Risk factors and frequency of postprocedural hemodynamic instability after carotid artery stent placement

2021 ◽  
Vol 99 (4) ◽  
pp. 162-168
Author(s):  
Jarosław Świstak ◽  
Aleksander Dębiec ◽  
Wojciech Szypowski ◽  
Piotr Piasecki ◽  
Krzysztof Brzozowski ◽  
...  
Keyword(s):  
Risk Factors ◽  
Carotid Artery ◽  
Hemodynamic Instability ◽  
Neurological Complications ◽  
Lesion Length ◽  
Symptomatic Carotid ◽  
Symptomatic Carotid Stenosis ◽  
Before And After ◽  
Patients At Risk

The frequency, risk factors and long term consequences of reflexive postprocedural hypotension (PH) following carotid artery stenting (CAS) are not well known. Prospective analysis of 30 patients with 6-month follow-up undergoing CAS with an emboli-protection device was performed. A validated 24-hour ABPM was taken 24 hours before and after CAS. PH was defined as systolic blood pressure (SBP) <90mm Hg, or decrease in mean arterial BP (MAP) of ≥20% or systolic BP (SBP) of ≥30 mm Hg of baseline BP reading. Neurological assessments were performed 24 hours after CAS and at 6 month follow-up visit. Median age was 69 years, 70% were male, 86% of patients had symptomatic carotid stenosis. Twenty patients (67%) experienced PH, 43% had transient bradycardia, 30% had both PH and bradycardia. The cumulated postprocedural mean SBP and DBP decreased from baseline 128/67 mm Hg to 108/54 mm Hg (p <0.01), mean day (69/min) and night HR (58/min) decreased to respectively 58/min and 49/min (p <0.01). We found no association of PH with age, ischemic heart disease, bifurcation involvement, balloon size, inflation pressure, longer lesion length. Patients with PH significantly (p <0.05) less often were treated with Ca-antagonist (25% vs 70%), more often had ipsilateral ulcerated plaque (85% vs 50%) and had hemodynamically significant stenosis of contralateral ICA (60% vs 30%). During 6 month follow-up only 1 case of neurological deterioration was noticed. PH was a common phenomenon after CAS, however it did not result in neurological complications. Patients at risk can be possibly identified through clinical and angiographic variables.

Predictors of periprocedural complications of carotid artery stenting - a multivariate analysis of a single-centre experience

VASA ◽  
2016 ◽  
Vol 45 (5) ◽  
pp. 387-393 ◽  
Author(s):  
Mehmet Bulent Vatan ◽  
Bilgehan Atılgan Acar ◽  
Murat Aksoy ◽  
Yusuf Can ◽  
Ceyhun Varım ◽  
...  
Keyword(s):  
Risk Factors ◽  
Carotid Artery ◽  
Carotid Artery Stenting ◽  
Multivariate Regression Analysis ◽  
Neurological Complications ◽  
Lesion Length ◽  
Plaque Morphology ◽  
Symptomatic Carotid ◽  
Symptomatic Carotid Stenosis ◽  
Independent Risk Factors

Abstract. Background: Carotid artery stenting (CAS) is currently used as an alternative treatment to carotid endarterectomy (CEA). The objective of this study was to analyse our 5-year experience performing CAS. Secondarily, we sought to determine independent risk factors which predict periprocedural complications. Patients and Methods: A total of 146 patients who underwent 153 CAS procedures were analysed. The majority of patients (123, 84.2%) had symptomatic carotid stenosis. Demographic and interventional data, angiographic lesion characteristics, and periprocedural complications were recorded. Using univariate and multivariate logistic regression analyses, risk factors associated with adverse clinical outcomes were determined. Results: Periprocedural neurological complications, including four (2.7 %) major strokes, three (2 %) transient ischaemic attacks, one (0.7%) amaurosis fugax, and two (1.3 %) cases of hyperperfusion syndrome occurred in ten (6.8%) patients. The incidence of periprocedural complications significantly increased in female patients (r = 0.214, p = 0.009) and patients with longer lesions (r = 0.183, p = 0.027), contralateral stenosis ≥50 % (r = 0.222, p = 0.007), the presence of complicated plaques (r = 0.478, p < 0.001) and inadequate glycaemic control (r = 0.259, p = 0.002). Multivariate regression analysis also determined four variables to be potential independent risk factors for 30-day adverse events: higher age (Odds ratio [OR] = 1.283; 95 % CI, 1.051 to 1.566, p = 0.014); longer lesions (OR = 1.459, 95 % CI, 1.124 to 1.893, p = 0.004); higher tortuosity index (OR = 1.015, 95 % CI, 1.001 to 1.030, p = 0.034), and the presence of complicated plaque morphology (OR = 4.321, 95 % CI, 1.621 to 10.23, p = 0.001). Conclusions: Patient and lesion characteristics including age, lesion length, complicated plaque morphology and tortuosity index, may be associated with periprocedural complications.

