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Prolonged hypotension after carotid artery stenting: incidence, predictors and consequences

  • Original Article - Vascular
  • Published:
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Abstract

Background

Hemodynamic changes frequently occur after carotid artery stenting (CAS), and in some patients these changes, particularly hypotension, may be prolonged. There are discrepant results for predicting patients at high risk for these prolonged hemodynamic changes and identifying the effect on clinical outcome. In this study, we aimed to determine the frequency, predictors and consequences associated with prolonged hypotension (PH) after CAS in our center.

Methods

We retrospectively analyzed the demographics, risk factors, nature of carotid disease, degree of stenosis of both internal carotid arteries, stent diameter and site of dilatation during stenting in 137 CAS procedures. After CAS, duration of hospital stay, complications during hospital stay and major vascular events or death in a 3-month period were evaluated. PH was defined as a systolic blood pressure <90 mmHg lasting more than 1 h despite adequate treatment after CAS.

Results

PH occured in 23 (16.8%) patients. The presence of contralateral stenosis ≥70% and absence of diabetes mellitus were significantly associated with PH. Duration of hospital stay was significantly longer in patients with PH. No patients with PH had a periprocedural complication or major vascular events in the follow-up period.

Conclusion

PH was more prevalent in patients with contralateral high-degree carotid stenosis and patients without diabetes mellitus after CAS. PH did not cause any post-procedural complications or major vascular events at follow-up, but it resulted longer hospital stays. Further studies are needed to better define the pathophysiologic mechanisms underlying these hemodynamic alterations.

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References

  1. Acampa M, Guideri F, Marotta G, Tassi R, D’Andrea P, Giudice GL, Gistri M, Rocchi R, Bernardi A, Bracco S, Venturi C, Martini G (2011) Autonomic activity and baroreflex sensitivity in patients submitted to carotid stenting. Neurosci Lett 491:221–226. doi:10.1016/j.neulet.2011.01.044

    Article  CAS  PubMed  Google Scholar 

  2. Borhani Haghighi A, Kokabi S, Yousefi S, Emami M, Shariat A, Nikseresht A, Ashjazadeh N, Izadi S, Petramfar P, Poursadegh M, Jaberi AR, Emami S, Agheli H, Nemati R, Yaghoubi E, Kashani K, Panahandeh M, Heidari-Khormizi SM, Cruz-Flores S, Edgell R (2015) The prevalence and factors contributing to hemodynamic depression in patients undergoing carotid angioplasty and stenting. J Vasc Interv Neurol 8:5–10

    PubMed  Google Scholar 

  3. Bradac O, Mohapl M, Kramar F, Netuka D, Ostry S, Charvat F, Lacman J, Benes V (2014) Carotid endarterectomy and carotid artery stenting: changing paradigm during 10 years in a high-volume centre. Acta Neurochir 156:1705–1712. doi:10.1007/s00701-014-2166-x

    Article  CAS  PubMed  Google Scholar 

  4. Dangas G, Laird JR Jr, Satler LF, Mehran R, Mintz GS, Larrain G, Lansky AJ, Gruberg L, Parsons EM, Laureno R, Monsein LH, Leon MB (2000) Postprocedural hypotension after carotid artery stent placement: predictors and short- and long-term clinical outcomes. Radiology 215:677–683. doi:10.1148/radiology.215.3.r00jn04677

    Article  CAS  PubMed  Google Scholar 

  5. Demirci M, Saribas O, Uluc K, Cekirge S, Boke E, Ay H (2006) Carotid artery stenting and endarterectomy have different effects on heart rate variability. J Neurol Sci 241:45–51. doi:10.1016/j.jns.2005.10.011

    Article  PubMed  Google Scholar 

  6. Dimitropoulos G, Tahrani AA, Stevens MJ (2014) Cardiac autonomic neuropathy in patients with diabetes mellitus. World J Diabetes 5:17–39. doi:10.4239/wjd.v5.i1.17

    Article  PubMed  PubMed Central  Google Scholar 

  7. Gupta R, Abou-Chebl A, Bajzer CT, Schumacher HC, Yadav JS (2006) Rate, predictors, and consequences of hemodynamic depression after carotid artery stenting. J Am Coll Cardiol 47:1538–1543. doi:10.1016/j.jacc.2005.08.079

    Article  PubMed  Google Scholar 

  8. Gupta R, Horowitz M, Jovin TG (2005) Hemodynamic instability after carotid artery angioplasty and stent placement: a review of the literature. Neurosurg Focus 18:e6

    Article  PubMed  Google Scholar 

  9. Kiani H, Haghighi A, Rostami A, Azargashb E, Tabaei SJ, Solgi A, Zebardast N (2016) Prevalence, risk factors and symptoms associated to intestinal parasite infections among patients with gastrointestinal disorders in Nahavand, western Iran. Rev Inst Med Trop Sao Paulo 58:42. doi:10.1590/S1678-9946201658042

