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Sezer M, Escaned J, Broyd CJ, Umman B, Bugra Z, Ozcan I, Sonsoz MR, Ozcan A, Atici A, Aslanger E, Sezer ZI, Davies JE, van Royen N, Umman S. Gradual Versus Abrupt Reperfusion During Primary Percutaneous Coronary Interventions in ST‐Segment–Elevation Myocardial Infarction (GUARD). J Am Heart Assoc 2022; 11:e024172. [PMID: 35574948 PMCID: PMC9238546 DOI: 10.1161/jaha.121.024172] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background
Intramyocardial edema and hemorrhage are key pathological mechanisms in the development of reperfusion‐related microvascular damage in ST‐segment–elevation myocardial infarction. These processes may be facilitated by abrupt restoration of intracoronary pressure and flow triggered by primary percutaneous coronary intervention. We investigated whether pressure‐controlled reperfusion via gradual reopening of the infarct‐related artery may limit microvascular injury in patients undergoing primary percutaneous coronary intervention.
Methods and Results
A total of 83 patients with ST‐segment–elevation myocardial infarction were assessed for eligibility and 53 who did not meet inclusion criteria were excluded. The remaining 30 patients with totally occluded infarct‐related artery were randomized to the pressure‐controlled reperfusion with delayed stenting (PCRDS) group (n=15) or standard primary percutaneous coronary intervention with immediate stenting (IS) group (n=15) (intention‐to‐treat population). Data from 5 patients in each arm were unsuitable to be included in the final analysis. Finally, 20 patients undergoing primary percutaneous coronary intervention who were randomly assigned to either IS (n=10) or PCRDS (n=10) were included. In the PCRDS arm, a 1.5‐mm balloon was used to achieve initial reperfusion with thrombolysis in myocardial infarction grade 3 flow and, subsequently, to control distal intracoronary pressure over a 30‐minute monitoring period (MP) until stenting was performed. In both study groups, continuous assessment of coronary hemodynamics with intracoronary pressure and Doppler flow velocity was performed, with a final measurement of zero flow pressure (primary end point of the study) at the end of a 60‐minute MP. There were no complications associated with IS or PCRDS. PCRDS effectively led to lower distal intracoronary pressures than IS over 30 minutes after reperfusion (71.2±9.37 mm Hg versus 90.13±12.09 mm Hg,
P
=0.001). Significant differences were noted between study arms in the microcirculatory response over MP. Microvascular perfusion progressively deteriorated in the IS group and at the end of MP, and hyperemic microvascular resistance was significantly higher in the IS arm as compared with the PCDRS arm (2.83±0.56 mm Hg.s.cm
−1
versus 1.83±0.53 mm Hg.s.cm
−1
,
P
=0.001). The primary end point (zero flow pressure) was significantly lower in the PCRDS group than in the IS group (41.46±17.85 mm Hg versus 76.87±21.34 mm Hg,
P
=0.001). In the whole study group (n=20), reperfusion pressures measured at predefined stages in the early reperfusion period showed robust associations with zero flow pressure values measured at the end of the 1‐hour MP (immediately after reperfusion:
r
=0.782,
P
<0.001; at the 10th minute:
r
=0.796,
P
<0.001; and at the 20th minute:
r
=0.702,
P
=0.001) and peak creatine kinase MB level (immediately after reperfusion:
r
=0.653,
P
=0.002; at the 10th minute:
r
=0.597,
P
=0.007; and at the 20th minute:
r
=0.538,
P
=0.017). Enzymatic myocardial infarction size was lower in the PCRDS group than in the IS group with peak troponin T (5395±2991 ng/mL versus 8874±1927 ng/mL,
P
=0.006) and creatine kinase MB (163.6±93.4 IU/L versus 542.2±227.4 IU/L,
P
<0.001).
Conclusions
In patients with ST‐segment–elevation myocardial infarction, pressure‐controlled reperfusion of the culprit vessel by means of gradual reopening of the occluded infarct‐related artery (PCRDS) led to better‐preserved coronary microvascular integrity and smaller myocardial infarction size, without an increase in procedural complications, compared with IS.
Registration
URL:
https://www.clinicaltrials.gov
; Unique identifier: NCT02732080.