scholarly journals Computed tomography indicators of cerebral microperfusion improve long term after carotid stenting in symptomatic patients

2019 ◽  
Author(s):  
Pawel J Winklewski ◽  
Mariusz Kaszubowski ◽  
Grzegorz Halena ◽  
Agnieszka Sabisz ◽  
Kamil Chwojnicki ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Carotid Artery ◽  
Predictive Value ◽  
Carotid Artery Stenting ◽  
Ct Perfusion ◽  
Carotid Stenting ◽  
Cerebral Microcirculation ◽  
Symptomatic Carotid ◽  
Symptomatic Carotid Stenosis ◽  
Before And After

Objectives: We tested the hypothesis that computed tomography (CT) perfusion markers of cerebral microcirculation would improve 36 months after internal carotid artery stenting for symptomatic carotid stenosis while results obtained 6–8 weeks after the stenting procedure would yield a predictive value. Methods: We recruited consecutive eligible patients with >70% symptomatic carotid stenosis with a complete circle of Willis and normal vertebral arteries to the observational cohort study. We detected changes in the cerebral blood flow (CBF), cerebral blood volume (CBV), mean transit time (MTT), time to peak (TTP) and permeability surface area-product (PS) before and after carotid stenting. We have also compared the absolute differences in the ipsilateral and contralateral CT perfusion markers before and after stenting. The search for regression models of “36 months after stenting” results was based on a stepwise analysis with bidirectional elimination method. Results: A total of 34 patients completed the 36 months follow-up (15 females, mean age of 69.68±S.D. 7.61 years). At 36 months after stenting, the absolute values for CT perfusion markers had improved: CBF (ipsilateral: +7.76%, contralateral: +0.95%); CBV (ipsilateral: +5.13%, contralateral: +3.00%); MTT (ipsilateral: –12.90%; contralateral: –5.63%); TTP (ipsilateral: –2.10%, contralateral: –4.73%) and PS (ipsilateral: –35.21%, contralateral: –35.45%). MTT assessed 6–8 weeks after stenting predicted the MTT value 36 months after stenting (ipsilateral: R2=0.867, contralateral R2=0.688). Conclusions: We have demonstrated improvements in CT perfusion markers of cerebral microcirculation health that persist for at least 3 years after carotid artery stenting in symptomatic patients. MTT assessed 6–8 weeks after stenting yields a predictive value.

Results using a self-expanding stent alone in the treatment of severe symptomatic carotid bifurcation stenosis

2008 ◽  
Vol 109 (3) ◽  
pp. 454-460 ◽  
Author(s):  
Miguel Bussière ◽  
David M. Pelz ◽  
Paul Kalapos ◽  
Donald Lee ◽  
Irene Gulka ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Carotid Stenosis ◽  
Multivariable Analysis ◽  
Balloon Dilation ◽  
Peak Systolic Velocity ◽  
Stent Insertion ◽  
Symptomatic Carotid ◽  
Symptomatic Carotid Stenosis ◽  
The Mean

