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Kazantsev AN, Lider RY, Korotkikh AV, Kazantseva EG, Bagdavadze GS, Kravchuk VN, Shmatov DV, Lebedev OV, Lutsenko VA, Zakeryaev AB, Artyukhov S, Palagin PD, Sirotkin AA, Sultanov RV, Taits D, Taits B, Snopova EV, Zharova AS, Zarkua N, Zakharova K, Belov Y. Effects of different types of carotid endarterectomy on the course of resistant arterial hypertension. Vascular 2024; 32:458-466. [PMID: 36409961 DOI: 10.1177/17085381221140620] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
OBJECTIVE Analysis of the dynamics of systolic blood pressure (SBP) and the results of various types of carotid endarterectomy (СЕЕ) (classical with plasty of the reconstruction zone with a patch, eversion, formation of a new bifurcation, autoarterial reconstruction, glomus-saving techniques) in patients with resistant arterial hypertension (RAH). MATERIALS AND METHODS The actual cohort, comparative, retrospective, open research for the period from January 2013 to December 2021 includes 1577 patients with significant hemodynamic stenosis of the internal carotid artery Depending on revascularization strategy five groups were formed: Group 1: 18.3% (n = 289) - classical Carotid endarterectomy with plasty of the reconstruction zone with a patch (from diepoxy-treated xenopericardium or synthetic); Group 2: 29.9% (n = 472) - eversional CEE with cut-off of carotid gloomus (CG); Group 3: 6.9% (n = 109) - the formation of a new bifurcation; Group 4: 7.4% (n = 117) - autoarterial reconstruction; Group 5: 37.4% (n = 590) - glomus-saving CEE (1 technique - according to A.N. Kazantsev; two technicians - according to R.A. Vinogradov; three technicians - according to K.A.Antsupov). According to the 24-h blood pressure monitor in the preoperative period, the following degrees of AH were identified: 1° - 5.7% (n = 89); 2° - 64.2% (n = 1013); and 3° - 30.1% (n = 475). RESULTS In the postoperative period, no significant differences were obtained in the frequency of deaths, myocardial infarction, stroke, hemorrhagic transformation. However, according to the frequency of the combined endpoint (death + myocardial infarction + ischemic stroke + hemorrhagic transformation), the lowest rates were observed in the group of classical carotid endarterectomy with plasty of the reconstruction zone with a patch and glomus-sparing CEE (group 1: 1.03% (n = 3); group 2: 3.6% (n = 17); group 3: 3.67% (n = 4); group 4: 2.56% (n = 3); group 5: 0.5% (n = 3); p = 0.10). This is due to the absence of cases of labile AH and hypertensive crises among patients of groups 1 and 5, which was ensured by the preservation of carotid glomus (CG). As a result, the number of patients with 2 and 3 degrees of hypertension in these groups decreased statistically significantly. The vast majority of patients after these operations achieved a stable target SBP. In groups 2, 3, and 4, there was a statistically significant increase in the number of patients with 2 and 3 degrees of AH, which is associated with excision of the CG. CONCLUSION Classical CEE and glomus-sparing CEE techniques make it possible to achieve a stable target SBP level in patients with RAH as a result of CG preservation. Removal or traumatization of the latter during eversional CEE, the formation of a new bifurcation, autoarterial reconstruction is accompanied by the development of labile hypertension, an increase in the degree of hypertension and a high risk of hemorrhagic transformation in the brain. Thus, the most effective and safe types of CEE in the presence of RAH are classical CEE with plasty of the reconstruction zone with a patch and glomus-sparing CEE, accompanied by the lowest incidence of adverse cardiovascular events caused by postoperative hypertensive crisis and hyperperfusion syndrome.
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Affiliation(s)
- Anton N Kazantsev
- Kostroma Regional Clinical Hospital Named after E. I. Korolev, Kostroma, Russia
| | - Roman Yu Lider
- Ministry of Health of the Russian Federation, Kemerovo State Medical University, Kemerovo, Russia
| | - Alexander V Korotkikh
- Clinic of Cardiac Surgery of the Amur State Medical Academy of the Ministry of Health of Russia, Blagoveshchensk, Russia
| | - Elizaveta G Kazantseva
- Ministry of Health of the Russian Federation, Kemerovo State Medical University, Kemerovo, Russia
| | - Goderzi Sh Bagdavadze
- North-Western State Medical University Named after I. I. Mechnikov, Saint Petersburg, Russia
| | - Vyacheslav N Kravchuk
- North-Western State Medical University Named after I. I. Mechnikov, Saint Petersburg, Russia
| | - Dmitriy V Shmatov
- Clinic of High Medical Technologies Named after N. I. Pirogov, St Petersburg State University, Saint Petersburg, Russia
| | - Oleg V Lebedev
- Kostroma Regional Clinical Hospital Named after E. I. Korolev, Kostroma, Russia
| | - Victor A Lutsenko
- Kemerovo Regional Clinical Hospital Named after S. V. Belyaeva, Kemerovo, Russia
| | - Aslan B Zakeryaev
- Research Institute Regional Clinical Hospital No. 1 Named Prof. S. V. Ochapovsky, Krasnodar, Russia
| | - Sergey Artyukhov
- North-Western State Medical University Named after I. I. Mechnikov, Saint Petersburg, Russia
| | - Petr D Palagin
- Kostroma Regional Clinical Hospital Named after E. I. Korolev, Kostroma, Russia
| | - Alexey A Sirotkin
- Kostroma Regional Clinical Hospital Named after E. I. Korolev, Kostroma, Russia
| | - Roman V Sultanov
- Kemerovo Regional Clinical Hospital Named after S. V. Belyaeva, Kemerovo, Russia
| | - Denis Taits
- North-Western State Medical University Named after I. I. Mechnikov, Saint Petersburg, Russia
| | - Boris Taits
- North-Western State Medical University Named after I. I. Mechnikov, Saint Petersburg, Russia
| | - Elena V Snopova
- Kostroma Regional Clinical Hospital Named after E. I. Korolev, Kostroma, Russia
| | - Alina S Zharova
- North-Western State Medical University Named after I. I. Mechnikov, Saint Petersburg, Russia
| | - Nona Zarkua
- North-Western State Medical University Named after I. I. Mechnikov, Saint Petersburg, Russia
| | - Kristina Zakharova
- North-Western State Medical University Named after I. I. Mechnikov, Saint Petersburg, Russia
| | - Yuriy Belov
- Russian Scientific Center of Surgery Named after Academician B. V. Petrovsky, Moscow, Russia
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Interplay between baroreflex sensitivity, obesity and related cardiometabolic risk factors (Review). Exp Ther Med 2021; 23:67. [PMID: 34934438 PMCID: PMC8649854 DOI: 10.3892/etm.2021.10990] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Accepted: 11/03/2021] [Indexed: 11/26/2022] Open
Abstract
The baroreflex represents a rapid negative feedback system implicated in blood pressure regulation, which aims to prevent blood pressure variations by regulating peripheral vascular tone and cardiac output. The aim of the present review was to highlight the association between baroreflex sensitivity (BRS) and obesity, including factors associated with obesity, such as metabolic syndrome, hypertension, cardiovascular disease and diabetes. For the present review, a literature search was conducted using the PubMed database until August 21, 2021. The searched terms included ‘baroreflex’, and other terms such as ‘sensitivity’, ‘obesity’, ‘metabolic syndrome’, ‘hypertension’, ‘diabetes’, ‘gender’, ‘aging’, ‘children’, ‘adolescents’, ‘physical activity’, ‘bariatric surgery’, ‘autonomous nervous system’ and ‘cardiometabolic risk factors’. Obesity and its related metabolic disorders can influence baroreflex functionality and decrease BRS, mostly by potentiating sympathetic nervous system activity. Obesity induces inflammation, which can increase sympathetic system activity and lead to a higher incidence of cardiovascular events. Obesity also represents an important risk factor for hypertension through numerous mechanisms; in this setting, dysfunctional baroreceptors are not able to protect against constantly elevated blood pressure. Furthermore, diabetes mellitus and oxidative stress result in deterioration of BRS, whereas aging is also generally related to reduced cardiovagal BRS. Differences in BRS have also been observed between men and women, and overall cardiovagal BRS in healthy women is less intense compared with that in men. BRS appears lower in children with obesity compared with that in children of a healthy weight. Notably, physical exercise can increase BRS in both hypertensive and normotensive subjects, and BRS can also be significantly improved following bariatric surgery and weight loss. In conclusion, obesity and its related metabolic disorders may influence baroreflex functionality and decrease BRS, and baroreceptors cannot protect against the constantly elevated blood pressure in obesity. However, following bariatric surgery and weight loss, BRS can be significantly improved. The present review summarizes the role of obesity and related metabolic risk factors in BRS, providing details on possible mechanisms and shedding light on their interplay leading to autonomic neuropathy.
