The Effect of Controlled Versus Uncontrolled Hypertension on Outcomes in Carotid Revascularization Procedures

Abstract

Hypertension has been implicated as a strong predictive factor for poorer outcomes in patients undergoing various vascular procedures. However, limited research is available that examines the effect of uncontrolled hypertension (uHTN) on outcomes after carotid revascularization. We aimed to determine which carotid revascularization procedure yields the best outcome in this patient population. We studied patients undergoing carotid endarterectomy (CEA), transfemoral carotid artery stenting (TFCAS), or transcarotid artery revascularization (TCAR) from April 2020 to June 2022 using data from Vascular Quality Initiative. Patients were stratified into two groups: those with controlled HTN (cHTN) and those with uHTN. Patients with cHTN were those with HTN treated with medication and a blood pressure <130/80. Patients with uHTN had a blood pressure ≥130/80. Our primary outcomes were in-hospital stroke, in-hospital death, in-hospital myocardial infraction (MI), and 30-day mortality. Our secondary outcomes were postoperative hypotension/hypertension, prolonged length of stay (>1 day), stroke/death, and stroke/death/MI. We used logistic regression models for the multivariate analysis. A total of 34,653 CEA (uHTN = 11,347, 32.7%), 8199 TFCAS (uHTN = 2307, 28.1%), and 17,309 TCAR (uHTN = 4990, 28.8%) patients were included in this study. There was no significant difference in age between patients with cHTN and uHTN for each carotid revascularization procedure. However, compared with cHTN, patients with uncontrolled HTN had significantly more comorbidities. Uncontrolled HTN was associated with an increased risk of combined in-hospital stroke/death/MI after CEA (adjusted odds ratio [aOR] = 1.55, 95% CI: 1.30-1.86; P < .001), TFCAS (aOR = 1.62, 95% CI: 1.24-2.11; P < .001), and TCAR (aOR = 1.39, 95% CI: 1.11-1.72; P = .004) compared with controlled HTN (Table I). In addition, uHTN was associated with prolonged length of stay following all carotid revascularization methods. For the subanalysis of patients with uHTN, TFCAS was associated with an increased risk of stroke (aOR = 1.82, 95% CI: 1.39-2.37; P < .001), in-hospital death (aOR = 3.73, 95% CI: 2.25-6.19; P < .001), and extended length of stay (aOR = 1.87, 95% CI: 1.51-2.32; P < .001) compared with CEA (Table II). There was no statistically significant difference between these outcomes for TCAR compared with CEA. The results from this study show that patients with uHTN are at a higher risk of stroke and death postoperatively compared with patients with HTN, highlighting the importance of treating HTN before undergoing elective carotid revascularization. In addition, in patients with uHTN, TFCAS yields the worst outcomes, whereas CEA and TCAR proved to be the safer interventions. Further studies are needed to address the challenges of better HTN control in symptomatic urgent carotid revascularization procedures.Table IMultivariate logistic regression analysis of postoperative outcomes carotid endarterectomy (CEA), transfemoral carotid artery stenting (TF-CAS), and transcarotid artery revascularization (TCAR), stratified by status of hypertension (reference = controlled hypertension)OutcomeCEATF-CASTCARaOR (95% CI)P valueaOR (95% CI)P valueaOR (95% CI)P valueStroke1.84 (1.46-2.30)<.0011.95 (1.45-2.63)<.0011.32 (1.00-1.73).051In-hospital death1.69 (1.17-2.47).0060.98 (0.65-1.49).9221.24 (0.78-1.96).36530-day mortality1.32 (1.00-1.75).0500.93 (0.62-1.41).7401.47 (1.03-2.11).036MI1.26 (0.91-1.74).1631.68 (0.74-3.79).2121.53 (0.94-2.48).088Stroke or death1.69 (1.37-2.08)<.0011.51 (1.14-2.01).0041.31 (1.02-1.68).037Stroke, death, or MI1.55 (1.30-1.86)<.0011.62 (1.24-2.11)<.0011.39 (1.11-1.72).004Postoperative hypertension1.64 (1.39-1.95)<.0011.96 (1.58-2.44)<.0011.67 (1.38-2.01)<.001Postoperative hypotension0.83 (0.69-1.00).0541.14 (0.95-1.36).1650.95 (0.82-1.10).491Extended LOS (>1 day)1.30 (1.18-1.45)<.0011.59 (1.34-1.90)<.0011.14 (1.01-1.29).029aOR, Adjusted odds ratio; CI, confidence interval; COPD, chronic obstructive pulmonary disease; LOS, length of stay; MI, myocardial infraction.All variables adjusted for background characteristics (age, race, and ethnicity), insurance, preoperative medications (aspirin, P2Y12 receptor antagonist, statin, and β-blocker), anesthesia type, urgency, smoking status, symptomatic status, and comorbidities (congestive heart failure, coronary artery disease, diabetes, COPD, and chronic kidney disease). Open table in a new tab Table IIMultivariate analysis of all patients with uncontrolled hypertension stratified by carotid revascularization type (reference = carotid endarterectomy [CEA])OutcomeTF-CASTCARaORP valueaORP valueStroke1.82 (1.39-2.37)<.0011.07 (0.79-1.45).648In-hospital death3.73 (2.25-6.19)<.0010.88 (0.54-1.43).59430-day mortality3.10 (2.01-4.76)<.0010.98 (0.68-1.43).932MI0.81 (0.41-1.59).5370.83 (0.52-1.32).433Stroke or death1.97 (1.51-2.58)<.0011.10 (0.83-1.46).501Stroke, death, or MI1.73 (1.35-2.23)<.0011.06 (0.83-1.35).654Postoperative hypertension0.76 (0.59-0.99).0430.63 (0.52-0.77)<.001Postoperative hypotension2.48 (1.94-3.18)<.0012.12 (1.77-2.55)<.001Extended LOS (>1 day)1.87 (1.51-2.32)<.0010.92 (0.80-1.05).216aOR, Adjusted odds ratio; CI, confidence interval; COPD, chronic obstructive pulmonary disease; LOS, length of stay; MI, myocardial infraction; TCAR, transcarotid artery revascularization; TF-CAS, transfemoral carotid artery stenting.All variables adjusted for background characteristics (age, race, and ethnicity), insurance, preoperative medications (aspirin, P2Y12 receptor antagonist, statin, and β-blocker), anesthesia type, urgency, smoking status, symptomatic status, and comorbidities (congestive heart failure, coronary artery disease, diabetes, COPD, and chronic kidney disease). 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