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Affiliation(s)
- Murat Sezer
- Department of Cardiology Istanbul Faculty of Medicine Istanbul University Istanbul Turkey
- Acibadem International Hospital Istanbul Turkey
| | - Javier Escaned
- Hospital Clínico San CarlosInstituto de Investigación Sanitaria San CarlosUniversidad Complutense de Madrid Madrid Spain
| | | | - Berrin Umman
- Department of Cardiology Istanbul Faculty of Medicine Istanbul University Istanbul Turkey
| | - Zehra Bugra
- Department of Cardiology Istanbul Faculty of Medicine Istanbul University Istanbul Turkey
| | - Ilke Ozcan
- Department of Cardiovascular Medicine Mayo Clinic Rochester MN
| | - Mehmet Rasih Sonsoz
- Department of Cardiology Istanbul Faculty of Medicine Istanbul University Istanbul Turkey
| | - Alp Ozcan
- Department of Cardiology Istanbul Faculty of Medicine Istanbul University Istanbul Turkey
| | - Adem Atici
- Department of Cardiology Istanbul Faculty of Medicine Istanbul University Istanbul Turkey
| | - Emre Aslanger
- Marmara UniversitySchool of Medicine Istanbul Turkey
| | | | - Justin E. Davies
- Hammersmith Hospital Imperial College London London United Kingdom
| | | | - Sabahattin Umman
- Department of Cardiology Istanbul Faculty of Medicine Istanbul University Istanbul Turkey
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Luther E, Swafford E, Saini V, King H, Burks J, Jamshidi A, Silva M, Starke R. Transient ipsilateral mydriasis following carotid artery stenting. Br J Neurosurg 2021:1-4. [PMID: 34553660 DOI: 10.1080/02688697.2021.1981241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 07/30/2021] [Accepted: 09/12/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND AND IMPORTANCE One of the most feared and devastating complications of carotid revascularization procedures is hyperperfusion hemorrhage. The acute onset of an ipsilateral mydriatic pupil following carotid endarterectomy (CEA) or carotid artery stenting (CAS) should prompt immediate neurosurgical evaluation to rule out hyperperfusion injury. CLINICAL PRESENTATION We describe a case of benign, transient ipsilateral mydriasis following CAS. After undergoing right common and internal carotid artery (ICA) angioplasty and stenting with distal embolic protection, the patient developed anisocoria with a right-sided 5 mm minimally reactive pupil. Imaging demonstrated no acute pathology, and the mydriasis resolved spontaneously within 48 hours. We hypothesise that the pathophysiologic mechanism is secondary to transient ischemia of parasympathetic structures within the petrous/cavernous ICA from arterial ostium occlusion that occurred during device placement. Alternatively, sympathetic stimulation during angioplasty is also plausible. CONCLUSIONS Although an ipsilateral mydriatic pupil following carotid revascularization necessitates evaluation, it may represent a self-limiting process especially in the absence of other focal neurologic deficits.
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Affiliation(s)
- Evan Luther
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Emily Swafford
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Vasu Saini
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Hunter King
- Drexel University College of Medicine, Philadelphia, PA, USA
| | - Joshua Burks
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Aria Jamshidi
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Michael Silva
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Robert Starke
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
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Leclerc A, Goia A, Gilard V, Derrey S, Curey S. Massive non-aneurysmal subarachnoid hemorrhage after cervical carotid angioplasty and stenting: a case report and review of the literature. Neurochirurgie 2021; 68:342-346. [PMID: 33895172 DOI: 10.1016/j.neuchi.2021.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 03/20/2021] [Accepted: 04/07/2021] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Carotid angioplasty and stenting (CAS) of the cervical segment is a safe and effective procedure for the treatment of carotid artery disease. In rare cases, this procedure causes intracranial hemorrhage (ICH), which is described most often as an ipsilateral intra-parenchymal hematoma. This ICH is the result of a cerebral hyperperfusion syndrome (CHS). Isolated subarachnoid hemorrhage may occur exceptionally, with only 9 cases that have been reported in the literature. OBSERVATION We reported a case of a 71-year-old man who presented a massive non-aneurysmal subarachnoid hemorrhage one hour after angioplasty and stenting of the cervical segment of the left internal carotid artery. Medical and surgical management included external ventricular drain placement. Rebleeding occurred two days later, worsening the patient's clinical condition. Finally, the patient died 2 weeks later. COMMENTS This rare presentation of ICH following CAS allows us to discuss the risk factors, complications and management of CHS.