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Kazantsev AN, Vinogradov RA, Chernykh KP, Chernyavsky MA, Kravchuk VN, Shmatov DV, Erofeev AA, Lutsenko VA, Sultanov RV, Shabaev AR, Radjabov IM, Bagdavadze GS, Zarkua NE, Matusevich VV, Vaiman EF, Solobuev AI, Lider RY, Abdullaev AD, Porkhanov VA, Khubulava GG. [A multicenter study on the influence of different kinds of carotidal endarterectomy on the course of resistant arterial hypertension]. Zh Nevrol Psikhiatr Im S S Korsakova 2021; 121:19-30. [PMID: 34693685 DOI: 10.17116/jnevro202112109119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To analyze the dynamics of systolic blood pressure (SBP) and the results of various types of carotid endarterectomy (CEE) in patients with resistant arterial hypertension (RAH). MATERIALS AND METHODS The study included 1577 patients with hemodynamically significant stenosis of the internal carotid artery (ICA) and RAH for more than 3 years. Patients were enrolled from January 2014 to December 2020. Depending on the implemented revascularization strategy, 5 groups were formed: group 1 (n=289 (18.3%)) with classical CEE with plasty of the reconstruction zone with a patch, group 2 (n=472 (29.9%)) with eversional CEE with cut-off of carotid glomus (CG); group 3 (n=109 (6.9%)) with the formation of a new bifurcation; group 4: (n=117 (7.4%)) with autoarterial reconstruction; group 5: (n=590 (37.4%)) with glomus-saving CEE. RESULTS In the postoperative period, no significant differences were obtained in the frequency of deaths (0.34% for group 1; 0.63% for group 2; 0% for groups 3, 4 and 5), myocardial infarction (0.34%, 0.84%, 1.83, 0.85%, 0.33%, respectively); ischemic stroke (0.34%, 1.27%, 0.91%, 0.85%, 0.17%, respectively), hemorrhagic transformation (0%, 0.84%, 0.91%, 0.85%, 0%, respectively). However, according to the frequency of the combined endpoint (death + myocardial infarction + ischemic stroke + hemorrhagic transformation), the lowest rates were observed in the group of classical carotid endarterectomy with plasty of the reconstruction zone with a patch and glomus-sparing CEE (1.03%, 3.6%, 3.67%, 2.56%, 0.5%, respectively). This is due to the absence of cases of labile AH and hypertensive crises among patients of groups 1 and 5, which was ensured by the preservation of carotid glomus (CG). As a result, the number of patients with 2 and 3 degrees of hypertension in these groups decreased statistically significantly. The vast majority of patients after these operations achieved a stable target SBP. In groups 2, 3, and 4, there was a statistically significant increase in the number of patients with 2 and 3 degrees of AH, which is associated with excision of the CG. CONCLUSION Classical CEE and glomus-sparing CEE techniques make it possible to achieve a stable target SBP level in patients with RAH as a result of CG preservation. Removal or traumatization of the latter during eversional CEE, the formation of a new bifurcation, autoarterial reconstruction is accompanied by the development of labile hypertension, an increase in the degree of hypertension and a high risk of hemorrhagic transformation in the brain. Thus, the most effective and safe types of CEE in the presence of RAH are classical CEE with plasty of the reconstruction zone with a patch and glomus-sparing CEE.
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Affiliation(s)
- A N Kazantsev
- City Alexandrovskaya Hospital, St. Petersburg, Russia
| | - R A Vinogradov
- Ochapovsky Research Institute Regional Clinical Hospital No.1, Krasnodar, Russia.,Kuban State Medical University, Krasnodar, Russia
| | - K P Chernykh
- City Alexandrovskaya Hospital, St. Petersburg, Russia
| | - M A Chernyavsky
- Almazov National Medical Research Center Ministry of Health of Russia, St. Petersburg, Russia
| | - V N Kravchuk
- Kirov Military Medical Academy named after SM., St. Petersburg, Russia.,Mechnikov North-Western State Medical University, St. Petersburg, Russia
| | - D V Shmatov
- St. Petersburg State University, Saint Petersburg, Russia
| | - A A Erofeev
- City Multidisciplinary Hospital No. 2, St. Petersburg, Russia
| | - V A Lutsenko
- Belyaeva Kemerovo Regional Clinical Hospital, Kemerovo, Russia
| | - R V Sultanov
- Belyaeva Kemerovo Regional Clinical Hospital, Kemerovo, Russia
| | - A R Shabaev
- Barbarash Kemerovo Regional Clinical Cardiological Dispensary, Kemerovo, Russia
| | - I M Radjabov
- Burdenko Military Clinical Hospital, Moscow, Russia
| | - G Sh Bagdavadze
- Mechnikov North-Western State Medical University, St. Petersburg, Russia
| | - N E Zarkua
- Mechnikov North-Western State Medical University, St. Petersburg, Russia
| | - V V Matusevich
- Ochapovsky Research Institute Regional Clinical Hospital No.1, Krasnodar, Russia
| | - E F Vaiman
- Kemerovo State Medical University, Kemerovo, Russia
| | - A I Solobuev
- Kemerovo State Medical University, Kemerovo, Russia
| | - R Yu Lider
- Kemerovo State Medical University, Kemerovo, Russia
| | - A D Abdullaev
- Pskov regional infectious diseases hospital, Pskov, Russia
| | - V A Porkhanov
- Ochapovsky Research Institute Regional Clinical Hospital No.1, Krasnodar, Russia
| | - G G Khubulava
- Kirov Military Medical Academy named after SM., St. Petersburg, Russia.,Pavlov First Saint Petersburg State Medical University, St. Petersburg, Russia
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Sudheer P, Agarwal A, Vishnu VY, Padma Srivastava MV. Predisposing Factors and Management of Hemodynamic Depression Following Carotid Artery Stenting. Ann Indian Acad Neurol 2021; 24:315-318. [PMID: 34446991 PMCID: PMC8370164 DOI: 10.4103/aian.aian_1299_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 01/13/2021] [Accepted: 01/19/2021] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- Pachipala Sudheer
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Ayush Agarwal
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Venugopalan Y Vishnu
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - M V Padma Srivastava
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
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Saleh M, Ali H, Atalla K, Shahat M, Cieri E. Predictors of Carotid Artery Stenting-Induced Hemodynamic Instability. Vasc Endovascular Surg 2021; 55:475-481. [PMID: 33779409 DOI: 10.1177/15385744211005654] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND To address the predictors of hemodynamic instability (HI) related to carotid artery stenting (CAS) and evaluate the association between HI and periprocedural adverse outcomes. METHODS This study comprised all consecutive patients who underwent CAS for atherosclerotic carotid artery stenosis from March 2014 to May 2018. A standardized dose of atropine (0.4 mg) was given prior to stent deployment. Changes in heart rate, blood pressure, and neurological status were monitored and recorded. Potential predictors of HI were tested in multivariate analysis using binary logistic regression model. RESULTS A total of 728 patients were enrolled. Two hundred twenty seven patients (31.2%) developed periprocedural HI. The presence of hypertension (OR, 2.037; 95% CI, 1.292-3.211; P = 0.0022), symptomatic carotid lesions (OR, 1.704; 95% CI, 1.057-2.747; P = 0.0287), right sided lesions (OR, 3.090; 95% CI, 1.934-4.935; P ≤ 0.0001), hyperechoic/calcified plaques (OR, 2.195; 95% CI, 1.458-3.304; p P = 0.0002), and longer lesions (OR, 1.043; 95% CI, 1.012-1.076; P = 0.0072) were significant predictable factors for the occurrence of HI. On the other hand, smoking was significantly associated with a 48.1% decrease in risk of development of HI (OR, 0.519; 95% CI, 0.358-0.754; P = 0.0006). There were no statistically significant differences in periprocedural morbidity or mortality between patients with and without HI. CONCLUSION HI occurs in a considerable percentage of patients undergoing CAS. Hypertension, right sided, symptomatic carotid lesions, calcified plaques, and longer lesions were shown to be independent risk factors for the development of periprocedural HI. Conversely, smoking demonstrated a protective effect. HI did not appear to predispose to periprocedural adverse events.