Object Conventional endovascular therapy for carotid stenosis involves placement of an embolic protection device followed by stent insertion and angioplasty. A simpler approach may be placement of a stent alone. The authors determined how often this approach could be used to treat patients with carotid stenosis, and assessed which factors would preclude this approach. Methods Over a period of 6 years, 97 patients with symptomatic carotid stenosis were treated with the intention of using a “stent-only” approach. Arteries in 77 patients (79%) were treated with stents alone, 13 required preinsertion balloon dilation, 6 postinsertion dilation, and 1 both pre- and postinsertion dilation. Results The mean stenosis according to North American Symptomatic Carotid Endarterectomy Trial criteria was reduced from 82 to 40% in the stent-only group and from 89 to 37% in the stent and balloon angioplasty group. The 30-day stroke and death rate was 7.2%. Patients were followed for a mean of 15 months. In the stent-alone group, the mean preoperative Doppler peak systolic velocity (PSV) was 409 cm/second, with an internal carotid artery/common carotid artery (ICA/CCA) ratio of 7.2. At follow-up review, the PSV decreased to 153 cm/second and the ICA/CCA ratio to 2.1. In the angioplasty group the mean preoperative PSV was 496 cm/second and the ICA/CCA ratio was 9.2, decreasing to 163 cm/second and 2, respectfully, at follow-up evaluation. Restenosis occurred in 12.8% of patients at 6 months and in 15.9% at 1 year. One stroke occurred during the follow-up period in each group. Using multivariable analysis, factors precluding the “stent-only” approach were as follows: severity of stenosis, circumferential calcification, and no history of hyperlipidemia. Conclusions Balloons may not be required to treat all patients with carotid stenosis. A stent alone was feasible in 79% of patients, and 79% of patients were alive and free from ipsilateral stroke or restenosis at 1 year. Restenosis rates with this approach are higher than with conventional angioplasty and stent insertion. Carotid arteries with very severe stenoses (> 90%) and circumferential calcification may be more successfully treated with angioplasty combined with stent placement.

Hypotension and Bradycardia after Elective Carotid Stenting: Frequency and Risk Factors

2003 ◽  
Vol 10 (5) ◽  
pp. 851-859 ◽  
Author(s):  
Wolfgang Mlekusch ◽  
Martin Schillinger ◽  
Schila Sabeti ◽  
Tassilo Nachtmann ◽  
Wilfried Lang ◽  
...  
Keyword(s):  
Risk Factors ◽  
Coronary Artery Disease ◽  
Coronary Artery ◽  
Carotid Artery ◽  
Carotid Artery Stenting ◽  
Carotid Stenting ◽  
Hemodynamic Instability ◽  
Neurological Complications ◽  
Severe Hypotension ◽  
Artery Disease

Purpose: To investigate the frequency of and risk factors for hypotension and bradycardia in response to elective carotid stenting and their association with neurological complications. Methods: A retrospective analysis was conducted of 471 patients (321 men; median age 72 years, interquartile range 64–77) who underwent elective carotid artery stenting without cerebral protection for high-grade (>70%) symptomatic (n = 147) or asymptomatic (n=324) internal carotid artery stenosis at a single center. Frequency and potential risk factors for severe hypotension (systolic blood pressure <80 mmHg) or bradycardia (heart rate <50 bpm) were studied. Results: Thirty-four (7%) patients had severe hypotension (n=23), bradycardia (n=2), or both (n=9) despite routine premedication with atropine and adequate fluid balance. Intravenous catecholamines (dopamine) were necessary in 8 patients with prolonged hypotension; none of the patients with bradycardia needed pacemaker support. Neurological complications (transient ischemic attack, minor stroke, major stroke, death) occurring in 33 (7%) patients were not significantly associated with hemodynamic instability (4/34 [12%] versus 29/437 [7%], p = 0.26). Age >77 years (fourth quartile; OR 6.40, 95% CI 1.80 to 22.78, p=0.004) and coronary artery disease (OR 2.81, 95% CI 1.29 to 6.14, p=0.010) were associated with an increased adjusted risk for hypotension or bradycardia. Conclusions: Hemodynamic instability due to hypotension and bradycardia in response to carotid artery stenting occurs in a relatively low proportion of patients. Elderly patients and those with coronary artery disease are at highest risk. Although the rate of neurological complications was not significantly increased in patients with hemodynamic instability, the higher frequencies of neurological complications in these patients admonish us to be careful.

