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Hemodynamic depression after carotid surgery: Incidence, risk factors and outcomes
Lauro A C Bogniotti1, Marcelo P Teivelis2, Francisco A M Cardozo3
1Anesthesiology Division, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil.
Insights
Hemodynamic depression (HD) is common after carotid surgery, affecting over half of patients. Predictors include asymptomatic stenosis and surgical approach, with severe hypotension linked to major cardiac events.
Area of Science:
- Cardiovascular Surgery
- Vascular Surgery
- Anesthesiology
Background:
- Hemodynamic depression (HD), characterized by hypotension and bradycardia, is a recognized complication of carotid surgery.
- It arises from direct autonomic stimulation within the carotid sinus.
- The study hypothesizes a high incidence and potential link to major cardiac complications.
Purpose of the Study:
- To determine the incidence of HD following carotid surgery.
- To identify independent predictors of HD.
- To investigate the association between HD and adverse cardiovascular events.
Main Methods:
- Retrospective analysis of patient records from January 2014 to December 2018.
- Inclusion of 237 carotid surgeries (endarterectomies and angioplasties).
- Definition of HD, bradycardia, hypotension, and adverse cardiovascular events.
Main Results:
- The overall incidence of HD was 54.4% (50.2% hypotension, 11.0% bradycardia).
- Independent predictors included asymptomatic carotid stenosis, endovascular surgery, and intraoperative HD.
- Hypotension requiring vasopressors was significantly associated with adverse cardiovascular events.
Conclusions:
- The incidence of HD post-carotid surgery is high.
- Surgical technique, stenosis characteristics, and intraoperative hemodynamics predict HD.
- Persistent hypotension requiring vasopressors is a key indicator for adverse cardiovascular outcomes.
Introduction:
Hemodynamic Depression (HD) characterized by hypotension and bradycardia is a complication of carotid surgery due to direct autonomic stimulation in the carotid sinus. The authors believe the incidence of HD is high and possibly related to major cardiac complications.
Methods:
Analysis of patient records during admissions for carotid surgery between January 2014 and December 2018 in two hospitals. HD was defined as bradycardia or hypotension in the first 24 postoperative hours. Bradycardia was defined as heart rate < 50bpm; hypotension as systolic blood pressure < 90 mmHg, continuous use of vasopressors, or a drop in SBP > 20% compared to preoperative values. Myocardial infarction, stroke, and cardiovascular death were defined as adverse events.
Results:
Overall, 237 carotid surgeries (178 endarterectomies, 59 angioplasties) were studied, and the global incidence of HD was 54.4% (hypotension in 50.2%, bradycardia in 11.0%, and hypotension and bradycardia in 6.8%). The independent predictors of HD were asymptomatic carotid stenosis (OR = 1.824; 95% CI 1.014-3.280; p = 0.045), endovascular surgery (OR = 3.319; 95% CI 1.675-6.576; p = 0.001) and intraoperative hypotension or bradycardia (OR = 2.144; 95% CI 1.222-3.762; p = 0.008). Hypotension requiring continuous vasopressor infusion was the only factor independently associated with adverse cardiovascular events (OR = 5.504; 95% CI 1.729-17.529; p = 0.004).
Discussion/Conclusion:
Incidence of Hemodynamic Depression after carotid surgery is high and independently associated with surgical technique, symptomatic repercussion of the carotid stenosis, and intraoperative hypotension or bradycardia. Hypotension requiring the continuous infusion of vasopressors was independently associated with the occurrence of MACE.
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