Hemodynamic Depression Research Articles

Operative Factors Associated with Severe Hypotension in the Postoperative Setting in Patients with Carotid Artery Endarterectomy

Background: Carotid endarterectomy is a recognized method for preventing stroke for both symptomatic and asymptomatic hemodynamically carotid artery stenosis. Hemodynamic depression is more frequently associated with carotid artery stenting, while postoperative hypertension and cerebral hyperperfusion syndrome are known frequent complications after carotid endarterectomy. Severe hypotension after carotid revascularization is associated with a higher risk of perioperative stroke, myocardial infarction, and death, with limited data existing regarding risk factors. This study aims to investigate intraoperative risk factors for severe hypotension after carotid endarterectomy. Methods: A total of 160 patients who underwent carotid endarterectomy were included in this study. Patients with other cardiac conditions that required concomitant cardiac surgery, patients with incomplete medical records, and patients considered high risk for surgery were excluded. Results: The incidence of severe hypotension was 30.6%. Patients with severe hypotension after carotid endarterectomy had a higher incidence of diabetes, moderate mitral valve regurgitation, a history of percutaneous coronary intervention, and higher operative times. Using logistic regression, temporary shunt insertion was independently associated with severe postoperative hypotension (OR = 2.26, 95% CI = 1.09–4.71, p = 0.029). Conclusions: This result favors the selective shunting strategy when performing carotid endarterectomies, especially for those patients with comorbidities predisposing to postoperative complications.

The Effect of Extracorporeal Membrane Oxygenation in the Management of Refractory Ventricular Tachycardia Developed after Fontan Procedure (Case Report)

Aim: to evaluate the effect of extracorporeal membrane oxygenation (ECMO) as a life support in the treatment of a patient with refractory ventricular tachycardia developed after Fontan procedure. Patient and treatment. A 4-year-old child developed refractory ventricular tachycardia (up to 250 bpm) and hemodynamic depression 18 hours after the Fontan procedure. After the failure of cardiopulmonary resuscitation and antiarrhythmic therapy, resternotomy with central venoarterial (VA) ECMO support was performed, followed by diagnostic angiocardiography. Contrast-enhanced cavopulmonary angiography revealed stenosis of the left pulmonary artery, which was treated with balloon angioplasty and stenting.Results. Ventricular tachycardia resolved and sinus rhythm was restored within 24 hours after left pulmonary artery stenting, supported by continuous ECMO and antiarrhythmic therapy. On day 3, transthoracic echocardiography showed good single ventricle contractility after a trial weaning from ECMO. As a result, the ECMO support was removed and the sternum sutured. The patient was discharged from the hospital on day 47 in stable condition.Conclusion. The prompt initiation of VA ECMO support in a 4-year old patient with refractory ventricular tachycardia post-Fontan procedure along with the complex management of post-procedural residual tachycardia using a combination of antiarrhythmic agents helped restoring sinus rhythm and could contribute to preventing neurological complications.

Comparison Between Esketamine and Alfentanil for Hysteroscopy: A Prospective, Double-Blind, Randomized Controlled Trial.

This study aimed to establish the 95% effective dose (ED95) of esketamine in combination with propofol for hysteroscopy and then to evaluate its efficacy and safety profile. This prospective, double-blind, randomized controlled trial consisted of two cohorts. In cohort 1, 45 women aged 18-65 years undergoing hysteroscopy were randomly assigned to either group E (esketamine + propofol) or group A (alfentanil + propofol). Dixon's up-and-down method was used to determine the ED95 of esketamine and alfentanil. In cohort 2, 86 patients were randomized to group E and group A, with the calculated ED95 dose of the study drugs used for induction. The success rate of anesthesia using the ED95% dose, along with parameters related to anesthesia induction, recovery, and adverse events were also recorded. The ED95 of esketamine was 0.254 mg/kg (95% CI: 0.214-1.004), while that of alfentanil was 9.121 μg/kg (95% CI: 8.479-13.364). The anesthesia success rate was 93.0% in group E and 95.2% in group A (p = 0.664). After resuscitation, both groups achieved a 100% success rate. The induction time was significantly shorter in group E (60.0 [55.0-70.0] s) compared to group A (67.0 [61.0-79.3] s) (p = 0.006). Group E had lower rates of respiratory depression (p < 0.001), hypoxia (p = 0.006), minimum perioperative SpO2 (p = 0.010), and hypotension (p = 0.001). Esketamine had less effect on respiratory rate, heart rate, mean blood pressure, and end-tidal carbon dioxide compared to alfentanil (all p < 0.001). There were no significant differences in postoperative pain between the two groups. This study determined the ED 95 dose of esketamine for intravenous general anesthesia during hysteroscopy. Esketamine showed less respiratory and hemodynamic depression, as well as fewer adverse effects compared to alfentanil. Esketamine is an ideal anesthetic agent compared to alfentanil for hysteroscopic anesthesia. www.chictr.org.cn, (ChiCTR2300077283); registered November 3, 2023.

