Long-Term Hemodynamic Effects After Carotid Artery Revascularization
Sungho Lim1, Michael J Javorski2, Sean P Nassoiy3
11 Department of Vascular Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA.
Insights
Carotid artery stenting (CAS) may reduce the need for antihypertensive medications in the first year post-procedure, unlike carotid endarterectomy (CEA). Patients on multiple medications require close monitoring for potential dosage adjustments after CAS.
Area of Science:
- Vascular Surgery
- Cardiology
- Nephrology
Background:
- The carotid body's baroreceptor is crucial for hemodynamic regulation.
- Carotid endarterectomy (CEA) and carotid artery stenting (CAS) can disrupt baroreceptor function, leading to hemodynamic instability.
- Understanding the long-term hemodynamic effects of CEA and CAS is essential for patient management.
Purpose of the Study:
- To evaluate the long-term effects of CEA and CAS on blood pressure (BP), heart rate (HR), and antihypertensive medication use.
- To identify predictors for changes in antihypertensive medication requirements after carotid revascularization procedures.
Main Methods:
- Retrospective chart review of 289 patients undergoing CEA or CAS (2009-2015).
- Analysis of baseline demographics, comorbidities, and operative details.
- Evaluation of BP, HR, and antihypertensive medication needs at 3, 6, 12, 24, and 36 months post-procedure.
Main Results:
- Systolic BP and HR remained stable postoperatively for both CAS and CEA groups.
- A significant reduction in antihypertensive medications was observed in the CAS cohort during the first postoperative year (P < .01).
- CAS and baseline use of multiple antihypertensive medications predicted a reduction in medication needs post-procedure.
Conclusions:
- While BP and HR are stable post-CEA and CAS, CAS is associated with a reduced need for antihypertensive medications in the first year.
- Patients undergoing CAS, especially those on multiple baseline medications, require close BP monitoring and assessment for medication reduction.
- Carotid revascularization impacts long-term hemodynamic management and medication requirements.
Objective:
The baroreceptor at the carotid body plays an important role in hemodynamic autoregulation. Manipulation of the baroreceptor during carotid endarterectomy (CEA) or radial force from carotid artery angioplasty and/or stenting (CAS) may cause both intraoperative and postoperative hemodynamic instability. The purpose of this study is to evaluate the long-term effects of CEA and CAS on blood pressure (BP), heart rate (HR), and subsequent changes on antihypertensive medications.
Methods:
A retrospective chart review was performed to identify patients who underwent CEA or CAS between 2009 and 2015 at a single tertiary care institution. Baseline demographics and comorbidities were recorded. Operative details of the carotid artery endarterectomy and the use of balloon angioplasty during the CAS were analyzed. Hemodynamic parameters such as BP, HR, and antihypertensive medication requirement were evaluated at 3, 6, 12, 24, and 36 months.
Results:
A total of 289 patients were identified. The average age was 70.6 years old, and males constituted 64.0%. All patients had moderate (>50%) to severe (>70%) carotid stenosis. Of those, 111 (40.5%) patients were symptomatic. Systolic BP (mm Hg) of CAS and CEA were similar over the entire follow-up period. Heart rate (beats/min) remained stable postoperatively. A reduced number of antihypertensive medications was observed in the CAS cohort during the first postoperative year when compared to the preoperative baseline: 2.03 at preop, 1.77 ( P < .01) at 3 months, 1.78 ( P = .02) at 6 months, 1.77 ( P = .02) at 12 months, 1.86 ( P = .09) at 24 months, and 2.03 ( P = =.50) at 36 months. Logistic regression analysis identified that CAS (odds ratio [OR]: 2.52, confidence interval [CI]: 1.09-5.83) and multiple (>2) antihypertensive medication use at baseline (OR: 5.89, CI: 2.62-13.26) were predictors for a reduction in the number of antihypertensive medications following carotid revascularization.
Conclusion:
Surgical intervention for carotid stenosis poses a risk of postoperative hemodynamic dysregulation. Although postoperative BP and HR remained relatively stable after both CAS and CEA, the number of postoperative antihypertensive medications was reduced in the CAS cohort for the first postoperative year when compared to baseline. Patients with multiple antihypertensive agents undergoing CAS should have close postoperative BP monitoring and should be monitored for a possible reduction in their antihypertensive medication regimen.
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