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Affiliation(s)
- Mahmoud Saleh
- Vascular and Endovascular Surgery Department, 68866Assiut University Hospitals, Assiut, Egypt
| | - Haitham Ali
- Vascular and Endovascular Surgery Department, 68866Assiut University Hospitals, Assiut, Egypt
| | - Khaled Atalla
- Vascular and Endovascular Surgery Department, 68866Assiut University Hospitals, Assiut, Egypt
| | - Mohammed Shahat
- Vascular and Endovascular Surgery Department, 68866Assiut University Hospitals, Assiut, Egypt.,Division of Vascular and Endovascular Surgery, 9309University of Perugia, Perugia, Italy
| | - Enrico Cieri
- Division of Vascular and Endovascular Surgery, 9309University of Perugia, Perugia, Italy
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Prolonged Autonomic Fluctuation Derived from Parasympathetic Hypertonia after Carotid Endarterectomy but not Stenting. J Stroke Cerebrovasc Dis 2018; 28:10-20. [PMID: 30366866 DOI: 10.1016/j.jstrokecerebrovasdis.2018.09.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 08/21/2018] [Accepted: 09/02/2018] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Carotid endarterectomy (CEA) is a standard treatment for carotid artery stenosis, but the incidence after periprocedural myocardial infarction (MI) is not negligible. The mechanism for the higher risk of MI following CEA compared with the carotid artery stenting (CAS) is unclear. We hypothesized that it may be explained by different autonomic nervous responses. METHODS This prospective, nonrandomized, observational study enrolled 50 patients from 2 centers: 25 underwent CEA and 25 CAS. Cardiac autonomic nervous activity was evaluated using 24-hour high-resolution ambulatory electrocardiography with parameters such as deceleration capacity (DC) and heart rate variability before the procedure, and at 1 week and 1-3 months after the procedure. RESULTS One week after CEA, decreased DC and increased acceleration capacity were recognized. Standard deviation of sequential 5-minute NN interval means and the low-frequency and high-frequency components were all decreased. By the later phase measurement, these changes returned to baseline or beyond. The results suggest that diminished autonomic activity reversed to excessive parasympathetic dominance. In contrast, the patients treated by CAS showed no remarkable autonomic modification in the early or later phases. CONCLUSIONS Distinct changes of sympathovagal response observed after CEA coincides with the time at which MI onset occurs, suggesting prolonged autonomic fluctuation may be a factor in the MI incidence after CEA.
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Gökçal E, Niftaliyev E, Deniz Ç, Ergelen M, Güzel V, Göktekin Ö, Asil T. Prolonged hypotension after carotid artery stenting: incidence, predictors and consequences. Acta Neurochir (Wien) 2017; 159:2081-2087. [PMID: 28815338 DOI: 10.1007/s00701-017-3295-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 08/01/2017] [Indexed: 01/24/2023]
Abstract
BACKGROUND Hemodynamic changes frequently occur after carotid artery stenting (CAS), and in some patients these changes, particularly hypotension, may be prolonged. There are discrepant results for predicting patients at high risk for these prolonged hemodynamic changes and identifying the effect on clinical outcome. In this study, we aimed to determine the frequency, predictors and consequences associated with prolonged hypotension (PH) after CAS in our center. METHODS We retrospectively analyzed the demographics, risk factors, nature of carotid disease, degree of stenosis of both internal carotid arteries, stent diameter and site of dilatation during stenting in 137 CAS procedures. After CAS, duration of hospital stay, complications during hospital stay and major vascular events or death in a 3-month period were evaluated. PH was defined as a systolic blood pressure <90 mmHg lasting more than 1 h despite adequate treatment after CAS. RESULTS PH occured in 23 (16.8%) patients. The presence of contralateral stenosis ≥70% and absence of diabetes mellitus were significantly associated with PH. Duration of hospital stay was significantly longer in patients with PH. No patients with PH had a periprocedural complication or major vascular events in the follow-up period. CONCLUSION PH was more prevalent in patients with contralateral high-degree carotid stenosis and patients without diabetes mellitus after CAS. PH did not cause any post-procedural complications or major vascular events at follow-up, but it resulted longer hospital stays. Further studies are needed to better define the pathophysiologic mechanisms underlying these hemodynamic alterations.
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Affiliation(s)
- Elif Gökçal
- Neurology Department, Bezmialem Vakıf University, İstanbul, Turkey.
| | - Elvin Niftaliyev
- Neurology Department, Bezmialem Vakıf University, İstanbul, Turkey
| | - Çiğdem Deniz
- Neurology Department, Bezmialem Vakıf University, İstanbul, Turkey
| | - Mehmet Ergelen
- Cardiology Department, Bezmialem Vakıf University, İstanbul, Turkey
| | - Vildan Güzel
- Neurology Department, Bezmialem Vakıf University, İstanbul, Turkey
| | - Ömer Göktekin
- Cardiology Department, Bezmialem Vakıf University, İstanbul, Turkey
| | - Talip Asil
- Neurology Department, Bezmialem Vakıf University, İstanbul, Turkey
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Vykoupil K, Galuszka J, Drac P, Taborsky M. Autonomic control of blood circulation in patients undergoing elective carotid endarterectomy. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2017; 162:36-39. [PMID: 29086771 DOI: 10.5507/bp.2017.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2017] [Accepted: 10/17/2017] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Internal carotid artery stenosis (ICAS) is associated with significantly higher risk of stroke. Autonomic function can be impaired in the presence of atheroma in the carotid sinus region. Two parameters of autonomic nervous system (ANS) function e.g. heart rate variability (HRV) and baroreflex sensitivity (BRS) are respected predictors of cardiovascular prognosis. We assessed the effect of elective unilateral carotid endarterectomy (CEA) on cardiovascular autonomic functions as a major prognostic factor for cardiovascular health. METHODS Nineteen patients indicated for CEA underwent formal autonomic assessment in the laboratory. Hemodynamic profiles, HRV and BRS were evaluated with the dedicated high-tech device Task Force Monitor before surgery (day-1) and postoperatively (day 3±1). Data were obtained during 5 min orthostatic challenge and subsequent 5 min in a supine position. RESULTS There were no significant early postoperative changes in evaluated parameters after CEA. There was a mild decrease of blood pressure and therefore only a slight increase in BRS. It was also possible to observe a rise in the value of total power and high frequency power. CONCLUSION In the early postoperative period, healing processes are occurring and the sympatho-vagal interaction is probably still unbalanced. Given the considerable clinical potential of BRS and HRV measurement, further short-term and, more importantly, long-term investigations are needed.