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Affiliation(s)
- A Leclerc
- CHU de Caen, Department of Neurosurgery, Avenue de la Côte de Nacre, 14000 Caen, France; Université Caen Normandie, Medical School, 14000 Caen, France.
| | - A Goia
- CHU de Rouen, Department of Neurosurgery, 76000 Rouen, France; Université Rouen Normandie, Medical School, 76000 Rouen, France
| | - V Gilard
- CHU de Rouen, Department of Neurosurgery, 76000 Rouen, France; Université Rouen Normandie, Medical School, 76000 Rouen, France
| | - S Derrey
- CHU de Rouen, Department of Neurosurgery, 76000 Rouen, France; Université Rouen Normandie, Medical School, 76000 Rouen, France
| | - S Curey
- CHU de Rouen, Department of Neurosurgery, 76000 Rouen, France
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Zhou Y, Zheng C, Chen L, Lin Y. Fatal intracranial hemorrhage after carotid artery stenting: Three case reports and a literature review. J Int Med Res 2020; 48:300060520937576. [PMID: 32806982 PMCID: PMC7436830 DOI: 10.1177/0300060520937576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION We herein describe three patients who developed fatal intracranial hemorrhage (ICH) after carotid artery stenting (CAS).Case Presentation: We retrospectively reviewed 126 patients who underwent CAS from January 2016 to December 2018 and identified 3 patients (2.4%) (all male, mean age of 59 years) who developed ICH after CAS. Two of them developed left basal ganglia hemorrhage with extension into the ventricle and subarachnoid space, and the third patient developed primary ventricular bleeding. One hemorrhage occurred immediately after CAS, whereas the other two occurred 3 hours and 8 hours after the procedure, respectively. The mean stenosis of the treated carotid arteries was 91%. All three hemorrhages were fatal, and the mean time from hemorrhage to death was 50 hours. CONCLUSION ICH is a potentially fatal complication of CAS and often occurs several hours after the procedure. Headache, vomiting, and consciousness disorders are the most common symptoms of ICH. Careful screening to identify high-risk patients and strict management of perioperative blood pressure are important to prevent this complication.
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Affiliation(s)
- Yumiao Zhou
- Neurointerventional Department, Zhejiang Hospital, Hangzhou, China
| | - Chaobo Zheng
- Neurointerventional Department, Zhejiang Hospital, Hangzhou, China
| | - Liang Chen
- Neurointerventional Department, Zhejiang Hospital, Hangzhou, China
| | - Yuanyuan Lin
- Internal Medicine Department, Zhejiang Greentown Cardiovascular Hospital, Hangzhou, China
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Sezer M, van Royen N, Umman B, Bugra Z, Bulluck H, Hausenloy DJ, Umman S. Coronary Microvascular Injury in Reperfused Acute Myocardial Infarction: A View From an Integrative Perspective. J Am Heart Assoc 2019; 7:e009949. [PMID: 30608201 PMCID: PMC6404180 DOI: 10.1161/jaha.118.009949] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Murat Sezer
- 1 Istanbul Faculty of Medicine Istanbul University Istanbul Turkey
| | | | - Berrin Umman
- 1 Istanbul Faculty of Medicine Istanbul University Istanbul Turkey
| | - Zehra Bugra
- 1 Istanbul Faculty of Medicine Istanbul University Istanbul Turkey
| | - Heerajnarain Bulluck
- 3 The Hatter Cardiovascular Institute Institute of Cardiovascular Science University College London London United Kingdom.,4 Papworth Hospital NHS Trust Cambridge United Kingdom
| | - Derek J Hausenloy
- 3 The Hatter Cardiovascular Institute Institute of Cardiovascular Science University College London London United Kingdom.,4 Papworth Hospital NHS Trust Cambridge United Kingdom.,5 National Heart Research Institute Singapore National Heart Centre Singapore Singapore.,6 Cardiovascular and Metabolic Disorders Program Duke-National University of Singapore Singapore.,7 Yong Loo Lin School of Medicine National University Singapore Singapore.,8 The National Institute of Health Research University College London Hospitals Biomedical Research Centre London United Kingdom.,9 Barts Heart Centre St Bartholomew's Hospital London United Kingdom
| | - Sabahattin Umman
- 1 Istanbul Faculty of Medicine Istanbul University Istanbul Turkey
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Rhim JK, Jeon JP, Park JJ, Choi HJ, Cho YD, Sheen SH, Jang KS. Prediction of Prolonged Hemodynamic Instability During Carotid Angioplasty and Stenting. Neurointervention 2016; 11:120-6. [PMID: 27621949 PMCID: PMC5018548 DOI: 10.5469/neuroint.2016.11.2.120] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Accepted: 08/25/2016] [Indexed: 11/24/2022] Open
Abstract
Purpose The aim of this study was to assess the risk factors of prolonged hemodynamic instability (HDI) after carotid angioplasty and stenting (CAS). Herein, a simplified predictive scoring system for prolonged HDI is proposed. Materials and Methods Sixty-six patients who had CAS from 2011 to 2016 at a single institution were evaluated. Prolonged HDI was defined as systolic blood pressure >160 mm Hg or <90 mm Hg or heart rate <50 beats/min, lasting over 30 minutes despite medical treatments. For the study, clinical data and radiologic data, including plaque morphology and stenosis were analyzed. Results Prolonged HDI was observed in 21 patients (31.8%). Multivariable analysis revealed that calcification (OR, 6.726; p=0.006), eccentric stenosis (OR, 3.645; p=0.047) and extensive plaque distribution (OR, 7.169; p=0.006) were related to prolonged HDI. According to these results, a simplified scoring scale was proposed based on the summation of points: 2 points for calcified plaque, 2 points for extensive plaque distribution, and 1 point for eccentric stenosis. The percentages of prolonged HDI according to the total score were as follows: score 0, 8.7%; score 1, 20.0%; score 2, 38.5%; score 3, 72.7%; score 4, 66.7%; score 5, 100%. From the analysis, the total score in patients with prolonged HDI was significantly higher than those without prolonged HDI (p<0.001). Conclusion Prolonged HDI can be associated with calcification of plaque, eccentric stenosis and extensive plaque distribution, and a simplified scoring system enables prediction of prolonged HDI according to our cohort.