Clinical analysis of patients with hemodynamic depression after carotid artery stenting

Hemodynamic depression (HD) is a complication after carotid artery stenting (CAS). However, there are existing controversies in predicting postoperative risk factors and subsequent clinical outcomes, especially in high-risk patients. Therefore, the present study aimed to investigate the rate of incidence, clinical predictors, and clinical significance associated with persistent HD (p-HD) pathology, as well as obstinate persistent HD (op-HD) after CAS in our center. We retrospectively analyzed 162 consecutively recruited carotid arteriosclerotic stenosis (CASS) patients who received interventional therapy in our hospital between September 2020 and September 2022. The acute/subacute effects of proximal internal CAS on p-HD and op-HD were studied to explore the relationship between CAS and perioperative adverse events. Logistic regression analysis was performed to identify independent predictors of p-HD after CAS. Pathological associations between p-HD/op-HD and clinical events at the 30-day time point were analyzed. Of 162 patients, 18.5 % (n = 30) patients had p-HD, while op-HD was observed in 5.6 % (n = 9) of patients. Hypertension (OR: 8.73; 95 % CI: 1.05–72.90; P = 0.045), history of stroke/transient ischemic attack (TIA) (OR: 4.05; 95 % CI: 1.55–10.59; P = 0.004), coronary artery disease (CAD) (OR: 3.38; 95 % CI: 1.29–8.89; P = 0.013), and distance from the carotid bifurcation to the lesion with maximum stenosis (OR: 2.467; 95 % CI: 1.02–5.93; P = 0.044) were significantly associated with p-HD onset. Patients with either p-HD or op-HD suffered from longer intensive care unit (ICU) stays (all P < 0.001) and were associated with a higher risk of stroke (P = 0.003; P < 0.001). Our data suggest that hypertension, previous stroke/TIA, CAD, and distance from the carotid bifurcation to the lesion with maximum stenosis may play roles in the development of p-HD after CAS. Moreover, this study indicates that either p-HD/op-HD can be associated with the risk of clinical adverse events, especially stroke.

Abstract 254: Imaging Findings of Stroke Following Treatment of Ruptured Cerebral Aneurysm Increases Risk of Postoperative Delirium

