Complications and Carotid Stenting

Abstract

Puncture site: Carotid stenting should be undertaken within an interventional (endovascular) program in which personnel are familiar with efficient and safe arterial sheath removal with minimal patient discomfort. Adequate hydration and pretreatment with atropine can prevent and treat hypotension associated with a vaso-vagal response to sheath removal. An unexplained decrease in blood pressure may be caused by retroperitoneal bleeding. Closure devices are recommended if used by trained personnel. Complications of closure devices could be disastrous (hematoma, infection, torn artery). The occurrence of spasm in the distal internal carotid artery is a common angiographic event caused by the mechanical irritation of the vessel. It usually resolves spontaneously after the catheter or guide wire has been removed. Usage of 0.014-inch softtipped wires minimizes the occurrence of spasm. Injections of 100 to 200 mg of nitroglycerine through the carotid access sheath will hasten the resolution of spasm. Spasm must be differentiated from kinking of the internal carotid artery. Bradycardia and episode of transient asystole are not uncommon during balloon inflations within the carotid bulbous. More prolonged hypotension and bradycardia were seen with balloon-expandable stents which place more sustained pressure on the baroreceptors. Both, bradycardia and asystole during balloon inflation are transient and respond promptly to balloon deflation. Prevention is pre-medication with atropine. Larger doses of atropine should be avoided in elderly patients. Hypotension is not uncommon after carotid stenting and may last from hours to days, depending on the sensitivity of the baroreceptors, the type of stent used, and whether CAS was performed bilaterally. The degree of hypotension appears to be more pronounced in heavily calcified lesions. Usually, there are no clinical sequelae and the modest decrease in blood pressure requires no specific intervention. Bed rest, sedation or narcotics exacerbate hypotension and mitigate against rapid ambulation and recovery. Patients, particularly the elderly, should be assisted with ambulation if Complications and Events Encountered During Carotid Stenting