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Affiliation(s)
- Karel Vykoupil
- Department of Internal Medicine I - Cardiology, University Hospital Olomouc, Czech Republic
| | - Jan Galuszka
- Department of Internal Medicine I - Cardiology, University Hospital Olomouc, Czech Republic
| | - Petr Drac
- Department of Surgery II - Vascular and Transplantation Surgery, University Hospital Olomouc, Czech Republic
| | - Milos Taborsky
- Department of Internal Medicine I - Cardiology, University Hospital Olomouc, Czech Republic
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Kim JW, Do Y. Hemodynamic Depression of Early Carotid Revascularization on Ischemic Stroke Patients with Symptomatic Carotid Stenosis. JOURNAL OF NEUROCRITICAL CARE 2017. [DOI: 10.18700/jnc.170012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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10
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Chang A, Hung HF, Hsieh FI, Chen WH, Yeh HL, Yeh JH, Chiu HC, Lien LM. Beneficial effects of prolonged blood pressure control after carotid artery stenting. Clin Interv Aging 2017; 12:103-109. [PMID: 28123290 PMCID: PMC5230727 DOI: 10.2147/cia.s122352] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objectives The main purpose of this study was to investigate whether carotid artery stenting (CAS) plus medicine in patients with severe carotid artery stenosis provide a better long-term blood pressure (BP) control compared to other medical treatments alone. The other aim was to explore the correlation between post-CAS hypotension within 6 h and long-term BP reductions after CAS. Materials and methods Patients with severe carotid stenosis were recruited either in the CAS group or in the medication group. BPs and the number of classes of antihypertensive agents were recorded at baseline, 6, and 12 months. Extra BP information was collected at 6 h, 3 days, and 1 month after CAS. Univariate and multivariate linear regressions were performed to test the relationship of BP changes among CAS and medication groups after 6 and 12 months of follow-up. Univariate linear regressions were also used to determine the correlations between the mean or maximal systolic BP (SBP) reductions at 6 h and 1 year post-CAS. Results In total, 72 members in the CAS group and 82 members in the medication group were recruited. Compared with the medication group, patients in the CAS group had greater BP reductions at 6 and 12 months of follow-up after adjusting for confounding factors (13.56 mmHg at 6 months, P=0.0002; 16.98 mmHg at 12 months, P<0.0001). This study also shows significant positive correlations between the mean or maximal SBP reductions 6 h post-CAS and SBP reductions 1 year post-CAS (β =0.20±0.07, P=0.0067 and β =0.47±0.10, P<0.0001, respectively). Conclusion As compared to medical treatment alone, CAS may provide significant beneficial effect on long-term BP control 1 year post-CAS. Furthermore, SBP reductions 6 h post-CAS may predict the SBP reductions 1 year post-CAS.
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Affiliation(s)
- Anna Chang
- Department of Neurology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei
| | - Huei-Fong Hung
- Department of Cardiology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei
| | - Fang-I Hsieh
- School of Public Health, College of Public Health, Taipei Medical University, Taipei
| | - Wei-Hung Chen
- Department of Neurology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei; School of Medicine, College of Medicine, Taipei Medical University, Taipei
| | - Hsu-Ling Yeh
- Department of Neurology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei; Institute of Public Health, National Yang-Ming University, Taipei
| | - Jiann-Horng Yeh
- Department of Neurology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei; School of Medicine, College of Medicine, Fu Jen Catholic University, Taipei, Taiwan
| | - Hou-Chang Chiu
- Department of Neurology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei; School of Medicine, College of Medicine, Fu Jen Catholic University, Taipei, Taiwan
| | - Li-Ming Lien
- Department of Neurology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei; School of Medicine, College of Medicine, Taipei Medical University, Taipei
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Rupprecht S. Reply. J Vasc Surg 2016; 64:1550-1551. [DOI: 10.1016/j.jvs.2016.08.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Accepted: 08/07/2016] [Indexed: 10/20/2022]
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Autonomic outcome is better after endarterectomy than after stenting in patients with asymptomatic carotid stenosis. J Vasc Surg 2016; 64:975-84. [DOI: 10.1016/j.jvs.2016.04.040] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 04/12/2016] [Indexed: 11/17/2022]
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Hosn MA, Adams B, Pederson M, Kresowik T, Pascarella L. Long-Term Effect of the Type of Carotid Endarterectomy on Blood Pressure. Ann Vasc Surg 2016; 39:204-208. [PMID: 27554699 DOI: 10.1016/j.avsg.2016.05.129] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Revised: 05/11/2016] [Accepted: 05/26/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND The dissection of the carotid sinus nerve in eversion carotid endarterectomy (eCEA) has been hypothesized to cause an increase in postoperative blood pressure (BP). The objective of this study is to evaluate the effect of eCEA on BP and changes in BP medications over the course of year-long follow-up after eCEA compared with longitudinal incision carotid endarterectomy patch angioplasty (pCEA). METHODS A retrospective review of patients who underwent CEA between July 1, 2009 and June 30, 2014 in the Vascular Surgery Department at The University of Iowa Hospital and Clinics was conducted. Demographics, comorbidities, BP, and number, dosage, and type of antihypertensive medications were collected preoperatively, at 30 days, and at 12 months. The differences in BP and medications between pCEA and eCEA patients were compared. Demographic data and comorbidities were compared using t-tests and chi-squared analysis. Differences in BP and medication dosages were analyzed using multivariate analysis of variance. RESULTS In total, 363 CEA procedures were performed during the study period, of which 275 procedures were included in the final analysis. Thirty percent of the patients underwent eCEA. Fifty-four percent of the patients who underwent eCEA and 60% of the patients who underwent pCEA were symptomatic. Thirty-day mortality was 1.4% and 12-month mortality was 6.4% for the entire population. No postoperative neurologic deficits, including stroke, were observed. Analysis of BP did not yield a significant difference among preoperative, 30-day, and 12-month follow-up measurements (P = 0.893). There was no significant change to the number and total daily dose of BP medications preoperatively, at 30 days, or at 12 months. CONCLUSIONS There is no statistical difference in mortality, morbidity, and patency rates at 30 days and 12 months between pCEA and eCEA. eCEA is also not associated with long-term BP changes compared with pCEA.
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Affiliation(s)
- Maen Aboul Hosn
- Division of Vascular Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA.
| | - Brian Adams
- Division of Vascular Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Mark Pederson
- Division of Vascular Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Timothy Kresowik
- Division of Vascular Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Luigi Pascarella
- Division of Vascular Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA
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Kansal N, Clair DG, Jaye DA, Scheiner A. Carotid baroreceptor stimulation blood pressure response mapped in patients undergoing carotid endarterectomy (C-Map study). Auton Neurosci 2016; 201:60-67. [PMID: 27539629 DOI: 10.1016/j.autneu.2016.07.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Revised: 07/08/2016] [Accepted: 07/29/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Continuous stimulation of the carotid baroreceptors has been shown to evoke a sustained systolic blood pressure (SBP) reduction in hypertensive subjects. This study conducted a detailed mapping of the SBP and heart rate response to electrical stimulus at different locations in the carotid sinus region in patients undergoing a carotid endarterectomy (CEA). METHODS The Carotid Sinus Autonomic Response Mapping (C-Map) Study is a multicenter, prospective, non-randomized, acute feasibility study conducted in 10 hypertensive subjects undergoing CEA. Electrode pairs were placed in multiple locations in the region of the carotid sinus for acute stimulation, and the tests were repeated after plaque removal and vessel repair. RESULTS The configuration that elicited the largest pressure reduction in 8 of 10 patients was with the electrodes arranged longitudinally along the medial (in relation to the bifurcation) wall of the internal carotid artery (ICA) near the bifurcation (11.2±8.1mmHg, p<0.05). There was no difference in average maximum response pre vs. post plaque removal. Spontaneous baroreflex sensitivity increased from 6.0±3.2ms/mmHg pre-CEA to 8.2±5.4ms/mmHg post-CEA (p=0.040). CONCLUSIONS Endarterectomy surgery did not affect maximal acute stimulation response but improved baroreflex sensitivity acutely. Acute extravascular baroreceptor stimulation (BRS) mapping demonstrated that blood pressure reductions are dependent on electrode location and orientation. In most subjects, the largest SBP reductions were elicited in the region of the medial wall of the ICA. This area can be targeted for future BRS lead design and implant.
