Peri-procedural variables and outcomes of long-period hemodynamic instability after carotid artery angioplasty and stenting

OBJECTIVES

The aim of this study is to identify the peri-procedural risk factors and outcomes of hemodynamic instability (HI) after carotid artery stenting (CAS).

METHODS

A single-center, retrospective study was performed in 168 patients who underwent CAS procedure between September 2017 and September 2020. The presence of HI, as defined by hypertension (systolic blood pressure >160 mmHg), hypotension (systolic blood pressure <90 mmHg), and/or bradycardia (heart rate <60 bpm), was recorded. Long-period HI was defined as persistent HI lasting more than 24 h. Patient demographics, comorbidities, peri-procedural variables, and risk factors were recorded. Clinical outcomes including cerebral hyperperfusion syndrome, hemorrhage, transient ischemic attack (TIA), stroke, myocardial infarction, and mortality within 30 days of the procedure were evaluated. Logistic regression was used to analyze the independent risk factors of long-period HI following CAS.

RESULTS

Among 168 patients (mean age, 68.2 ± 8.3 years; 81.5% male), the frequency of post-procedural long-period HI was noted in 42 patients (25.0%). Male was prone to experience HI (odds ratio, 9.156, p = 0.021). Aggressive inflation pressure (>7 atm) and 5 mm balloon for pre-dilatation were risk factors of long-period HI (OR, 7.372, p = 0.035; OR, 3.527, p = 0.023). Intraoperative peak blood pressure and larger-sized stents remained independent predictors for the development of HI (OR, 1.043, p = 0.027, and OR, 1.973, p = 0.015). Patients with prolonged HI were more likely to suffer TIA and stroke compared to other patients and significant difference was found in the occurrence of TIA (p < 0.05). Non-significance was found in mortality rate and other outcomes.

CONCLUSIONS

CAS-induced HI occurs in a considerable percentage while several peri-procedural variables are determined as independent predictors to develop long-period HI. Patients with prolonged HI are associated with increased risk of neurologic events and thus standardized intervention as well as management of long-period HI are of critical importance during clinical process.

Predictors of hemodynamic instability during and persistent after carotid artery stenting

OBJECTIVES

The risk factors for post-carotid artery stenting severe hemodynamic instability remain elusive. This study aimed to identify the predictors of severe hemodynamic instability during and persisted after carotid artery stenting.

MATERIALS AND METHODS

Consecutive patients who underwent carotid artery stenting for extracranial carotid artery stenosis at a single-center between September 2018 and July 2021 were retrospectively assessed. The predictive factors of severe hemodynamic instability intraoperation and post-operation were analyzed.

RESULTS

Among the 139 patients included, 63 experienced severe hemodynamic instability, with 45 and 18 cases occurring intra and postoperatively, respectively. Persistent was observed in 21 patients. Smoke exposure (odds ratio [OR], 2.38; p=0.039), carotid bifurcation stenosis (OR, 0.91; p=0.018), and large-diameter balloon (>4 mm) dilatation (OR, 11.95; p<0.001) were identified as independent risk factors for hemodynamic instability at any stage of carotid artery stenting. Intraoperatively, large-diameter balloon (>4 mm) dilatation was associated with an increased risk of hemodynamic instability occurrence (OR, 4.67; p=0.01), whereas general anesthesia (OR, 0.19; p=0.001) and a longer distance from the stenosis to the carotid bifurcation (OR, 0.89; p=0.01) were negatively associated with hemodynamic instability. Furthermore, smoking exposure (OR, 3.73; p=0.03), large diameter balloon dilatation (OR, 6.12; p=0.032), distance from stenosis to bifurcation (OR, 0.85; p=0.047) and long-stent (40 mm) implantation (OR, 0.84 [95% confidence interval, 0.74-0.95]; p=0.007) could independently predict persistent hemodynamic instability.

CONCLUSION

Patients with a smoking history, lesions near the carotid bulb, or dilatation using a large-diameter balloon were most likely to suffer severe hemodynamic instability. General anesthesia can protect against severe hemodynamic instability only intraoperatively. Long-term stent implantation may reduce persistent hemodynamic instability.

Incidence and predictors of prolonged hemodynamic depression after carotid artery stenting: Yet another benefit of statins?

OBJECTIVES

We aimed to assess the incidence and predictors of prolonged hemodynamic depression (PHD) after carotid artery stenting (CAS).