    Article  PubMed  PubMed Central  Google Scholar 

  10. Leisch F, Kerschner K, Hofmann R, Steinwender C, Grund M, Bibl D, Leisch FA Jr, Bergmann H (2003) Carotid sinus reactions during carotid artery stenting: predictors, incidence, and influence on clinical outcome. Catheter Cardiovasc Interv 58:516–523. doi:10.1002/ccd.10483

    Article  PubMed  Google Scholar 

  11. Lian X, Lin M, Liu M, Huang J, He X (2014) Complications and predictors associated with persistent hemodynamic depression after carotid artery stenting. Clin Neurol Neurosurg 124:81–84. doi:10.1016/j.clineuro.2014.06.008

    Article  PubMed  Google Scholar 

  12. Lian X, Lin M, Zhu S, Liu W, Li M, Sun W, Yin Q, Xu G, Zhang R, Liu X (2011) Risk factors associated with haemodynamic depression during and after carotid artery stenting. J Clin Neurosci 18:1325–1328. doi:10.1016/j.jocn.2011.01.030

    Article  PubMed  Google Scholar 

  13. Lin PH, Zhou W, Kougias P, El Sayed HF, Barshes NR, Huynh TT (2007) Factors associated with hypotension and bradycardia after carotid angioplasty and stenting. J Vasc Surg 46:846–853; discussion 853-844. doi:10.1016/j.jvs.2007.07.020

    Article  PubMed  Google Scholar 

  14. Mancia G, Ferrari A, Gregorini L, Parati G, Ferrari MC, Pomidossi G, Zanchetti A (1979) Control of blood pressure by carotid sinus baroreceptors in human beings. Am J Cardiol 44:895–902

    Article  CAS  PubMed  Google Scholar 

  15. McKevitt FM, Sivaguru A, Venables GS, Cleveland TJ, Gaines PA, Beard JD, Channer KS (2003) Effect of treatment of carotid artery stenosis on blood pressure: a comparison of hemodynamic disturbances after carotid endarterectomy and endovascular treatment. Stroke 34:2576–2581. doi:10.1161/01.STR.0000097490.88015.3A

    Article  CAS  PubMed  Google Scholar 

  16. Mlekusch W, Schillinger M, Sabeti S, Nachtmann T, Lang W, Ahmadi R, Minar E (2003) Hypotension and bradycardia after elective carotid stenting: frequency and risk factors. J Endovasc Ther 10:851–859; discussion 860-851. doi:10.1583/1545-1550(2003)010%3C0851:HABAEC%3E2.0.CO;2

    Article  PubMed  Google Scholar 

  17. Mylonas SN, Moulakakis KG, Antonopoulos CN, Kakisis JD, Liapis CD (2013) Carotid artery stenting-induced hemodynamic instability. J Endovasc Ther 20:48–60. doi:10.1583/12-4015.1

    Article  PubMed  Google Scholar 

  18. Nonaka T, Oka S, Miyata K, Mikami T, Koyanagi I, Houkin K, Yoshifuji K, Imaizumi T (2005) Prediction of prolonged postprocedural hypotension after carotid artery stenting. Neurosurgery 57:472–477 discussion 472-477

    Article  PubMed  Google Scholar 

  19. North American Symptomatic Carotid Endarterectomy Trial (1991) Methods, patient characteristics, and progress. Stroke 22:711–720

    Article  Google Scholar 

  20. Nouraei SA, Al-Rawi PG, Sigaudo-Roussel D, Giussani DA, Gaunt ME (2005) Carotid endarterectomy impairs blood pressure homeostasis by reducing the physiologic baroreflex reserve. J Vasc Surg 41:631–637. doi:10.1016/j.jvs.2005.01.009

    Article  PubMed  Google Scholar 

  21. Pappada G, Beghi E, Marina R, Agostoni E, Cesana C, Legnani F, Parolin M, Petri D, Sganzerla EP (2006) Hemodynamic instability after extracranial carotid stenting. Acta Neurochir 148:639–645. doi:10.1007/s00701-006-0752-2

    Article  CAS  PubMed  Google Scholar 

  22. Park BD, Divinagracia T, Madej O, McPhelimy C, Piccirillo B, Dahn MS, Ruby S, Menzoian JO (2009) Predictors of clinically significant postprocedural hypotension after carotid endarterectomy and carotid angioplasty with stenting. J Vasc Surg 50:526–533. doi:10.1016/j.jvs.2009.05.005

    Article  PubMed  Google Scholar 

  23. Qazi U, Obeid TE, Enwerem N, Schneider E, White JR, Freischlag JA, Perler BA, Malas MB (2014) The effect of ballooning following carotid stent deployment on hemodynamic stability. J Vasc Surg 59:756–760. doi:10.1016/j.jvs.2013.09.027

    Article  PubMed  Google Scholar 

  24. Qureshi AI, Luft AR, Sharma M, Janardhan V, Lopes DK, Khan J, Guterman LR, Hopkins LN (1999) Frequency and determinants of postprocedural hemodynamic instability after carotid angioplasty and stenting. Stroke 30:2086–2093

