This was followed by significant variations in blood pressure and heart rates during her admission. Unfortunately, during an episode of bradycardia, a premature ventricular contraction occurred during the T wave which resulted in polymorphic ventricular tachycardia. As described in the case and in graphic depiction, this hemodynamic instability resolved after stenting of the carotid artery.
Beta-blocker use is associated with lower stroke and death after carotid artery stenting
2016, Journal of Vascular Surgery
Proper selection of patients for carotid artery stenting (CAS) remains controversial despite multiple controlled trials. This relates in part to differences in interpretation of the relative importance of myocardial vs stroke complications after the procedure by different specialties and a lack of granular clinical data to analyze outcomes outside the large clinical trials. The objective of this study was to assess the effect of preoperative medications, procedure parameters, and patient characteristics on outcomes of CAS performed in a multispecialty national database.
We analyzed all patients who underwent CAS between 2005 and 2014 in the Vascular Quality Initiative. A multivariate logistic regression model was built to assess the effects of age, gender, comorbidities, smoking, preprocedure medications, procedure details, and hypotension or hypertension that required intravenous medication on 30-day death or stroke rates.
A total of 5263 patients underwent CAS (mean age, 70 years; 63% male). The 30-day stroke/death rate was 3.4% (1.5% minor stroke, 0.9% major stroke, and 1.2% death; 40% of patients who had major strokes died within 30 days), and the myocardial infarction rate was 0.8%. Postprocedural hypertension requiring treatment occurred in 519 cases (9.9%), and it was associated with a 3.4-fold increase in stroke/death (odds ratio, 3.39; 95% confidence interval, 2.30-5.00; P < .0001). Preprocedural beta-blocker use for >30 days was associated with a 34% reduction in the stroke/death risk (odds ratio, 0.66; 95% confidence interval, 0.46-0.95; P = .025) compared with nonuse. Beta-blocker use was not associated with postprocedural hypotension. Other predictors of postoperative stroke and death included age, symptomatic status, diabetes (type 1 or type 2), and postprocedural hypotension, whereas prior carotid endarterectomy and distal embolic protection use were protective.
Postprocedural hypertension and hypotension that require treatment are both strongly associated with periprocedural stroke/death after CAS. Beta blockers significantly reduce the stroke/death risk associated with carotid stenting and should be investigated prospectively for potential use during CAS.
Predictors and consequences of hemodynamic instability after carotid artery stenting full presentation at the 29th Annual Meeting of the Western Vascular Society, Coronado, CA, September 22, 2014.
2015, Annals of Vascular Surgery
Citation Excerpt :
A variety of hemodynamic shifts including bradycardia, hypotension, and hypertension with a variable duration have been associated with CAS. The incidence of HI varies widely based on recent literature.2–7 Some studies have suggested that the routine use of atropine decreases the incidence of bradycardia during CAS.8
The purpose of this study was to determine the predictors and consequences of hemodynamic instability (HI) after carotid artery stenting (CAS).
The records of all patients undergoing CAS in a single institution were reviewed. Patient demographics and risk factors were recorded. Indications for CAS, medications including statins, atropine, and beta blockers, anatomic risk factors, balloon and stent length and diameter, and degree of stenosis were noted. The presence of periprocedural hypertension (systolic blood pressure [SBP] >160), hypotension (SBP <90), and bradycardia (heart rate <60) lasting longer than 1 hr was documented, as was more transient HI. Rates of transient ischemic attack (TIA), stroke, myocardial infarction (MI), and death within 30 days of the procedure were calculated. Chi-squared analysis was used to determine the role of periprocedural factors in predicting the risk of HI and to determine if patients experiencing HI were more likely to experience major adverse events (MAEs) than those who did not.
Between 2005 and 2012, 199 CAS were performed in 191 patients. One hundred seventeen were men and 74 were women. Their ages ranged from 46 to 92 years (mean, 73.6 years). Eighty-seven percent had hypertension, 48.5% were smokers, 48% had coronary disease, and 38% were diabetic. CAS was performed for asymptomatic stenosis in 55% of patients, 24% had previous TIA, and 20% previous stroke. Sixty-three percent of patients were on statins, 41.4% on beta blockers, and 92% received atropine before balloon dilatation or stent placement. Overall, 130 (65.3%) patients experienced HI and 67 patients (33.7%) experienced HI lasting longer than 1 hr. Octogenarians were more likely to experience both transient and prolonged HI, whereas angina or contralateral occlusion was predictive of any HI, and female sex was predictive of prolonged HI. Transient HI was not predictive of MAE. Patients with HI persisting longer than 1 hr were more likely to experience a TIA than those who did not (P = 0.045), but they were no more likely to experience stroke, MI, or death (P > 0.35 for each).
Periprocedural HI occurs frequently during CAS even with prophylactic atropine administration. Although patients experiencing HI were more likely to experience a TIA, its presence is not associated with an increase in stroke, MI, or death.

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^☆: This study was supported by the National Research Service Award 2T32HL07101-21A from the National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland.

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MiscellaneousAcute hemodynamic changes during carotid artery stenting☆

Abstract

Section snippets

Patients

Clinical characteristics

Discussion

Acknowledgements

Am J Cardiol

Lancet

Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis

N Engl J Med

Endarterectomy for asymptomatic carotid artery stenosis

JAMA

Carotid artery stenosistreatment with balloon angioplasty and stent placement

Radiology

Cervical carotid artery stenosiswhich technique, balloon angioplasty or surgery?

J Cardiovasc Surg

Stenting in the carotid arteryinitial experience in 110 patients

J Endovasc Surg

Elective stenting of the extracranial carotid arteries

Circulation

Procedural results and early clinical outcomes after carotid stent-supported angioplasty in high-risk patients (abstr)

J Am Coll Cardiol

Miscellaneous
Acute hemodynamic changes during carotid artery stenting☆