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Affiliation(s)
- Nikhil Kansal
- University of California, San Diego, VA San Diego Healthcare System, Division of Vascular and Endovascular Surgery, San Diego, CA, United States.
| | - Daniel G Clair
- The Cleveland Clinic Foundation, Department of Vascular Surgery, Cleveland, OH, United States
| | - Deborah A Jaye
- Medtronic plc, Cardiac Rhythm and Heart Failure, Minneapolis, MN, United States
| | - Avram Scheiner
- Medtronic plc, Cardiac Rhythm and Heart Failure, Minneapolis, MN, United States
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Švigelj V, Šinkovec M, Avbelj V, Trobec R, Gaspar L, Petrovič D, Kruzliak P. Cardiovagal and adrenergic function tests in unilateral carotid artery stenosis patients-a Valsalva manoeuvre tool to show an autonomic dysfunction? Wien Klin Wochenschr 2016; 128:504-12. [PMID: 26980215 DOI: 10.1007/s00508-016-0980-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2015] [Accepted: 02/18/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND The stability of an arterial baroreflex depends also upon the integrity of the afferent limb. For its quantification, we can use a noninvasive test such as baroreceptor sensitivity estimation during Valsalva manoeuvre. The aim of this study was to evaluate potential autonomic dysfunction in patients with unilateral severe carotid disease and compare the results to the results obtained from an age and gender matched group of healthy volunteers. METHODS We evaluated dynamic changes during Valsalva manoeuvre (Valsalva ratio, cardiovagal and adrenergic baroreceptor sensitivity, sympathetic indexes and its dynamic ranges) in 41 patients (29 males; 62.9 ± 7.4 years) and compared the results to results obtained from volunteers (62.8 ± 7.0 years). RESULTS Valsalva ratio between the patients and control group revealed no significant difference, as well as cardiovagal and adrenergic baroreceptor sensitivity. Sympathetic indexes, except for sympathetic index 2, reflecting the sympathetic vasoconstrictor baroreceptor response in late phase 2 of Valsalva manoeuvre (7.1 ± 13.1 mmHg in patients vs. 11.4 ± 10.2 mmHg in control group; p = 0.012) showed no significant differences between the studied groups. The most prominent dynamic range between the groups was within the sympathetic index 2. CONCLUSION With some Valsalva manoeuvre test results, we were not able to show severe autonomic dysfunction in unilateral severe carotid stenosis patients except for lower vasoconstriction response within the late phase 2 of the manoeuvre.
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Affiliation(s)
- Viktor Švigelj
- Division of Neurology, Department of Vascular Neurology and Neurological Intensive Care, Neurological Intensive Care Unit, University Medical Centre Ljubljana, Zaloška 2, 1525, Ljubljana, Slovenia.
| | - Matjaž Šinkovec
- Division of Internal Medicine, Department of Cardiology, University Medical Centre Ljubljana, Zaloška 2, 1525 Ljubljana, Slovenia
| | - Viktor Avbelj
- Department of Communication Systems, Jožef Stefan Institute, Jamova 39, 1000 Ljubljana, Slovenia
| | - Roman Trobec
- Department of Communication Systems, Jožef Stefan Institute, Jamova 39, 1000 Ljubljana, Slovenia
| | - Ludovit Gaspar
- 2nd Department of Internal Medicine, Faculty of Medicine, Comenius University and University Hospital, Mickiewiczova 13, 813 69, Bratislava, Slovak Republic
| | - Daniel Petrovič
- Institute of Histology and Embryology, Faculty of Medicine, University of Ljubljana, Korytkova 2, 1000 Ljubljana, Slovenia
| | - Peter Kruzliak
- 2nd Department of Internal Medicine, Faculty of Medicine, Masaryk University, Pekarska 53, 656 91, Brno, Czech Republic.,Laboratory of Structural Biology and Proteomics, Faculty of Pharmacy, University of Veterinary Medicine and Pharmaceutical Sciences, Brno, Czech Republic
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Švigelj V, Šinkovec M, Avbelj V, Trobec R. Simple cardiovagal and adrenergic function tests in carotid artery stenosis patients as a potential tool for determining a transient autonomic dysfunction. Clin Auton Res 2015; 25:383-90. [PMID: 26374301 DOI: 10.1007/s10286-015-0316-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2014] [Accepted: 08/24/2015] [Indexed: 11/24/2022]
Abstract
PURPOSE The arterial baroreflex depends on the integrity of the afferent limb, which can be quantified using the baroreceptor's sensitivity (BRS) during the Valsalva maneuver (VM). The aim of this study was to evaluate, using autonomic nervous system tests, the autonomic function in patients after a carotid artery angioplasty (CAS). METHODS We evaluated the changes in blood pressure (BP) during the VM (Valsalva ratio, BRS, sympathetic indexes) in 41 patients with symptomatic, unilateral, internal carotid artery stenosis. RESULTS The Valsalva ratio between the baseline and the post-procedural day (1.3 ± 0.1 vs 1.44 ± 0.3; P = 0.002) and the post-procedural day and a month later (1.44 ± 0.3 vs 1.3 ± 0.3; P = 0.0002) revealed significant differences. This was confirmed with a cardiovagal BRS test. However, the adrenergic BRS did not reveal any differences. Sympathetic indexes [BP fall (SI1) and recovery during phase 2 (SI2)] showed differences for the periods before and a day after the treatment (36.9 ± 18.0 vs 27.2 ± 21.4 and 7.1 ± 13.1 vs 3.0 ± 8.2, respectively; P = 0.004) and for SI1 a day and a month after the treatment (27.2 ± 21.4 vs 37.1 ± 21.8; P = 0.036). The dynamic ranges between S1 and S3 (the difference in the BP between the baseline and the end of phase 2) were also different (P = 0.007 and P = 0.044, respectively). CONCLUSION We found heterogeneous responses in the BP regulation obtained with the Valsalva maneuver in our patients; however, we could not confirm that CAS provoked any long-term autonomic dysfunction, except for 1 day after the procedure.
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Affiliation(s)
- Viktor Švigelj
- Neurological Intensive Care Unit, Division of Neurology, Department of Vascular Neurology and Intensive Care, University Medical Centre Ljubljana, Zaloška 2, 1525, Ljubljana, Slovenia.
| | - Matjaž Šinkovec
- Division of Internal Medicine, Department of Cardiology, University Medical Centre Ljubljana, Zaloška 7, 1525, Ljubljana, Slovenia
| | - Viktor Avbelj
- Department of Communication Systems, Jožef Stefan Institute, Jamova 39, 1000, Ljubljana, Slovenia
| | - Roman Trobec
- Department of Communication Systems, Jožef Stefan Institute, Jamova 39, 1000, Ljubljana, Slovenia
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Vanpeteghem C, Moerman A, De Hert S. Perioperative Hemodynamic Management of Carotid Artery Surgery. J Cardiothorac Vasc Anesth 2015; 30:491-500. [PMID: 26597466 DOI: 10.1053/j.jvca.2015.07.030] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Indexed: 01/21/2023]
Affiliation(s)
| | - Anneliese Moerman
- Department of Anesthesiology, University Hospital Ghent, Ghent, Belgium
| | - Stefan De Hert
- Department of Anesthesiology, University Hospital Ghent, Ghent, Belgium
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Giani L, Lovati C, Rosa S, Gambaro P, De Angeli F, Mariani C. Episodes of flushing, dyspnea and hypertension after carotid stenting for severe carotid stenosis. Auton Neurosci 2015; 193:147-8. [PMID: 26165879 DOI: 10.1016/j.autneu.2015.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2014] [Revised: 07/02/2015] [Accepted: 07/06/2015] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Carotid angioplasty and stenting (CAS) is a treatment option for carotid stenosis in high surgical risk patients. As it implies instrumentation of the carotid bulb, baroreceptors dysfunction may be provoked with consequent hemodynamic instability. REPORT An 83-year-old woman treated by CAS presented with episodes of flushing, dyspnea and palpitations accompanied by transitory desaturation, hypertension, agitation and anxiety. Symptoms started 12h after the procedure. Each episode lasted 10 min. Five episodes in 3 days were observed. DISCUSSION A dysfunction of the carotid baroreceptors and chemoreceptors was hypothesized.
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Affiliation(s)
- L Giani
- Department of Neurology, L. Sacco Hospital, University of Milan, Italy.
| | - C Lovati
- Department of Neurology, L. Sacco Hospital, University of Milan, Italy
| | - S Rosa
- Department of Neurology, L. Sacco Hospital, University of Milan, Italy
| | - P Gambaro
- Department of Neurology, L. Sacco Hospital, University of Milan, Italy
| | - F De Angeli
- Department of Neurology, L. Sacco Hospital, University of Milan, Italy
| | - C Mariani
- Department of Neurology, L. Sacco Hospital, University of Milan, Italy
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Cao Q, Zhang J, Xu G. Hemodynamic changes and baroreflex sensitivity associated with carotid endarterectomy and carotid artery stenting. INTERVENTIONAL NEUROLOGY 2015; 3:13-21. [PMID: 25999987 DOI: 10.1159/000366231] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Atherosclerotic carotid lesion is a major cause of stroke which accounts for up to 20% of ischemic stroke. Aggressive treatment of carotid stenosis may prevent stroke. Currently, carotid endarterectomy (CEA) and carotid artery stenting (CAS) are the first-line treatments for severe carotid stenosis. CEA is superior to medical therapy in preventing stroke and cardiovascular death. CAS has emerged as an alternative to CEA in recent years due to its less invasive nature. However, both CEA and CAS may be associated with adverse hemodynamic changes as well as a variation of carotid baroreflex sensitivity. There is no consensus on which of these two methods is more advantageous concerning the procedure-related hemodynamic changes. This article reviews the hemodynamic changes and baroreflex sensitivity after CEA and CAS.