Safety and efficacy of symptomatic carotid artery stenting performed in an emergency setting

2020 ◽  
pp. 159101992097755
Author(s):  
Darko Quispe-Orozco ◽  
Kaustubh Limaye ◽  
Cynthia B Zevallos ◽  
Mudassir Farooqui ◽  
Alan Mendez-Ruiz ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Carotid Artery Stenting ◽  
Carotid Occlusion ◽  
Rank Test ◽  
Optimal Timing ◽  
Emergency Setting ◽  
Safety And Efficacy ◽  
Symptomatic Carotid ◽  
Symptomatic Carotid Stenosis

Introduction Carotid artery stenting (CAS) has increasingly emerged as an alternative strategy to carotid endarterectomy in the treatment of patients with symptomatic carotid stenosis. Optimal timing for CAS after symptoms onset remains unclear. We aimed to evaluate the safety and efficacy of CAS when performed in an emergency setting. Patients and methods We performed a retrospective analysis of CAS patients admitted to our CSC with symptomatic extracranial carotid occlusion or significant stenosis from January 2014-September 2019. Emergency CAS was defined as CAS performed during the same hospitalization from TIA/stroke onset, whereas elective CAS as CAS performed on a subsequent admission. The primary outcome was defined as the occurrence of any stroke, myocardial infarction, or death related to the procedure at 3 months of follow-up. Secondary outcomes included periprocedural complications and the rate of restenosis/occlusion at follow-up. Logistic regression and survival analyses were used to compare outcomes and restenosis at follow-up. Results We identified 75 emergency and 104 elective CAS patients. Emergency CAS patients had significantly higher rates of ipsilateral carotid occlusion (17% vs. 2%, p < 0.001) and use of general anesthesia (19% vs. 4%, p = 0.001) than elective CAS. There were no significant differences between emergency and elective CAS in the primary (5.7% vs. 1%, p = 0.161) and secondary (9% vs. 4.8%, p = 0.232) outcomes. We did not find differences in the rate of restenosis/occlusion (7% vs. 11.6%; log-rank test p = 0.3) at a median of 13 months follow-up. Conclusion In our study, emergency CAS in symptomatic patients might have a similar safety and efficacy profile to elective CAS at 3 months and long-term follow-up.

scholarly journals Carotid artery stenting compared with endarterectomy in patients with symptomatic carotid stenosis (International Carotid Stenting Study): a randomised controlled trial with cost-effectiveness analysis

2016 ◽  
Vol 20 (20) ◽  
pp. 1-94 ◽  
Author(s):  
Roland L Featherstone ◽  
Joanna Dobson ◽  
Jörg Ederle ◽  
David Doig ◽  
Leo H Bonati ◽  
...  
Keyword(s):  
Relative Risk ◽  
Carotid Artery ◽  
Carotid Stenosis ◽  
Health Technology ◽  
Symptomatic Carotid ◽  
Symptomatic Carotid Stenosis ◽  
Randomised Controlled ◽  
Stroke Death

BackgroundCarotid artery stenting (CAS) is an alternative to carotid endarterectomy (CEA) for the treatment of carotid stenosis, but safety and long-term efficacy were uncertain.ObjectiveTo compare the risks, benefits and cost-effectiveness of CAS versus CEA for symptomatic carotid stenosis.DesignInternational, multicentre, randomised controlled, open, prospective clinical trial.SettingHospitals at 50 centres worldwide.ParticipantsPatients older than 40 years of age with symptomatic atheromatous carotid artery stenosis.InterventionsPatients were randomly allocated stenting or endarterectomy using a computerised service and followed for up to 10 years.Main outcome measuresThe primary outcome measure was the long-term rate of fatal or disabling stroke, analysed by intention to treat (ITT). Disability was assessed using the modified Rankin Scale (mRS). A cost–utility analysis estimating mean costs and quality-adjusted life-years (QALYs) was calculated over a 5-year time horizon.ResultsA total of 1713 patients were randomised but three withdrew consent immediately, leaving 1710 for ITT analysis (853 were assigned to stenting and 857 were assigned to endarterectomy). The incidence of stroke, death or procedural myocardial infarction (MI) within 120 days of treatment was 8.5% in the CAS group versus 5.2% in the CEA group (72 vs. 44 events) [hazard ratio (HR) 1.69, 95% confidence interval (CI) 1.16 to 2.45;p = 0.006]. In the analysis restricted to patients who completed stenting, age independently predicted the risk of stroke, death or MI within 30 days of CAS (relative risk increase 1.17% per 5 years of age, 95% CI 1.01% to 1.37%). Use of an open-cell stent conferred higher risk than a closed-cell stent (relative risk 1.92, 95% CI 1.11 to 3.33), but use of a cerebral protection device did not modify the risk. CAS was associated with a higher risk of stroke in patients with an age-related white-matter changes score of 7 or more (HR 2.98, 95% CI 1.29 to 6.93;p = 0.011). After completion of follow-up with a median of 4.2 years, the number of patients with fatal or disabling stroke in the CAS and CEA groups (52 vs. 49), and the cumulative 5-year risk did not differ significantly (6.4% vs. 6.5%) (HR 1.06, 95% CI 0.72 to 1.57;p = 0.776). Stroke of any severity was more frequent in the CAS group (15.2% vs. 9.4% in the CEA group) (HR 1.712, 95% CI 1.280 to 2.300;p < 0.001). There was no significant difference in long-term rates of severe carotid restenosis or occlusion (10.8% in the CAS group vs. 8.6% in the CEA group) (HR 1.25, 95% CI 0.89 to 1.75;p = 0.20). There was no difference in the distribution of mRS scores at 1-year, 5-year or final follow-up. There were no differences in costs or QALYs between the treatments.LimitationsPatients and investigators were not blinded to treatment allocation. Interventionists’ experience of stenting was less than that of surgeons with endarterectomy. Data on costs of managing strokes were not collected.ConclusionsThe functional outcome after stenting is similar to endarterectomy, but stenting is associated with a small increase in the risk of non-disabling stroke. The choice between stenting and endarterectomy should take into account the procedural risks related to individual patient characteristics. Future studies should include measurement of cognitive function, assessment of carotid plaque morphology and identification of clinical characteristics that determine benefit from revascularisation.Trial registrationCurrent Controlled Trials ISRCTN25337470.FundingThis project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full inHealth Technology Assessment; Vol. 20, No. 20. See the NIHR Journal Library website for further project information. Further funding was provided by the Medical Research Council, Stroke Association, Sanofi-Synthélabo and the European Union.