Introduction Delirium is an acute cognitive or perceptual disturbance that is associated with prolonged hospital and ICU length of stay, therefore, extending recovery time. According to a recent study, approximately one in five patients undergoing intracranial procedures are vulnerable to postoperative delirium within the first three days of surgery.1‐4 Retrospective cohort studies found a link between postoperative delirium and intraoperative hypotension, indicating reduced cerebral blood flow.5 ICSS‐ MRI study (International Carotid Stenting Study Magnetic Resonance Imaging Study), indicated that patients with periprocedural hemodynamic depression had decreased cerebral blood flow and increased the risk of new lesions in imaging.6 Ruptured intracerebral aneurysms are associated with higher morbidity and mortality than unruptured ones. This is secondary to delayed postoperative cerebral ischemia and infarction caused by vasospasm.7 Clinical indicators like delirium can play a role in evaluating for delayed cerebral ischemia and infarction leading to timely management of vasospasms.5,8,9 Our study aimed to assess the association between imaging findings of stroke and delirium in patients who underwent treatment for ruptured aneurysms. Methods We reviewed the medical records of 167 patients with ruptured intracranial aneurysms between 2015‐2019. We included all the patients who had a postoperative delirium assessment, neurological assessments, and MRI/CT scans for evaluation of cerebral ischemia. Patients were divided into 2 groups, one group with delirium and the other without delirium. Delirium was assessed by using the ICD9/10 codes and The Intensive Care Delirium Screening Checklist (ICDSC).10 Results A total of 167 patients presented with ruptured aneurysm and the incidence of delirium was 38.3% (64 patients). Patients with delirium had a median age of 57 (50.0‐65.8) compared to a median age of 55 (44.0‐64.0) in patients without delirium. Additional risk factors (delirium vs no delirium) included a history of stroke (17.5%/7.8%), smoking (30.1% vs 40.6%), female gender (63.1% vs 71.9%), preop‐benzodiazepines (26.2% vs 23.4%), intraoperative hypotension (78.6% vs 85.9%), and history of alcohol abuse (9.7% vs 9.4%). None of these factors reached statistical significance between patients with and without Delirium (p‐value &gt;0.05). A new neurological deficit was noted in 17 (26.6%) patients with delirium compared to 12 (11.7%) patients without delirium (p‐value, 0.01). 24/29 (82.8%) patients with new neurological deficits had imaging finding suggesting acute ischemic changes (p‐value, &lt;0.001). 30/64 (49.9%) patients with delirium had imaging findings associated with acute ischemic changes on imaging (p‐value, 0.001). After adjusting for confounders such as age, preop benzodiazepines, history of drug abuse, and history of stroke. Patients with delirium had imaging findings suggestive of acute ischemic changes of stroke ORadj 2.46 (CI 95%, 1.12 – 5.36, p‐value 0.02), while patients with new neurological deficit did not ORadj 1.66 (CI 95%, 0.62 – 4.41, p‐value 0.31). Conclusion Our findings suggest that delirium might be one of the manifestations associated with imaging changes indicating acute silent ischemic strokes. Delirium might be one of the manifestations postoperatively for delayed cerebral ischemia as noted on imaging, this highlights the importance of timely identification and management of patients with delirium.

Prognostic Factors for Postoperative Bleeding Complications and Prolonged Intensive Care after Percutaneous Hepatic Chemosaturation Procedures with Melphalan.

Percutaneous hepatic melphalan perfusion (chemosaturation) in patients with liver metastases is known to be associated with procedure-related hemodynamic depression and coagulation impairment, which may cause bleeding complications and/or a prolonged intensive care unit length of stay (ICU LOS). We retrospectively analyzed possible predictive factors for bleeding complications and an ICU LOS > 1 d in a cohort of 31 patients undergoing 90 chemosaturation procedures. Using a multivariable mixed-model approach, we identified the amount of perioperative fluid volume (OR 12.0, 95% CI 2.3-60.0, p = 0.003) and protamine (OR 0.065, 95% CI 0.007-0.55, p = 0.012) to be associated with bleeding complications. Furthermore, the amount of perioperative fluid volume was associated with an ICU LOS > 1 d (OR 5.2, 95% CI 1.4-19.0, p = 0.011). Heparin dosage, melphalan dosage, extracorporeal circulation time, and noradrenaline dosage had no significant effects on outcomes. Protamine use was not associated with anaphylactic or thromboembolic complications. Despite the limited sample size, these results suggest a restrictive perioperative fluid regime to be beneficial, and support the use of protamine for heparin reversal after chemosaturation procedures. Further prospective randomized trials are needed to confirm these findings.

Building of a Clinical Prediction Model for Hemodynamic Depression after Carotid Artery Stenting

Objective To analyze the risk factors and build a clinical prediction model for hemodynamic depression (HD) after carotid artery stenting (CAS). Methods A total of 116 patients who received CAS in the Department of Vascular Surgery,Drum Tower Clinical College of Nanjing Medical University and the Department of Vascular Surgery,the Affiliated Suqian First People's Hospital of Nanjing Medical University from January 1,2016 to January 1,2022 were included in this study.The patients were assigned into a HD group and a non-HD group.The clinical baseline data and vascular disease characteristics of each group were collected,and multivariate Logistic regression was employed to identify the independent predictors of HD after CAS and build a clinical prediction model.The receiver operating characteristic (ROC) curve was drawn,and the area under the ROC curve (AUC) was calculated to evaluate the predictive performance of the model. Results The HD group had lower proportions of diabetes (P=0.014) and smoking (P=0.037) and higher proportions of hypertension (P=0.031),bilateral CAS (P=0.018),calcified plaque (P=0.001),eccentric plaque (P=0.003),and the distance<1 cm from the minimum lumen level to the carotid bifurcation (P=0.009) than the non-HD group.The age,sex,coronary heart disease,symptomatic carotid artery stenosis,degree of stenosis,and length of lesions had no statistically significant differences between the HD group and the non-HD group (all P>0.05).Based on the above predictive factors,a clinical prediction model was established,which showed the AUC of 0.807 and the 95% CI of 0.730-0.885 (P<0.001).The model demonstrated the sensitivity of 62.7% and the specificity of 87.7% when the best cut-off value of the model score reached 12.5 points. Conclusions Diabetes,smoking,calcified plaque,eccentric plaque,and the distance<1 cm from the minimum lumen level to the carotid bifurcation are independent predictors of HD after CAS.The clinical prediction model built based on the above factors has good performance in predicting the occurrence of HD after CAS.