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Affiliation(s)
- Qinqin Cao
- Department of Neurology, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Jun Zhang
- Department of Neurology, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Gelin Xu
- Department of Neurology, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
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Csobay-Novák C, Bárány T, Zima E, Nemes B, Sótonyi P, Merkely B, Hüttl K. Role of Stent Selection in the Incidence of Persisting Hemodynamic Depression After Carotid Artery Stenting. J Endovasc Ther 2015; 22:122-9. [DOI: 10.1177/1526602814566404] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Purpose: To investigate the possible role of stent selection and procedure-related vessel diameter changes in the development of persisting hemodynamic depression (PHD) and to demonstrate the effectiveness and safety of permanent pacemaker implantation in patients with refractory PHD. Methods: Data from 584 procedures performed in 542 patients (398 men; mean age 67.3 years) between 2008 and 2011 using Wallstent, Precise, and Xact stents in a nonrandomized fashion were analyzed retrospectively. Cardiovascular risk factors and lesion, stent, and balloon characteristics were collected, and the pre- and postprocedure diameters of the common carotid artery (CCA) and internal carotid artery were measured. PHD was defined as any episode of hypotension (systolic blood pressure <90 mm Hg) and/or bradycardia (heart rate <60/min) lasting >6 hours. Risk factors for PHD were sought using logistic regression analyses; the results are presented as the odds ratio (OR) and 95% confidence interval (CI). Results: The incidence of PHD was 37.0% (216/584). Refractory PHD was encountered in 9 patients; among these, 6 were successfully treated with pacemaker implantation. A history of prior ipsilateral carotid endarterectomy (OR 0.44, 95% CI 0.22 to 0.87, p=0.019) and the presence of a contralateral high-grade stenosis (OR 0.12, 95% CI 0.02 to 0.95, p=0.045) were independent protective factors, while calcification (OR 1.5, 95% CI 1.03 to 2.18, p=0.034), involvement of the carotid bulb (OR 2.56, 95% 1.62 to 4.03, p<0.001), and implantation of a nitinol stent (adjusted OR 1.62, 95% CI 1.12 to 2.34, p=0.011) were independent risk factors for developing PHD after carotid artery stenting. The ratio of the post-/preprocedure CCA diameter (p=0.002), the stent to CCA diameter ratio (p=0.009), and the presence of residual stenosis (p=0.009) were significantly higher in the PHD group. Conclusion: Stent selection and procedure-related changes in vessel diameter may have an influence on the development of PHD. Permanent pacemaker implantation is an effective treatment option in patients with refractory PHD.
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Affiliation(s)
| | - Tamás Bárány
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Endre Zima
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Balázs Nemes
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Péter Sótonyi
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Béla Merkely
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Kálmán Hüttl
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
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Carotid interventions and blood pressure. Wien Med Wochenschr 2014; 164:503-7. [DOI: 10.1007/s10354-014-0327-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Accepted: 10/21/2014] [Indexed: 10/24/2022]
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Complications and predictors associated with persistent hemodynamic depression after carotid artery stenting. Clin Neurol Neurosurg 2014; 124:81-4. [DOI: 10.1016/j.clineuro.2014.06.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Revised: 05/31/2014] [Accepted: 06/10/2014] [Indexed: 11/17/2022]
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Silva RMFLD, Silva CAB, Greco OJ, Moreira MDCV. Spectral analysis related to bare-metal and drug-eluting coronary stent implantation. Arq Bras Cardiol 2014; 103:138-45. [PMID: 25029473 PMCID: PMC4150665 DOI: 10.5935/abc.20140094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Accepted: 04/30/2014] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND The autonomic nervous system plays a central role in cardiovascular regulation; sympathetic activation occurs during myocardial ischemia. OBJECTIVE To assess the spectral analysis of heart rate variability during stent implantation, comparing the types of stent. METHODS This study assessed 61 patients (mean age, 64.0 years; 35 men) with ischemic heart disease and indication for stenting. Stent implantation was performed under Holter monitoring to record the spectral analysis of heart rate variability (Fourier transform), measuring the low-frequency (LF) and high-frequency (HF) components, and the LF/HF ratio before and during the procedure. RESULTS Bare-metal stent was implanted in 34 patients, while the others received drug-eluting stents. The right coronary artery was approached in 21 patients, the left anterior descending, in 28, and the circumflex, in 9. As compared with the pre-stenting period, all patients showed an increase in LF and HF during stent implantation (658 versus 185 ms2, p = 0.00; 322 versus 121, p = 0.00, respectively), with no change in LF/HF. During stent implantation, LF was 864 ms2 in patients with bare-metal stents, and 398 ms2 in those with drug-eluting stents (p = 0.00). The spectral analysis of heart rate variability showed no association with diabetes mellitus, family history, clinical presentation, beta-blockers, age, and vessel or its segment. CONCLUSIONS Stent implantation resulted in concomitant sympathetic and vagal activations. Diabetes mellitus, use of beta-blockers, and the vessel approached showed no influence on the spectral analysis of heart rate variability. Sympathetic activation was lower during the implantation of drug-eluting stents.
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Bost RB, Hendrikse J, Algra A, de Borst GJ, Kappelle LJ, Jongen LM, Brown MM, van der Worp HB. Effects of Carotid Endarterectomy or Stenting on Arterial Diameters in the Circle of Willis. J Stroke Cerebrovasc Dis 2014; 23:699-705. [DOI: 10.1016/j.jstrokecerebrovasdis.2013.06.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2013] [Revised: 05/16/2013] [Accepted: 06/10/2013] [Indexed: 10/26/2022] Open
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Marrocco-Trischitta MM, Cremona G, Lucini D, Natali-Sora MG, Cursi M, Cianflone D, Pagani M, Chiesa R. Peripheral baroreflex and chemoreflex function after eversion carotid endarterectomy. J Vasc Surg 2013; 58:136-44.e1. [DOI: 10.1016/j.jvs.2012.11.130] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2012] [Revised: 08/20/2012] [Accepted: 11/25/2012] [Indexed: 12/19/2022]
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Monitoring of Hemodynamic Change in Patients with Carotid Artery Stenosis During the Tilt Test Using Wearable Near-Infrared Spectroscopy. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2013. [DOI: 10.1007/978-1-4614-7411-1_62] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register]
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Alici G, Ozkan B, Acar G, Sahin M, Yazicioglu MV, Bulut M, Kiraz OG, Esen AM. Evaluation of autonomic functions by heart rate variability after stenting in patients with carotid artery stenosis. Ann Noninvasive Electrocardiol 2013; 18:126-9. [PMID: 23530482 DOI: 10.1111/anec.12054] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE Although carotid stenting is an effective treatment for severe carotid stenosis, it has been associated with alterations in autonomic functions during or shortly after the procedure. Heart rate variability (HRV) is an established tool for the asessment of autonumic functions. In this study, our aim was to investigate the relation between the alterations in autonomic functions and HRV by Holter monitoring parameters. METHODS Patients (19 male, 8 female) that are suitable for carotid artery stenting, without a history of hypertension, diabetes mellitus, severe coronary artery or valvular heart disease, were enrolled to our study. Short-term HRV analysis recordings were obtained at the beginning, and after the procedure. The square root of the mean squared differences of successive NN intervals (RMSSD), total frequency, low frequency (LF), high frequency (HF), normalized units LF (LFnu), normalized units HF (HFnu), LF/HF ratios were analyzed. Results were statistically analysed by using Wilcoxon test. RESULTS Total frequency did not show any significant changes after the procedure (1101 ± 829, 981 ± 855). While RMSSD and HFnu values significantly increased respectively (23 ± 12/33 ± 22, and 22 ± 10/35 ± 10, p < 0.05) after the procedure, HF values increased nonsignificantly after the procedure (82 ± 92/92 ± 108). LF, LFnu, and LF/HF values were significantly decreased after the procedure. (228 ± 166/112 ± 100, 70 ± 15/55 ± 18, 4 ± 2.5/2.1 ± 2, respectively, p < 0.05) CONCLUSIONS While RMSSD and HF are used as markers of vagal activity, LF is a marker of sympathetic modulation and LF/HF ratio shows sympathovagal balance. In our study, we showed that carotid artery stenting is associated with increase in parasympathetic activation, and this finding is demonstrated by HRV parameters.