Factors associated with early and late failure after goniotomy for primary pediatric glaucoma

2018 ◽  
Vol 30 (1) ◽  
pp. 162-167 ◽  
Author(s):  
Dina H Hassanein ◽  
Ahmed Awadein ◽  
Hala Elhilali
Keyword(s):  
Risk Factors ◽  
Intraocular Pressure ◽  
First Year ◽  
Failure Rates ◽  
Factors Associated ◽  
Pediatric Glaucoma ◽  
Late Failure ◽  
Before And After ◽  
The Mean

Purpose: To analyze the risk factors associated with early and late failure after goniotomy for primary pediatric glaucoma. Methods: A retrospective study was done on infants who underwent goniotomy as the initial surgical procedure for primary pediatric glaucoma, and had a follow-up period ⩾48 months after surgery. Early and late failures were defined as intraocular pressure ⩾18 mmHg or signs of glaucoma progression before and after the end of first year, respectively. Results: A total of 81 eyes of 47 children were included. The mean age at the time of surgery was 6.1 ± 6.7 months, 34 children (72.3%) were bilateral. The mean follow-up was 5.9 ± 2.8 years. Of the included eyes, 41 eyes (50.6%) showed success, 25 eyes (30.9%) showed an early failure, and 15 eyes (18.5%) showed a late failure. The mean survival time was 43 months. However, only surgery before the end of the first month and positive consanguinity of the parents (P < 0.01 for both) were independent risk factors for early and late failure of goniotomy for primary pediatric glaucoma. Patients with late failure showed a statistically significant lower preoperative intraocular pressure (P = 0.02). A larger preoperative corneal diameter and a male gender were associated with higher but statistically insignificant failure rates. There were no differences in the early or late failure rates between unilateral and bilateral cases. Conclusion: A positive consanguinity of the parents and surgery before the end of the first month are the major predictors of failure of goniotomy.

Prevalence and risk factors of asymptomatic carotid artery stenosis in Indian population: An 8-year follow-up study

2017 ◽  
Vol 65 (2) ◽  
pp. 279 ◽  
Author(s):  
Subhash Kaul ◽  
Suvarna Alladi ◽  
KRukmini Mridula ◽  
V C SSrinivasarao Bandaru ◽  
Matapathi Umamashesh ◽  
...  
Keyword(s):  
Risk Factors ◽  
Carotid Artery ◽  
Carotid Artery Stenosis ◽  
Indian Population ◽  
Artery Stenosis ◽  
Asymptomatic Carotid ◽  
Follow Up Study ◽  
Asymptomatic Carotid Artery Stenosis
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