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Affiliation(s)
- Jong Kook Rhim
- Department of Neurosurgery, Jeju National University College of Medicine, Jeju, Korea
| | - Jin Pyeong Jeon
- Department of Neurosurgery, Hallym University College of Medicine, Chuncheon, Korea
| | - Jeong Jin Park
- Department of Neurology, Konkuk University College of Medicine, Seoul, Korea
| | - Hyuk Jai Choi
- Department of Neurosurgery, Hallym University College of Medicine, Chuncheon, Korea
| | - Young Dae Cho
- Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
| | - Seung Hun Sheen
- Department of Neurosurgery, Bundang Jesaeng Hospital, Bundang, Korea
| | - Kyung-Sool Jang
- Department of Neurosurgery, Catholic University College of Medicine, Incheon, Korea
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Okamura A, Nakaoka M, Ohbayashi N, Yahara K, Nabika S. Intraoperative idiopathic subarachnoid hemorrhage during carotid artery stenting: A case report and literature review. Interv Neuroradiol 2015; 21:592-7. [PMID: 26184053 DOI: 10.1177/1591019915594332] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Carotid artery stenting (CAS) has a fatal complication of intracranial hemorrhage (ICH) associated with cerebral hyperperfusion syndrome (CHS), i.e. brain hemorrhage and subarachnoid hemorrhage (SAH). Although SAH accounts for a small percentage of these patients, it is difficult to make a differential diagnosis of this syndrome from CHS without ICH because the clinical presentations resemble each other. Furthermore, not only does the cause of SAH following CAS remain unclear but also the role of controlling postoperative blood pressure is not detected in preventing ICH after CAS. Herein, we report a case of SAH following CAS and review previous literature to discuss the mechanism and the management of this fatal complication. A 78-year-old woman with a history of arteriosclerotic obliteration and myocardial infarction was referred to our department for intervention to asymptomatic severe stenosis of the right internal carotid artery. We performed CAS under local anesthesia. Although her blood pressure was controlled to normotension during the procedure, the patient complained of headache following predilation. Postoperative emergent non-contrast computed tomography revealed SAH with leakage of contrast medium occupying the right sylvian fissure. We continued strict blood pressure control, and the patient was discharged without any neurological deficit. A well-opened lumen of the stent was recognized three months later at the outpatient visit. Strict control of intraoperative and postoperative blood pressure may improve the outcome of SAH following CAS though the role in preventing ICH after CAS is unclear.
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Affiliation(s)
- Akitake Okamura
- Department of Neurosurgery, Matsue Red Cross Hospital, Japan
| | - Mitsuo Nakaoka
- Department of Neurosurgery, Matsue Red Cross Hospital, Japan
| | | | - Kaita Yahara
- Department of Neurosurgery, Matsue Red Cross Hospital, Japan
| | - Shinya Nabika
- Department of Neurosurgery, Matsue Red Cross Hospital, Japan
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Faught RWF, Satti SR, Hurst RW, Pukenas BA, Smith MJ. Heterogeneous practice patterns regarding antiplatelet medications for neuroendovascular stenting in the USA: a multicenter survey. J Neurointerv Surg 2014; 6:774-9. [DOI: 10.1136/neurintsurg-2013-010954] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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9
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Clark WM, Brott TG. Intracranial hemorrhage complicating carotid artery stenting and carotid endarterectomy. Stroke 2011; 42:2720-1. [PMID: 21836086 DOI: 10.1161/strokeaha.111.626788] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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