Complications and predictors associated with persistent hemodynamic depression after carotid artery stenting

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Abstract

We aimed to investigate the complications and predictors associated with persistent hemodynamic depression (PHD) after carotid artery stenting (CAS). A total of 204 patients undergoing CAS in two centers between January 2011 and November 2013 were enrolled for study into two cohorts: PHD (systolic blood pressure <90 mm Hg and heart beat rate <60/min, which lasted more than 1 h) and non-PHD according to their periprocedure detections. The complications were recorded and compared between the two groups. The predictors of PHD were analyzed by univariate analysis and logistic regression model. 43 patients developed PHD, which lasted for 17.22 h on average. The complications occurred in 9 patients of PHD group (angina pectoris 2, myocardial infarction 1, cerebral infarction 3, transient ischemic attack 2 and intestinal obstruction 1), which was significantly more than non- PHD group (angina pectoris 1, cerebral infarction 1, transient ischemic attack 5, p = 0.001). Regression analysis revealed that diabetes, severe calcified plaque and a balloon dilation pressure of more than 8 atmospheres (atm) were the independent predictors for PHD after CAS. We concluded that PHD may be related to increased complications of CAS. Patients with diabetes, more severe calcified plaque and more balloon dilation pressure are more prone to develop PHD after CAS.

Introduction

Hemodynamic depression (HD), which includes hypotension and bradycardia, is a frequent phenomenon during and after carotid artery stenting (CAS) [1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15]. A recent review reported that the frequency of HD was 7.2–80% [1]. At present, many studies reported that HD was a process of CAS and did not significantly increase the periprocedural complications [1], [5], [11], [13], [15]. But in several large sample studies, persistent HD (PHD, defined as HD lasting more than 1 h, in spite of treating with fluid or vasoactive agent) was associated with more ischemic events, such as stroke and/or myocardial infarction (MI) [4], [10], [12]. So far, only a few studies analyzed the predictors associated with PHD [4], [7], which reported the effect of clinical and vascular morphologic variables on PHD. We presumed that surgical factors may also affect the occurrence of PHD. Through study, this article reported the complications associated with PHD and further analyzed the predictors associated with PHD based on clinical, vascular morphologic and surgical factors. The definition of HD adopted in this study is the most popular definition: systolic blood pressure <90 mm Hg and heart beat rate <60/min [1], [4], [9], [12], [15], [16], [17], [18], [19], [20], [21].

Section snippets

Subjects and methods

We retrospectively analyzed 204 consecutive patients with carotid stenosis treated with CAS between January 2011 and November 2013 in Department of Neurology of the Third Affiliated Hospital of Soochow University and Dongfang Hospital. The inclusion criteria of patients who underwent CAS were symptomatic carotid stenosis >50% and asymptomatic >70%, and >45 years of age. Exclusion criteria were the following: thrombocytopenia (<100 × 109/L), leukopenia (<4 × 109/L), neutropenia, cerebral hemorrhage

Results

Of the total 204 patients, 139 were male and 65 were female. The mean age was 64.45 ± 8.84 years old. All of the patients had successful treatment of the carotid lesion by angioplasty and/or stenting. 34 patients received a simultaneous bilateral stenting. Out of 204 patients, 43 developed PHD (21.08%). In PHD group, the complications occurred in 9 patients (angina pectoris 2, MI 1, cerebral infarction (CI) 3, transient ischemic attack (TIA) 2 and intestinal obstruction 1), which was

Discussion

As one of the most frequent adverse events triggered by CAS during and after the procedure, HD was previously thought to be triggered by the baroreceptors in the carotid sinus. When carotid sinus baroreceptors are dilated and expanded by the balloon or stents, the impulses from the baroreceptors translate to the nucleus tractus solitarius in the medulla. Stimulation from the nucleus tractus solitarius travels to the peripheral vascular, inhibits vessel construction, and ultimately leads to a

Conclusion

PHD may result in more clinical events after CAS. The patients with diabetes, more severe calcified plaque and more balloon dilation pressure are easier to develop PHD after CAS.

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    These authors contributed equally to this work and share first authorship.

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