Impact of residual stenosis on clinical outcomes when performing carotid artery stenting without postdilation.

Many centers consider postdilation if the final angiography after carotid artery stenting (CAS) shows residual stenosis of >30% to 40%. Postdilation has been demonstrated to potentially increase the risk of developing neurologic events. This study aimed to investigate the safety of CAS without postdilation regardless of the degree of residual stenosis. We retrospectively investigated 191 patients who underwent transfemoral CAS without postdilation intendedly. All cases underwent mild predilation and self-expanding stent implantation. We divided the patients into a residual stenosis of ≥40% group (n= 69 [36.1%]) and a residual stenosis of<40% group (n= 122 [63.9%]) according to their final angiography. We compared the procedural (within 30days after CAS) and nonprocedural (afterward) adverse cardiovascular events and in-stent restenosis between the two groups. We also investigated the incidence of perioperative hemodynamic depression between the groups and the changes in residual stenosis over the follow-up time. Patients in the residual stenosis of ≥40% group had a higher preoperative stenosis rate and a greater proportion of severely calcified lesions than those in the<40% group. There was one procedural cardiac death (0.5%), five strokes (2.6%), and four myocardial infarctions (2.1%). A total of 2.9% had stroke or death procedurally in the residual stenosis of ≥40% group and 3.2% in the residual stenosis of<40% group (P> .950). The median nonprocedural follow-up time was 22months, with a total of six deaths and four strokes. The cumulative 2-year death or stroke rate was 6.2%, with 5.9% in the residual stenosis of ≥40% group versus 6.7% in the residual stenosis of<40% group (P= .507). There were two cases of in-stent restenosis in the residual stenosis of ≥40% group and three in the residual stenosis of<40% group (P= .927). The difference in the peak systolic velocity of the target lesion between groups at 3months after CAS was no longer present, and residual stenosis stabilized at 10% to 20% at 6months in both groups. The patients showed an association between increasing hemodynamic depression incidence and residual stenosis in a significantly graded response (P=.021). Residual stenosis after carotid stenting without postdilation is not associated with a risk of postoperative adverse events. This study provides evidence for the feasibility of a no postdilation strategy for CAS.

Comparison of Remimazolam and Propofol for Intubated General Anesthesia for Oral and Maxillofacial Surgery

Objective Remimazolam is a new, ultra-short-acting benzodiazepine that can be used for induction and maintenance of general anesthesia. We compared the hemodynamic stability and depth of anesthesia during general anesthesia using remimazolam or propofol along with remifentanil for oral and maxillofacial surgery. Methods A total of 95 patients were divided into remimazolam and propofol groups and then subdivided into bispectral index (BIS) and patient state index (PSI) groups. Blood pressure, heart rate, and BIS/PSI values were compared at fixed time points perioperatively. Time to loss of consciousness and total opioid doses were also compared across groups. Other items that were compared included intraoperative arousal and postoperative nausea and vomiting. Results Propofol produced more significant hemodynamic depression than remimazolam, although both groups were stable. BIS/PSI values were similar in both groups. Time to loss of consciousness was significantly shorter in the remimazolam group. Total opioid dosing was higher in the remimazolam group, and there were no differences regarding other postoperative complications. Conclusion The perioperative hemodynamics with remimazolam were more stable that with propofol, especially during induction. Therefore, remimazolam may be a safe alternative to propofol for providing TIVA general anesthetics.

Lipid Emulsion-Mediated Improvement of Hemodynamic Depression Caused by Amlodipine Toxicity.

Lipid Emulsion-Mediated Improvement of Hemodynamic Depression Caused by Amlodipine Toxicity.

