Periprocedural Hemodynamic Depression Is Associated With a Higher Number of New Ischemic Brain Lesions After Stenting in the International Carotid Stenting Study-MRI Substudy

Abstract

In patients with symptomatic carotid artery stenosis, carotid artery stenting (CAS) is associated with a higher risk of periprocedural stroke than carotid endarterectomy (CEA). 1Patients treated by CAS also more frequently have new ischemic lesions on post-treatment MRI scans with diffusionweighted imaging (DWI). 2 The cause of the higher risk of new cerebral ischemia early after CAS compared with CEA is uncertain.Embolism from the carotid artery plaque during stent deployment or arterial dissection is generally held responsible for the majority of new ischemic lesions during carotid revascularization. During CAS and CEA, cerebral microembolic signals are often detected with transcranial Doppler. 3A high frequency of these signals has been associated with a higher risk of stroke, 4 but the majority of the underlying emboli do not lead to cerebral ischemia.5 It has been proposed that under circumstances of a normal cerebral perfusion, most of these emboli are cleared by the cerebral circulation and that hypoperfusion increases the risk of a focal ischemic lesion. This is supported by a study that showed that patients with impaired perfusion in the hemisphere ipsilateral to the carotid artery stenosis before stenting had more ischemic lesions Background and Purpose-Carotid artery stenting (CAS) is associated with a higher risk of both hemodynamic depression and new ischemic brain lesions on diffusion-weighted imaging than carotid endarterectomy (CEA). We assessed whether the occurrence of hemodynamic depression is associated with these lesions in patients with symptomatic carotid stenosis treated by CAS or CEA in the randomized International Carotid Stenting Study (ICSS)-MRI substudy. Methods-The number and total volume of new ischemic lesions on diffusion-weighted imaging 1 to 3 days after CAS or CEA was measured in the ICSS-MRI substudy. Hemodynamic depression was defined as periprocedural bradycardia, asystole, or hypotension requiring treatment. The number of new ischemic lesions was the primary outcome measure. We calculated risk ratios and 95% confidence intervals per treatment with Poisson regression comparing the number of lesions in patients with or without hemodynamic depression. Results-A total of 229 patients were included (122 allocated CAS; 107 CEA). After CAS, patients with hemodynamic depression had a mean of 13 new diffusion-weighted imaging lesions, compared with a mean of 4 in those without hemodynamic depression (risk ratio, 3.36; 95% confidence interval, 1.73-6.50). The number of lesions after CEA was too small for reliable analysis. Lesion volumes did not differ between patients with or without hemodynamic depression. Conclusions-In

Upper Extremity Blood Pressure Difference in Patients Undergoing Carotid Revascularisation

“…In patients treated by CAS, peri-procedural haemodynamic depression was associated with an excess of new ischaemic brain lesions. 2,15 A further detailed analysis of procedural strokes in this randomized trial showed that one third of procedural strokes were caused by peri-procedural haemodynamic disturbances, suggesting that careful attention to blood pressure control could further lower the risk of this procedural complication. 14 In this context it is interest to note that in our study, all patients with procedural strokes caused by hyperperfusion, were known to have a SBP difference.…”

How Recent Data Have Impacted the Treatment of Internal Carotid Artery Stenosis

“…For CAS, in addition to the hazards of Another procedure-specific hazard of CAS is periprocedural bradycardia or hypotension. In some instances, bradycardia or hypotension can be prolonged and lead to intensive care unit admission and increased periprocedural morbidity (25). Hypotension can also follow CEA in up to 12% to 27% of patients (26,27).…”

Endovascular Treatment of Carotid Atherosclerosis: Concerns and Perspectives

“…В этом исследовании впервые было показано, что новые ишемические изменения стати-стически значимо чаще встречаются у пациентов с ИБС (37% против 13%). Риск развития эмболических осложнений также увеличивается при развитии пери-и послеоперационной гипотензии, что позволяет об-суждать роль гипоперфузии в увеличении восприим-чивости мозга к эмболии и гемодинамическое про-исхождение ишемических очагов, особенно при их ло-кализации в зонах смежного кровообращения [69]. Ишемические изменения на МРТ в режиме DWI вы-являются у 15% пациентов со стабильной и у 32% боль-ных с нестабильной гемодинамикой, что требует рас-смотрения вопроса о тактике гипотензивной и инфу-зионной терапии в периоперационный период [70].…”