Carotid artery angioplasty with stenting and postprocedure hypotension

Although carotid endarterectomy (CEA) has become established as the preferred approach to the management of critical carotid stenosis, carotid angioplasty with stenting (CAS) has arisen as a competitive modality. We report here a nonindustry-supported experience using CAS in a nonselected patient population suffering from critical carotid stenosis.

All patients suffering from carotid stenosis (>50% symptomatic or >80% asymptomatic) were offered CAS or CEA. The first 36 patients who underwent attempted CAS over this last year are reported here. CAS was performed with the SMART PRECISE (Cordis, Inc, Miami Lakes, FL) or ACCULINK (Guidant, Inc, St Paul, MN) stents. All procedures were performed with cerebral protection.

The planned procedure success rate was 97%, and the major adverse event (MAE) rate was 3.0% in 35 patients who underwent successful CAS. This included a minor stroke and a subendocardial myocardial infarction in the same individual. Both events were attributed to sustained postprocedure hypotension. The most frequent intraprocedure complications observed were bradycardia and hypotension. Persistent postprocedure hypotension requiring vasopressor support complicated 23% of cases. The average duration of vasopressor support in this group was 21 hours.

CAS can be accomplished with an MAE comparable to CEA and will likely become the dominant alternative to CEA for the management of carotid stenosis. Management of periprocedural cardiovascular instability represents one of the most important elements in the safe conduct of CAS.