    Article  CAS  PubMed  Google Scholar 

  25. Rowaiye OO, Jankowska EA, Ponikowska B (2013) Baroreceptor sensitivity and diabetes mellitus. Cardiol J 20:453–463. doi:10.5603/CJ.2013.0130

    Article  PubMed  Google Scholar 

  26. Ruiz J, Monbaron D, Parati G, Perret S, Haesler E, Danzeisen C, Hayoz D (2005) Diabetic neuropathy is a more important determinant of baroreflex sensitivity than carotid elasticity in type 2 diabetes. Hypertension 46:162–167. doi:10.1161/01.HYP.0000169053.14440.7d

    Article  CAS  PubMed  Google Scholar 

  27. Taha MM, Toma N, Sakaida H, Hori K, Maeda M, Asakura F, Fujimoto M, Matsushima S, Taki W (2008) Periprocedural hemodynamic instability with carotid angioplasty and stenting. Surg Neurol 70:279–285; discussion 285-276. doi:10.1016/j.surneu.2007.07.006

    Article  PubMed  Google Scholar 

  28. Trocciola SM, Chaer RA, Lin SC, Ryer EJ, De Rubertis B, Morrissey NJ, McKinsey J, Kent KC, Faries PL (2006) Analysis of parameters associated with hypotension requiring vasopressor support after carotid angioplasty and stenting. J Vasc Surg 43:714–720. doi:10.1016/j.jvs.2005.12.008

    Article  PubMed  Google Scholar 

  29. Ullery BW, Nathan DP, Shang EK, Wang GJ, Jackson BM, Murphy EH, Fairman RM, Woo EY (2013) Incidence, predictors, and outcomes of hemodynamic instability following carotid angioplasty and stenting. J Vasc Surg 58:917–925. doi:10.1016/j.jvs.2012.10.141

    Article  PubMed  Google Scholar 

  30. Wu TY, Ham SW, Katz SG (2015) Predictors and consequences of hemodynamic instability after carotid artery stenting. Ann Vasc Surg 29:1281–1285. doi:10.1016/j.avsg.2015.03.035

    Article  PubMed  Google Scholar 

  31. Yakhou L, Constant I, Merle JC, Laude D, Becquemin JP, Duvaldestin P (2006) Noninvasive investigation of autonomic activity after carotid stenting or carotid endarterectomy. J Vasc Surg 44:472–479. doi:10.1016/j.jvs.2006.06.004

    Article  PubMed  Google Scholar 

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Acknowledgements

E.G. provided the concept, literature search, analysis and writing of the manuscript. E.N. provided the data collection design and processing. V.G. and Ç.D. provided technical help. T.A. provided critical review and supervision. M.E and Ö.G. provided general support.

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Authors and Affiliations

  1. Neurology Department, Bezmialem Vakıf University, İstanbul, Turkey

    Elif Gökçal, Elvin Niftaliyev, Çiğdem Deniz, Vildan Güzel & Talip Asil

  2. Cardiology Department, Bezmialem Vakıf University, İstanbul, Turkey

    Mehmet Ergelen & Ömer Göktekin

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  1. Elif Gökçal
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Corresponding author

Correspondence to Elif Gökçal.

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The authors declare that no funding was received for this research.

Conflict of interest

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Human and animal rights and informed consent

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

For this retrospective study, formal consent is not required.

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Comments

This was a retrospective study to determine the incidence of and factors contributing to and eventual clinical relevance of prolonged hypotension (PH) in the setting of carotid artery stenting. The utilized definition for PH, defined as a systolic blood pressure <90 mmHg lasting more than 1 h despite adequate treatment, is consistent with the previous literature parameters. The authors determined that PH was significantly associated with >70% contralateral stenosis and with the absence of DM. Although there were no post-procedural complications or major vascular events at follow-up, PH was associated with longer hospital stays.

There is controversy in the literature regarding the cardiovascular sequelae after hemodynamic instability surrounding carotid artery stenting. The authors postulate that baroreceptor reflex sensitivity and reserve (and its role in the physiologic mechanism behind why PH occurs) may be more likely in patients with contralateral stenosis and in non-diabetics. Similar findings have been shown for patients with CEA. Despite the modest sample size of this study, examining this problem in CAS patients as well is worthwhile.

This is an interesting and scholarly analysis and observation. There is much more we still need to understand. The most encouraging finding in this study is that with good care and assiduous management, prolonged postoperative hypotension does not lead to worsened outcomes.

Anand Kaul

Christopher M. Loftus

Philadelphia, PA, USA

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Gökçal, E., Niftaliyev, E., Deniz, Ç. et al. Prolonged hypotension after carotid artery stenting: incidence, predictors and consequences. Acta Neurochir 159, 2081–2087 (2017). https://doi.org/10.1007/s00701-017-3295-9

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  • DOI: https://doi.org/10.1007/s00701-017-3295-9

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