Risk factors and impact of postoperative hypotension after carotid artery stenting in the Vascular Quality Initiative

Noori, Vincent J.; Aranson, Nathan J.; Malas, Mahmoud B.; Schermerhorn, Marc L.; O’Connor, David; Powell, Richard J.; Eldrup-Jørgensen, Jens; Nolan, Brian

doi:10.1016/j.jvs.2020.06.116

Cited by 13 publications

(12 citation statements)

References 23 publications

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“…These include proximity of stenosis to carotid bifurcation, presence of calcified plaque, length of stenosis, asymptomatic stenosis, balloon-to-artery ratio, concurrent contralateral stenosis, eccentric (versus concentric) stenosis, atherosclerotic (versus restenotic) lesion, female gender, positive stress test, age > 70, history of MI or angina, and an urgent (versus elective) procedure [ 6 , 8 , 10 – 12 ]⁠⁠. These hemodynamic complications of CAS are associated with a higher risk of postoperative stroke/TIA, MI, chronic heart failure (CHF), dysrhythmia, prolonged length of stay, and in-hospital mortality [ 6 , 12 ]⁠. Furthermore, the CAS-related hypotension might be persistent, possibly due to the continued stretching of the carotid sinus by the self-expanding stent [ 14 ]⁠.…”

Section: Discussionmentioning

confidence: 99%

“…Asymptomatic stenosis, stenosis proximity to bifurcation, calcification at the bifurcation, eccentric stenosis, and dilation percentage may predict the risk of hemodynamic complications of CAS [ 10 , 11 ]. Post-CAS hypotension correlates with higher risk of stroke/transient ischemic attack (TIA), myocardial infarction (MI), prolonged hospital stay (> 1 day), and in-hospital mortality [ 12 ]⁠.…”

Section: Introductionmentioning

confidence: 99%

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Treatment via oral midodrine in a patient with prolonged hypotension following carotid artery stenting: a case report

2022

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Background Hypotension and bradycardia are common hemodynamic complications following carotid artery stenting in patients with carotid artery stenosis. Intravenous fluid resuscitation and inotropes such as dopamine are conventional treatments for post-carotid artery stenting hypotension. However, in case of resistant hypotension, there is no clear treatment method. In this report, while intravenous fluid and inotropes did not resolve the patient’s hypotension, oral midodrine treated post-carotid artery stenting hypotension. Case presentation In this report, we present an 82-year-old Caucasian man complaining of a single episode of unilateral visual loss. The patient had left internal carotid artery stenosis and underwent carotid artery stenting. After the procedure, he developed prolonged post-carotid artery stenting hypotension, which was resistant to intravenous fluids and inotropes but immediately showed a promising response to oral midodrine. Conclusion Oral midodrine can be considered in treatment of post-carotid artery stenting hemodynamic complications.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Treatment via oral midodrine in a patient with prolonged hypotension following carotid artery stenting: a case report

2022

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“…Drawing a comparison between bradycardia/hypotension and protamine dosing should be interpreted with caution as it may be more likely related to other factors such as anesthesia, cardiac complications, blood loss, and balloon dilation of the carotid bulb before and during stent deployment. 14 Liang et al 8 queried the VQI national database on protamine use in TCAR and found no difference in hypotension (bradycardia not evaluated) between patients who received protamine and those that did not. However, a limitation of that study is the exclusion of protamine dosing in the VQI, so they were unable to evaluate the impact of different protamine/heparin ratios.…”

Section: Discussionmentioning

confidence: 99%

Protamine use in transcarotid arterial revascularization

et al. 2022

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Objective The literature suggests that heparin reversal with protamine in transcarotid arterial revascularization (TCAR) decreases postoperative bleeding complications without an increase in stroke or death. However, the dosing of protamine in TCAR has not yet been evaluated. We aimed to evaluate our experience with intraoperative heparin reversal with protamine. Methods This was a single-center, retrospective, observational study that evaluated the heparin and protamine doses used during TCAR. All adult patients who underwent TCAR between 9/1/2019 and 4/2/2021 were included. Demographic data was obtained from the Vascular Quality Initiative and protamine/heparin doses were obtained from a chart review. Multivariate logistic regression models were used to assess the association between the protamine/heparin dose ratio and other variables. Results Sixty-two patients were included. The average protamine/heparin dose ratio used was 0.96 ± 0.12 mg/U; seven had a ratio less than 0.8 mg/U, and one was greater than 1.2 mg/U. Two patients experienced bleeding complications, which were managed non-operatively. No patient with a protamine/heparin ratio greater than 0.8 mg/U had postoperative bleeding. Postoperative bradycardia was observed in 32.3% of patients and hypotension in 35%, with 19% requiring vasopressors. No relationship was identified between the protamine/heparin ratio and bleeding, bradycardia, or hypotension. No 30-day myocardial infarction, stroke or death occurred. Conclusions We identified a near 1:1 ratio of a protamine/heparin dosing regimen for the reversal of heparin during TCAR, with postoperative bleeding complications similar to those reported in the literature. However, patients who received a lower protamine/heparin ratio did not experience bleeding complications. In the era of protamine shortages, a future larger-scale study is needed to evaluate the impact of a lower protamine dose on postoperative complications.

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“… 113 Hemodynamic changes in this setting that require intravenous medications are associated with worse 30-day mortality, stroke, myocardial infarction, and length of stay. 114 – 116 As such, the goal in the postprocedural period is to maintain normotensive blood pressures (systolic blood pressure ⩽ 160 mmHg) while minimizing hypotension to maintain appropriate cerebral perfusion. 117 …”

Section: Postoperative Managementmentioning

confidence: 99%

Preoperative evaluation and perioperative management of patients undergoing major vascular surgery

et al. 2022

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Patients undergoing major vascular surgery have an increased risk of perioperative major adverse cardiovascular events (MACE). Accordingly, in this population, it is of particular importance to appropriately risk stratify patients’ risk for these complications and optimize risk factors prior to surgical intervention. Comorbidities that portend a higher risk of perioperative MACE include coronary artery disease, heart failure, left-sided valvular heart disease, and significant arrhythmic burden. In this review, we provide a current approach to risk stratification prior to major vascular surgery and describe the strengths and weaknesses of different cardiac risk indices; discuss the role of noninvasive and invasive cardiac testing; and review perioperative pharmacotherapies.

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Risk factors and impact of postoperative hypotension after carotid artery stenting in the Vascular Quality Initiative

Cited by 13 publications

References 23 publications

Treatment via oral midodrine in a patient with prolonged hypotension following carotid artery stenting: a case report

Treatment via oral midodrine in a patient with prolonged hypotension following carotid artery stenting: a case report

Protamine use in transcarotid arterial revascularization

Preoperative evaluation and perioperative management of patients undergoing major vascular surgery

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