Predictors of clinically significant postprocedural hypotension after carotid endarterectomy and carotid angioplasty with stenting

• Published in: Journal of vascular surgery 2009-09, Vol.50 (3), p.526-533
• Main Authors: Park, Brian D., MD, Divinagracia, Thomas, MD, Madej, Olga, BA, McPhelimy, Caitlin, BA, Piccirillo, Bryan, BA, Dahn, Michael S., MD, Ruby, Steven, MD, Menzoian, James O., MD
• Format: Article
• Language: English
• Subjects: Aged; Angioplasty - adverse effects; Angioplasty - instrumentation; Angioplasty - mortality; Biological and medical sciences; Carotid Stenosis - mortality; Carotid Stenosis - surgery; Connecticut - epidemiology; Endarterectomy, Carotid - adverse effects; Endarterectomy, Carotid - mortality; Female; Humans; Hypotension - etiology; Hypotension - mortality; Length of Stay; Male; Medical sciences; Myocardial Infarction - etiology; Neurology; Nitrates - adverse effects; Retrospective Studies; Risk Assessment; Risk Factors; Severity of Illness Index; Smoking - adverse effects; Stents; Stroke - etiology; Surgery; Surgery (general aspects). Transplantations, organ and tissue grafts. Graft diseases; Time Factors; Treatment Outcome; Vascular diseases and vascular malformations of the nervous system; Vascular surgery: aorta, extremities, vena cava. Surgery of the lymphatic vessels; Vasodilator Agents - adverse effects
• ISSN: 0741-5214; 1097-6809
• DOI: 10.1016/j.jvs.2009.05.005

Objectives Significant hypotension after carotid endarterectomy (CEA) and carotid angioplasty with stenting (CAS) has been correlated with adverse outcomes. The objective of this study was to determine risk factors that predict hypotension after patients undergo CEA and CAS. Methods The review included 1474 CEA patients and 157 CAS patients who underwent procedures from 2002 to 2008. Specific patient characteristics, such as comorbid diseases, degree of carotid stenosis, presence of neurologic symptoms, and preprocedure medications, were assessed. Also reviewed were specific postprocedural clinical outcomes, including hypotension requiring pressors, myocardial infarction, stroke, death, and hospital length of stay. Results The incidence of clinically significant hypotension was 12.6% in CEA patients and 35% in CAS patients ( P < .001). Clinically significant hypotension was correlated with increased postprocedural myocardial infarction (2.1% vs 0.5%, P = .022), increased mortality (2.1% vs 0.1%, P < .001), and length of stay >2 days (46.3% vs 27.4%, P = .01). Hypotension was not associated with increased postprocedural strokes (0.8% vs 0.6%, P = .75) or recurrent neurologic symptoms (0.4% vs 0.3%, P = .55). Preoperative nitrate use predicted a greater incidence of postprocedural hypotension ( P = .043). A history of tobacco use was correlated with postprocedure hypotension ( P = .033). Preprocedural strokes, the use of calcium channel blockers, β-blockers, angiotensin-converting enzyme inhibitors, prior myocardial infarction, degree of preprocedural carotid stenosis, type of stent, previous ipsilateral and contralateral interventions, and female gender did not correlate with postprocedural hypotension ( P >.05). Conclusions Postprocedural hypotension occurs more commonly with CAS than CEA and is associated with increased postprocedural myocardial infarction and length of stay, and death. Nitrates and tobacco use predict a higher incidence of postprocedural hypotension. High-risk patients should be aggressively managed to prevent the increased morbidity and mortality due to postprocedural hypotension.