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Affiliation(s)
- Gokhan Alici
- Department of Cardiology, Kartal Kosuyolu Yuksek Ihtisas Hospital, Istanbul, Turkey 34865.
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Society for Vascular Nursing clinical practice guideline (CPG) for carotid artery stenting. JOURNAL OF VASCULAR NURSING 2013; 31:32-55. [PMID: 23481879 DOI: 10.1016/j.jvn.2012.12.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2012] [Revised: 11/30/2012] [Accepted: 12/03/2012] [Indexed: 02/07/2023]
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Mylonas SN, Moulakakis KG, Antonopoulos CN, Kakisis JD, Liapis CD. Carotid Artery Stenting–Induced Hemodynamic Instability. J Endovasc Ther 2013; 20:48-60. [DOI: 10.1583/12-4015.1] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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30
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Alici G, Ozkan B, Yazicioglu MV, Sahin M, Bulut M, Acar G, Kiraz OG, Esen AM. P-wave dispersion by 12-lead electrocardiography in carotid artery stenting. Clin Auton Res 2013; 23:81-4. [PMID: 23275131 DOI: 10.1007/s10286-012-0186-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2012] [Accepted: 12/06/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Although carotid artery stenting (CAS) is an effective treatment for severe carotid stenosis, it has been associated with alterations in autonomic functions during or shortly after the procedure. And, autonomic functions influence P-wave durations. In this study, our aim was to investigate P-wave durations on 12-lead surface electrocardiography after CAS. METHODS Patients (19 male, 8 female) who are suitable for CAS, without a history of hypertension, diabetes mellitus, severe coronary artery or valvular heart disease, were enrolled in our study. 12-lead surface electrocardiography recordings were obtained at the beginning, immediately after and at the 24 h of the procedure. P-wave maximum, minimum and dispersion durations were analyzed by double-blinded observers. Results were statistically analysed using Friedman and Wilcoxon tests. RESULTS The P maximum and P dispersion values were significantly increased immediately after the procedure and continued with high levels at 24-h recordings, respectively (128 ± 10/19 ± 7, 143 ± 14/37 ± 11, and 137 ± 11/30 ± 7 ms, p value <0.05). The P minimum value was significantly decreased immediately after the procedure (109 ± 11/105 ± 10 ms, p value <0.05). At 24-h recordings, a nonsignificant increase occured in P minimum values (106 ± 8 ms). CONCLUSIONS P maximum and dispersion durations were significantly increased after the CAS and continued with high levels at 24-h recordings, which may be associated with the alterations in autonomic functions via augmented parasympathetic activity by vagally mediated stimulus. Overall, these findings suggest that decline in cardiovascular activity is prolonged at least 24 h after CAS.
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Affiliation(s)
- Gokhan Alici
- Department of Cardiology, Kartal Kosuyolu Yuksek Ihtisas Education and Research Hospital, Istanbul, Turkey.
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Hsu LC, Chang FC, Kuo TBJ, Wong WJ, Hu HH. Cerebral hemodynamics and baroreflex sensitivity after carotid artery stenting. Acta Neurol Scand 2013; 127:46-52. [PMID: 22616889 DOI: 10.1111/j.1600-0404.2012.01679.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2012] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The long-term hemodynamic effects of carotid angioplasty and stenting (CAS) are unclear. We performed a longitudinal study to investigate the variations in cerebral hemodynamics in patients undergoing CAS. MATERIALS AND METHODS We performed prospective evaluation of 63 symptomatic male patients (19 patients had transient ischemic attack and 44 had minor stroke; mean age: 77.3 ± 6.3 years [range: 51-86]). The mean blood flow velocities (MBFV) and pulsatility index (PI) of the middle cerebral arteries (MCA) on both sides were evaluated using transcranial color-coded Doppler (TCCD) ultrasonography. Cardiac autonomic activities were evaluated by measuring baroreflex sensitivity (BRS). All parameters were measured at baseline prior to CAS and at 1, 3, 6, and 12 months after CAS. RESULTS The preoperative MBFV and PI of the ipsilateral MCA were significantly lower than those of the contralateral side. However, after CAS, MBFV in the ipsilateral MCA increased significantly until 2 weeks after stenting, after which the MBFV gradually decreased and remained stable for 1 year after CAS. Further, we observed a nonsignificant increase in MBFV in the contralateral MCA after CAS. In contrast to the MBFV, the BRS values decreased significantly 1 month after stenting and returned to baseline levels 6 months after CAS. CONCLUSIONS Patients with CAS showed improved global cerebral hemodynamic status. However, the BRS did not normalize initially, and baseline value was achieved at 6 months after stenting.
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Affiliation(s)
| | | | - T. B. J. Kuo
- Institute of Brain Science, National Yang-Ming University; Taipei; Taiwan
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Tsekouras NS, Katsargyris A, Skrapari I, Bastounis EE, Georgopoulos S, Klonaris C, Bakoyiannis C, Tsekouras E. Alterations of baroreflex sensitivity after carotid endarterectomy according to the preoperative carotid plaque echogenicity. J Vasc Surg 2012; 56:1591-7. [DOI: 10.1016/j.jvs.2012.05.103] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2012] [Revised: 05/30/2012] [Accepted: 05/30/2012] [Indexed: 10/27/2022]
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A novel index of sympathovagal balance from independent component analysis of heart rate and blood pressure variability: performance in patients with carotid stenting and in the EuroBavar data set. J Clin Neurophysiol 2011; 28:227-32. [PMID: 21399520 DOI: 10.1097/wnp.0b013e31821219f5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The authors applied independent component analysis to oscillations of heart rate and blood pressure and obtained a new index of sympathovagal balance. The performance of this index was tested in patients with carotid artery stenting and in the EuroBavar data set according to the following criteria: (1) the index should vary similarly among subjects in response to different autonomic conditions; (2) the variability in the index among subjects exposed to the same autonomic conditions should be small; and (3) the response of the index to various autonomic conditions should reflect the underlying changes in the physiological state and have a meaningful interpretation. The new index from independent component analysis better fulfilled the criteria than the commonly used sympathovagal index, the ratio of low-to-high frequency spectra power of heart rate variability, and had higher discrimination power in distinguishing the autonomic status of the patients who had undergone carotid artery stenting from that of the control subjects.
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Autonomic activity and baroreflex sensitivity in patients submitted to carotid stenting. Neurosci Lett 2011; 491:221-6. [DOI: 10.1016/j.neulet.2011.01.044] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2010] [Revised: 01/05/2011] [Accepted: 01/16/2011] [Indexed: 11/23/2022]
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Yuan HK, Lin C, Tsai PH, Chang FC, Lin KP, Hu HH, Su MC, Lo MT. Acute increase of complexity in the neurocardiovascular dynamics following carotid stenting. Acta Neurol Scand 2011; 123:187-92. [PMID: 20569227 DOI: 10.1111/j.1600-0404.2010.01384.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Percutaneous carotid angioplasty and stenting (CAS) has been used to improve cerebral circulation and autoregulation. However, whether CAS ameliorates the autonomic regulatory dynamics remains unclear. This prospective study examines the neurocardiovascular dynamics following carotid stenting. METHODS Thirty minutes electrocardiograms were recorded at three different time points (pre-operative, 1-h post-operative, 1-day post-operative) on twelve male patients (mean age 70.8 ± 9.6 years) receiving unilateral primary CAS. The HR data were analyzed by the conventional heart rate variability (HRV) and the multiscale entropy (MSE) methods; the former associates with autonomic activities and the latter quantifies the regulatory complexity of heart beat intervals. Loss of complexity at multiple scales has been associated with decoupled regulatory network in vivo. RESULTS Conventional HRV indices showed no difference after CAS. Complexity indices increased significantly on scales 2-8 at 1-h and on scales 2-3 1-day post-treatment. The lower scale MSE (1-5) correlated with the frequency components of conventional HRV indices. The increased complexity could imply a restoration of the neurocardiovascular dynamics on the path to a healthier state. CONCLUSIONS Primary CAS can induce a recovery in the neurocardiovascular regulatory dynamics in patients with high-grade carotid stenosis.