Angioplasty and Stenting for Carotid Artery Near-Occlusion

Carotid near-occlusion (CNO) is the type of severe atherosclerotic stenosis of the internal carotid artery (ICA) with or without collapse of the vessel distally to the narrow part. According to the North American Symptomatic Carotid Endarterectomy Trial (NASCET), severity of ICA stenosis highly correlates with the risk of stroke, except for cases of extremely critical stenosis &gt; 94%, where the risk is lower, and, according to recent guidelines, conservative treatment is preferable. This consideration is questionable due to the recent data about early stroke recurrence and worldwide practice. Rapid improvement of endovascular technique during the last decade makes carotid angioplasty and stenting (CAS) a feasible option for the treatment of patients with CNO and is widely reported in the literature. However, in uncertain circumstances, more scientific data are necessary to fulfill the gap in indications, terms and risks of CAS for CNO.&#x0D; The aim. To evaluate the results of the treatment of patients with CNO after CAS.&#x0D; Materials and methods. Three hundred and fifteen patients were surgically treated at Scientific-Practical Center of Endovascular Neuroradiology of the National Academy of Medical Sciences of Ukraine due to ICA stenosis between 2010 and 2020. Among them, 39 (12.4%) patients (11 woman / 28 men (age 57.9±2.1 years) had CNO and underwent CAS at our Center. Patient population, clinical and radiological investigations, procedure compli-cations were investigated. Procedure complications (stroke, hemodynamic depression [HD] and hyperperfusion syndrome [HPS]) were meticulously studied. All the patients had routine ultrasound and clinical check 30 days after the procedure.&#x0D; Results. All the patients with CNO were successfully stented with the improvement of the site of stenosis after CAS, with only minimal residual stenosis in cases of severe HD. We observed two procedural vascular accidents, first patient had transient ischemic attack (TIA) and one had stroke due to middle cerebral artery occlusion after stent placement and further urgent mechanical thrombectomy. The patient had no neurologic decline and was discharged home. We didn’t observe any cases of myocardial infarction (MI) or death in our series during the hospital stay. HD was seen in 13 (33.3%) patients, and mostly resolved after the procedure except for 3 casesthat required prolonged intensive care unit stay. HPS was diagnosed in 2 (5.1%) patients and also didn’t have anyneurologic consequences after supportive care. During 30 days of follow-up, one (2.6%) patient had TIA because of anti-platelets cessation and 1 (2.6%) patient had MI after 1 week since discharge. All control images revealedstents patency without the evidence of critical residual stenosis.&#x0D; Conclusions. CNO remains important diagnostic and therapeutic challenge. Recent data showed high risk ofrecurrent stroke in case of CNO on best medical therapy, especially at an early stage, but it remains a preferred option according to guidelines. Considering worldwide improvement of stroke rates after CAS in patients with symptomatic ICA stenosis, further studies are warranted to evaluate its risk-benefit in case of CNO, especially with full collapse. Our data shows that CAS with careful preoperative diagnosis and planning is an effective procedure for selected patients with CNO.

Remimazolam tosilate compared with propofol for gastrointestinal endoscopy in elderly patients: a prospective, randomized and controlled study

