Complications and Predictors of Hypotension Requiring Vasopressor after Carotid Artery Stenting

Abstract

A significant controversy exists regarding the clinical impact of hemodynamic depression on major adverse events after carotid artery stenting (CAS). The purpose of this study was to evaluate the incidence, predictors, and clinical significance of hypotension after CAS. A total of 118 cases of carotid artery stenosis were treated with CAS. Hypotension was defined as sustained systolic blood pressure <80 mmHg and requiring intravenous administration of vasopressor to maintain adequate systolic blood pressure after the procedure. Baseline characteristics, procedural characteristics, and periprocedural major adverse events were retrospectively compared between postprocedural hypotension group and non-hypotension group. Morphological and procedural characteristics were not significantly different between the two groups. Periprocedural major adverse events, presence of new ischemic lesions, and number of new ischemic lesions were not significantly different between the two groups (P = 1, P = 0.36, P = 0.68). Hypertension was an independent protective factor (P = 0.037), and use of proximal protection and the distance from carotid bifurcation to maximum stenotic lesion ≤ 10 mm were independent risk factors for developing hypotension after CAS (P = 0.034, P = 0.027). There was no significant relationship between hypotension after CAS and major adverse events in this study. Maintenance of periprocedural adequate cerebral perfusion is thought to be important to prevent ischemic complications due to hypotension after CAS, especially in these cases.

Multivariable Analysis of Patients With Severe Persistent Postprocedural Hypotension After Carotid Artery Stenting

“…We believe the association between PPH and the type of stent is more relevant. 33,35,36 Indeed, the unlikely scenario that only one factor significantly predicted PPH, as well as the small number of events available for modeling, should be considered reflections of the limited sample size rather than evidence of a single important factor. Hence, it would be premature to dismiss as unimportant the variables found to be significant in the univariable analysis.…”

Low left atrial volume is an independent predictor of persistent hypotension after carotid artery stenting

“…Although various risk factors for hemodynamic instability after CAS have been reported, little attention has been directed toward cardiac function and morphology, the factors which actually control circulation. The underlying mechanism of hemodynamic instability after CAS has been proposed as follows: stimulation of the baroreceptors by direct compression during CAS sends impulses to the nucleus of the solitary tract in the medulla oblongata; this causes the inhibition of sympathetic nerves and stimulation of parasympathetic nerves within the vagus nerve; ultimately, this results in the inhibition of cardiac function and peripheral vasodilation 3 4. Meanwhile, vasovagal syncope is also considered to cause loss of consciousness due to hypotension via the nucleus of the solitary tract, following the same mechanism described above for hemodynamic instability after CAS (figure 1).…”

Persistent Hemodynamic Depression After Carotid Artery Stenting: A Review and Update

“…The carotid sinus in severe carotid stenosis may be stretched more than in mild or moderate carotid artery stenosis during CAS. 14 Therefore, the baroreceptor reflex is more frequent in severe carotid artery stenosis. The carotid bulb is an expanded structure in the inner carotid artery (ICA) and originates from the common carotid artery (CCA) supplied by the glossopharyngeal.…”