Analysis of parameters associated with hypotension requiring vasopressor support after carotid angioplasty and stenting

Abstract

Systemic hypotension has been observed for up to 36 hours in response to stimulation of the carotid baroreceptor by carotid angioplasty and stenting (CAS). The aim of this study was to identify risk factors and cardiac outcomes for postprocedural hypotension requiring vasopressor support after CAS. Between 2003 and 2005, 143 patients (87 men; mean age, 75 years) with high-grade carotid artery stenosis (mean, 87.3%) were treated with CAS and prospectively entered into a vascular registry. Data were retrospectively analyzed to determine factors predictive of hypotension requiring vasopressor support after CAS. Atropine and appropriate intravenous crystalloid solution were administered during CAS. For the first 30 patients, atropine was only used for symptomatic patients but then became routine and was used for all patients with primary carotid stenosis. Hypotension (systolic blood pressure <90 mm Hg or a mean arterial blood pressure <50 mm Hg) unresponsive to conservative measures was treated with vasopressors (phenylephrine or norepinephrine). Patients were stratified into three groups based on hypotension requiring vasopressors: (1) no vasopressors, (2) vasopressors for < or = 24 hours (short duration), and (3) vasopressors for >24 hours (prolonged duration). Risk factors for hypotension requiring vasopressors were analyzed by univariate and multivariate logistic regression analysis. Postprocedural hypotension requiring vasopressor treatment was seen in 16 (11%) of 143 of patients, with 6 (4%) requiring vasopressor support for >24 hours. Mean duration of vasopressor administration for all patients was 17 +/- 10 hours (range, 6 to 36 hours). By univariate analysis, a history of a previous myocardial infarction (P = .02) or use of the PercuSurge occlusion balloon (P = .05) were both associated with increased incidence of short duration (</=24 hours) use of vasopressors, and female sex (P = .03) and age >80 years old (P = .02) were associated with prolonged (>24 hours) vasopressor requirement. On multivariate analysis adjusted for age and sex, a history of myocardial infarction (odds ratio [OR], 4.1; 95% confidence interval [CI], 1.0 to 16.4; P = .05) remained an independent predictor of short-duration vasopressors. On multivariate analysis, female sex (OR, 10.9; 95% CI, 1.2 to 100.4; P = .04) and age >80 years old (OR, 13.8, 95% CI, 1.5 to 127.2; P = .02) remained independent predictors of prolonged vasopressor use. The incidence of periprocedural myocardial infarctions, arrhythmias, or congestive heart failure did not differ between those patients who did not receive vasopressors (5/127) and those who received vasopressors for a short (< or = 24 hours) duration (1/10, P = NS) or prolonged (>24 hours) duration (0/6, P = NS). Prolonged hypotension requiring vasopressor support occurs in a minority of patients after CAS, with higher incidences in older women. In contrast, hypotension requiring a more limited duration of vasopressor use occurs more commonly in patients who had a prior myocardial infarction, independent of age or sex. In this cohort of patients, vasopressors required for hypotension were not associated with an increased incidence of periprocedural cardiac complications. Despite the increased incidence of prolonged hypotension in older women, this study demonstrates that CAS can be performed without an increase in cardiac morbidity in older women.