BackgroundRemimazolam tosilate (HR7056, RT), a novel ultrashort-acting benzodiazepine, can be used for procedural sedation and general anaesthesia. However, few studies have focused on the sedative effect of RT during gastrointestinal endoscopy in elderly patients. The purpose of this study is to compare the sedative effect of RT and propofol for gastrointestinal endoscopy in elderly patients.MethodsA total of 82 patients aged ≥65 years with an American Society of Anaesthesiologists (ASA) grade I-II and a body mass index (BMI) of 18.0 to 30.0 kg/m2 who were scheduled for gastrointestinal endoscopy from Jan 2021 to Aug 2021 were selected and randomly divided into a RT group and a propofol group. Alfentanil 5 μg/kg was used for analgesia in both groups. The RT group was given remimazolam tosilate 0.15 mg/kg with supplemental doses of 0.05 mg/kg as need, while the propofol group was given propofol 1.5 mg/kg with supplemental doses of 0.5 mg/kg. The supplemental doses were determined by the modified observational alertness/sedation assessment (MOAA/S) score and the patients’ body movements. Sedative effects, such as the time to loss of consciousness (LOC) (MOAA/S score ≤ 1), successful sedation in one dose, number of supplemental doses after successful induction, and recovery time, were evaluated. Sedation-related side effects, such as injection pain, haemodynamic events and respiratory depression, were also noted. Postoperative nausea and vomiting (PONV), visual analogue scale (VAS) scores at rest, remedial analgesics, and dizziness or headache were recorded. In addition, patients’ satisfaction and physician’s satisfaction of the procedure were compared between the two groups.ResultsData from 77 patients were analysed. The success rate of sedation in both groups was 100%. The time to LOC (MOAA/S score ≤ 1) in the RT group was longer than that in the propofol group (20.7 ± 6.1s vs. 13.2 ± 5.2s, P < 0.001). There were fewer patients in the RT group reporting injection pain than that in the propofol group (0/39 vs. 5/38, P = 0.025). Haemodynamic events and respiratory depression in the RT group were less frequent than those in the propofol group ((6/39 vs. 17/38, P = 0.005), (2/39 vs. 9/38, P = 0.026), respectively). The number of supplemental doses after successful induction in the RT group was greater than that in the propofol group (4/9/11/13/1/1 vs. 8/4/18/6/2/0 requiring 0, 1, 2, 3, 4 or 5 supplemental doses, P = 0.014). The characteristics of the patients enrolled, postoperative parameters of the patients, and patients’ and physician’s satisfaction of the procedure were comparable in the two groups.ConclusionsCompared with propofol, RT can be safely and effectively used for gastrointestinal endoscopy sedation in elderly patients, and the incidence of sedation-related adverse reactions, especially haemodynamic events and respiratory depression, is lower. When RT is used, the number of supplemental doses after successful induction may increase slightly.Trial registrationChictr.org.cn ChiCTR2000040498. Retrospectively registered (date of registration: December 1, 2020).

Persistent Hemodynamic Depression After Carotid Artery Stenting: A Review and Update.

According to the American Heart Association, ischemic stroke is the second leading cause of death globally and is responsible for approximately 11% of deaths. Carotid endarterectomy (CEA) is the standard treatment for moderate or severe extracranial internal carotid artery (ICA) stenoses. With the development of materials and technology in neurointervention, the Centers for Medicare and Medicaid Services (CMS) have proposed that carotid artery stenting (CAS) can serve as an alternative treatment for CEA. As CAS is widely used worldwide, comorbidities, especially persistent hemodynamic depression (PHD) and stroke, have attracted public attention. In this review, we summarized the current advances in PHD after CAS. A better understanding of CAS-related PHD may inspire the design of potential prognostic and therapeutic tools.

Simultaneous bilateral angioplasty and stenting for carotid stenosis - a single center experience.

Carotid artery stenosis is responsible for up to 12% of all ischemic strokes. The prevalence of bilateral carotid artery stenosis is nearly 8–39% among patients with stroke, and its management is still controversial. This study aimed to report the treatment results of bilateral carotid artery stenosis with simultaneous bilateral angioplasty and stenting (sbCAS) in a single institution during the last 10 years. 315 patients underwent carotid stenting in the Scientific-Practical Center of Endovascular Neuroradiology, NAMS of Ukraine during 2010–2020. 39 (12.4%) patients (mean age 57.9±2.1 – 28 men) underwent sbCAS. Primary clinical endpoints (stroke, myocardial infarction, or death) and secondary endpoints (hemodynamic depression (HD) – hypotension (<90 mmHg) or bradycardia (<60 bpm) and hyperperfusion syndrome (HPS) were evaluated. All sbCAS were technically successful, and a reduction of stenosis was noted in each case. There were two periprocedural neurological complications, one transient ischemic attack (TIA), and one minor stroke with the Modified Rankin Scale (mRS) – 3 at discharge. No myocardial infarction (MI) or death during hospitalization was noted. 28 patients (71.8%) had HD, and 2 (5.1%) had HPS. All patients except those with periprocedural stroke were discharged or transferred to another hospital without neurological deterioration. sbCAS is an effective and relatively safe procedure for carefully selected patients with bilateral carotid stenosis. Patients with bilateral carotid stenosis should be carefully examined, and the best treatment strategy should be assessed using a multidisciplinary approach taking into account the possibility of sbCAS.

Hemodynamic depression after carotid surgery: Incidence, risk factors and outcomes

IntroductionHemodynamic 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. MethodsAnalysis 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. ResultsOverall, 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/conclusionIncidence 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.