METHODS

We retrospectively analyzed data from 216 CAS procedures performed in 207 patients (156 male; median and interquartile range (IQR) of age 68 (62-73) yr) between July 2012 and October 2020. PHD was defined as hypotension (systolic blood pressure ≤ 90 mmHg) and/or bradycardia (heart rate < 60 bpm) lasting >1 h.

RESULTS

The incidence of PHD was 25.9%. At multivariate analysis, asymptomatic lesions (OR: 2.43, 95% CI (1.16-5.06), p: 0.018), the stenosis proximity (<10 mm) to bifurcation (OR: 2.94, 95% CI (1.34-6.43), p: 0.007) and implantation of a Protege stent (OR: 2.93, 95% CI (1.14-7.53), p: 0.025) were independent risk factors, while statin usage (OR: 0.48, 95% CI (0.24-0.95), p: 0.036) was an independent protective factor for PHD after CAS.

CONCLUSIONS

Patients with asymptomatic lesions and stenosis close to the bifurcation are more prone to PHD. The type of the stent selected significantly influences the risk of PHD. Further prospective randomized studies are warranted to investigate the possible protective role of statins against PHD after CAS.

Prolonged Autonomic Fluctuation Derived from Parasympathetic Hypertonia after Carotid Endarterectomy but not Stenting

BACKGROUND

Carotid endarterectomy (CEA) is a standard treatment for carotid artery stenosis, but the incidence after periprocedural myocardial infarction (MI) is not negligible. The mechanism for the higher risk of MI following CEA compared with the carotid artery stenting (CAS) is unclear. We hypothesized that it may be explained by different autonomic nervous responses.

METHODS

This prospective, nonrandomized, observational study enrolled 50 patients from 2 centers: 25 underwent CEA and 25 CAS. Cardiac autonomic nervous activity was evaluated using 24-hour high-resolution ambulatory electrocardiography with parameters such as deceleration capacity (DC) and heart rate variability before the procedure, and at 1 week and 1-3 months after the procedure.

RESULTS

One week after CEA, decreased DC and increased acceleration capacity were recognized. Standard deviation of sequential 5-minute NN interval means and the low-frequency and high-frequency components were all decreased. By the later phase measurement, these changes returned to baseline or beyond. The results suggest that diminished autonomic activity reversed to excessive parasympathetic dominance. In contrast, the patients treated by CAS showed no remarkable autonomic modification in the early or later phases.

CONCLUSIONS

Distinct changes of sympathovagal response observed after CEA coincides with the time at which MI onset occurs, suggesting prolonged autonomic fluctuation may be a factor in the MI incidence after CEA.

Incidence and timing of hypotension after transcervical carotid artery stenting: correlation with postoperative complications

OBJECTIVES

To assess the incidence and timing of hypotension after carotid artery stenting (CAS) and its correlation with postoperative complications.

BACKGROUND

CAS-associated postoperative hypotension has been linked to surgical morbidity and mortality, especially to stroke and cardiac complications.

METHODS

Ninety-seven consecutive patients undergoing transcervical CAS were monitored for at least 12 hr after operation. Hypotension was defined as systolic blood pressure < 90 mm Hg. Patients were divided into three groups: normal blood pressure and early (≤6 hr) and late (>6 hr) hypotension. Complications were recorded.

RESULTS

Hypotension occurred in 34% of the patients (early hypotension in 63% of them). Hypotension was recorded in 21.6% of patients during surgery and in 21.6%, 15.5%, and 1.0% at 6, 12, and 24 hr postoperatively. Bradycardia occurred in 26.8% during operation and in 25.8%, 13.4%, and 10.3% at 6, 12, and 24 hr after surgery. Intraoperative bradycardia (P = 0.01) and hypotension (P = 0.02) were predictors of postoperative hypotension. The overall rate of complications was 5% without differences between the study groups. The mean length of stay was 3, 3.6, and 2.8 days in the normotensive, early hypotension, and late hypotension groups, respectively.

CONCLUSIONS

Most postoperative hypotension episodes occurred within the first 6 hr, and more than one-third between the 6 and 12 hr post-procedure. All patients with late hypotension were asymptomatic. There was no difference in complications between the study groups. In patients undergoing ambulatory CAS, hemodynamic monitoring in the postoperative period is particularly important during the first 12 hr.