Incidence and Predictors of Prolonged Hemodynamic Depression After Carotid Artery Stenting: Yet Another Benefit of Statins?

Incidence and Predictors of Prolonged Hemodynamic Depression After Carotid Artery Stenting: Yet Another Benefit of Statins?

Carotid stenting in patients with renal insufficiency – A case series and review of literature

Carotid artery disease is typically the result of atherosclerosis at the bifurcation of the common carotid artery or in the origins of either the internal or external carotid artery. Chronic kidney disease (CKD) has been associated with increased morbidity and mortality after carotid revascularization. In contrast, there are only limited and conflicting data on the impact of CKD in patients undergoing carotid revascularization. Hemodynamic depression which occurs between 7% and 42% of patients undergoing carotid artery stenting might also have an important role in the pathogenesis of associated acute kidney injury. We hereby report two cases of carotid stenting in patients with underlying renal impairment.

Incidence and predictors of prolonged hemodynamic depression after carotid artery stenting: Yet another benefit of statins?

ObjectivesWe aimed to assess the incidence and predictors of prolonged hemodynamic depression (PHD) after carotid artery stenting (CAS). MethodsWe retrospectively analyzed data from 216 CAS procedures performed in 207 patients (156 male; median and interquartile range (IQR) of age 68 (62−73) yr) between July 2012 and October 2020. PHD was defined as hypotension (systolic blood pressure ≤ 90 mmHg) and/or bradycardia (heart rate < 60 bpm) lasting >1 h. ResultsThe incidence of PHD was 25.9%. At multivariate analysis, asymptomatic lesions (OR: 2.43, 95% CI (1.16–5.06), p: 0.018), the stenosis proximity (<10 mm) to bifurcation (OR: 2.94, 95% CI (1.34–6.43), p: 0.007) and implantation of a Protege stent (OR: 2.93, 95% CI (1.14–7.53), p: 0.025) were independent risk factors, while statin usage (OR: 0.48, 95% CI (0.24–0.95), p: 0.036) was an independent protective factor for PHD after CAS. ConclusionsPatients with asymptomatic lesions and stenosis close to the bifurcation are more prone to PHD. The type of the stent selected significantly influences the risk of PHD. Further prospective randomized studies are warranted to investigate the possible protective role of statins against PHD after CAS.

Predisposing Factors and Management of Hemodynamic Depression Following Carotid Artery Stenting.

Carotid artery stenting (CAS) involves dilatation of carotid bulb which can trigger a series of neuronal responses resulting in hemodynamic depression that might influence the outcome of the procedure. This is a frequent but underdiagnosed complication of CAS. Although it is mild, transient and self-limiting in majority of cases, it can result in significant morbidity and mortality if persistent. Neurologists should be aware of the predisposing factors and management of this common complication. In patients who present with stroke following carotid stenting, neurologists should be aware of hypoperfusion secondary to hemodynamic depression as a cause of stroke apart from the stent thrombosis and occlusion.

Time-dependent influence of infliximab on hemodynamic responses and cardiac injuries of isoproterenol-induced myocardial infarction in rats

Immune-induced inflammation plays an important role both in aggravating and healing of post myocardial infarction (MI) injuries. Potent anti-inflammatory and local immunomodulatory activity of infliximab has been suggested to have modulating effects on immune responses after MI. The aim of the present study was to evaluate the efficacy of infliximab on hemodynamic responses and myocardial injuries following isoproterenol-induced myocardial infarction. Male Wistar rats, weighting 260 ± 20 g were assigned into ten groups (n = 6) of saline (normal saline), infliximab (7 mg/kg), isoproterenol (100 mg/kg for two consecutive days), and isoproterenol plus infliximab (30 min after the second injection of isoproterenol). The heart tissues and serums were analyzed 24, 48, 72, and 96 h post-MI and hemodynamic parameters, histopathological changes, malondialdehyde (MDA), Total antioxidant capacity (TAC), lactate dehydrogenase (LDH), and lactate levels were assessed in the respective groups. Infliximab partially improved hemodynamic depression in the first days after MI, but the heart became more suppressed later. A similar result also obtained at the MDA tissue levels but not serum levels. Anti-inflammatory effects of Infliximab may improve cardiac function and prevent heart tissue injury early after MI; however, it can worsen the condition later by inhibiting compensatory reactions such as cardiac remodeling and tissue repair.