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Affiliation(s)
- H-K Yuan
- Department of Biomedical Engineering, Duke University, Durham, NC, USA
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Huang CC, Wu YS, Chen T, Chang WN, Du YC, Wu CJ, Yip HK, Tsai NW, Tan TY, Chuang YC, Wang HC, Lu CH. Long-term effects of baroreflex function after stenting in patients with carotid artery stenosis. Auton Neurosci 2010; 158:100-4. [DOI: 10.1016/j.autneu.2010.06.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2010] [Revised: 04/24/2010] [Accepted: 06/21/2010] [Indexed: 10/19/2022]
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Kar S, Krishnaswamy A, Shishehbor M, Cam A, Tuzcu E, Bhatt D, Bajzer C, Kapadia S. Safety and efficacy of carotid stenting in individuals with concomitant severe carotid and aortic stenosis. EUROINTERVENTION 2010; 6:492-7. [DOI: 10.4244/eij30v6i4a82] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Mense L, Reimann M, Rüdiger H, Gahn G, Reichmann H, Hentschel H, Ziemssen T. Autonomic function and cerebral autoregulation in patients undergoing carotid endarterectomy. Circ J 2010; 74:2139-45. [PMID: 20689219 DOI: 10.1253/circj.cj-10-0365] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Carotid endarterectomy (CEA) is the first-line treatment in severe carotid stenosis to prevent stroke. Because of methodological limitations, the acute impact of CEA on baroreflex function and cerebral autoregulation is not well defined and was therefore investigated by applying a novel algorithm. METHODS AND RESULTS Systemic arterial blood pressure, ECG and respiration during metronomic breathing and Valsalva maneuver were continuously recorded in 18 patients with carotid stenosis before and after CEA, and in 10 healthy controls. Baroreflex sensitivity, frequency spectra of RR intervals and indices for cerebral autoregulation were evaluated by trigonometric regressive spectral analysis. Compared with the controls, patients had impaired baroreflex sensitivity. Baroreflex sensitivity and frequency spectra were not changed by CEA. Cerebral autoregulation of patients with carotid stenosis as calculated by phase shift was reduced compared with controls but it improved significantly after CEA. Improvement of cerebral autoregulation was independent of changes in cerebral blood flow velocity. CONCLUSIONS Baroreflex sensitivity and cerebral autoregulation are impaired in patients with carotid stenosis, conferring a high stroke risk. CEA improves cerebral autoregulation, but does not affect baroreflex sensitivity. For further risk reduction, interventional approaches targeting baroreflex function need to be considered.
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Affiliation(s)
- Lars Mense
- Autonomic and Neuroendocrinological Laboratory, Department of Neurology, Dresden University of Technology, School of Medicine Carl Gustav Carus, Dresden, Germany
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Wustmann K, Kucera JP, Scheffers I, Mohaupt M, Kroon AA, de Leeuw PW, Schmidli J, Allemann Y, Delacrétaz E. Effects of chronic baroreceptor stimulation on the autonomic cardiovascular regulation in patients with drug-resistant arterial hypertension. Hypertension 2009; 54:530-6. [PMID: 19620513 DOI: 10.1161/hypertensionaha.109.134023] [Citation(s) in RCA: 127] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In patients with drug-resistant hypertension, chronic electric stimulation of the carotid baroreflex is an investigational therapy for blood pressure reduction. We hypothesized that changes in cardiac autonomic regulation can be demonstrated in response to chronic baroreceptor stimulation, and we analyzed the correlation with blood pressure changes. Twenty-one patients with drug-resistant hypertension were prospectively included in a substudy of the Device Based Therapy in Hypertension Trial. Heart rate variability and heart rate turbulence were analyzed using 24-hour ECG. Recordings were obtained 1 month after device implantation with the stimulator off and after 3 months of chronic electric stimulation (stimulator on). Chronic baroreceptor stimulation decreased office blood pressure from 185+/-31/109+/-24 mm Hg to 154+/-23/95+/-16 mm Hg (P<0.0001/P=0.002). Mean heart rate decreased from 81+/-11 to 76+/-10 beats per minute(-1) (P=0.001). Heart rate variability frequency-domain parameters assessed using fast Fourier transformation (FFT; ratio of low frequency:high frequency: 2.78 versus 2.24 for off versus on; P<0.001) were significantly changed during stimulation of the carotid baroreceptor, and heart rate turbulence onset was significantly decreased (turbulence onset: -0.002 versus -0.015 for off versus on; P=0.004). In conclusion, chronic baroreceptor stimulation causes sustained changes in heart rate variability and heart rate turbulence that are consistent with inhibition of sympathetic activity and increase of parasympathetic activity in patients with drug-resistant systemic hypertension; these changes correlate with blood pressure reduction. Whether the autonomic modulation has favorable cardiovascular effects beyond blood pressure control should be investigated in further studies.
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Affiliation(s)
- Kerstin Wustmann
- Departments of Cardiology and Cardiovascular Surgery, University Hospital Bern, Bern, Switzerland
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Tsurumi A, Miyachi S, Hososhima O, Izumi T, Ohshima T, Matsubara N, Kinkori T, Naito T, Wakabayashi T. Can periprocedural hypotension in carotid artery stenting be predicted? A carotid morphologic autonomic pathologic scoring model using virtual histology to anticipate hypotension. Interv Neuroradiol 2009; 15:17-28. [PMID: 20465945 DOI: 10.1177/159101990901500104] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2008] [Accepted: 10/05/2008] [Indexed: 11/17/2022] Open
Abstract
SUMMARY Periprocedural hypotension, which frequently occurs during carotid artery stenting (CAS), is an important risk factor for complications such as stroke or death after CAS. To determine if a scoring model can be established to predict periprocedural hypotension (systolic blood pressure < or = 90 mm Hg) and prolonged periprocedural hypotension (requiring vasopressor for > 3 hours) in CAS, we conducted a prospective cohort study of patients undergoing interventional treatment of cervical carotid artery stenosis in an urban tertiary referral hospital from April 2006 to April 2007. Forty-eight stenotic lesions in 45 consecutive patients treated with CAS were included in the study. Multivariate analysis showed three independent risk factors of periprocedural hypotension; "fibrous plaque on Virtual Histology" (P = 0.029), "stenotic lesion involving both the common carotid artery and internal carotid artery on angiogram" (P = 0.004), and "patients without history of diabetes mellitus" (P = 0.020). Further, "distance between carotid bifurcation and point of minimum lumen size < or = 10 mm on angiogram" (P = 0.003) was an independent risk factor of prolonged periprocedural hypotension. Carotid morphologic autonomic pathologic score (carotid MAPS), determined by adding one point for each of those risk factors (total 0 to 4), had good discrimination for both periprocedural hypotension (area under receiver operating characteristic curve: ROC AUC = 0.876; SE 0.053) and prolonged periprocedural hypotension (ROC AUC = 0.811; SE 0.066). Carotid MAPS is useful for predicting periprocedural hypotension and prolonged periprocedural hypotension during CAS.
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Affiliation(s)
- A Tsurumi
- Department of Neurosurgery, Nagoya University Graduate School of Medicine; Nagoya, Japan -
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Stoneham M, Thompson J. Arterial pressure management and carotid endarterectomy. Br J Anaesth 2009; 102:442-52. [DOI: 10.1093/bja/aep012] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
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Abstract
Carotid endarterectomy (CEA) is performed to prevent embolic stroke in patients with atheromatous disease at the carotid bifurcation. There is now substantial evidence to support early operation in symptomatic patients, ideally within 2 weeks of the last neurological symptoms. Thus, the anaesthetist may be faced with a high risk patient in whom there has been limited time for preoperative preparation. The operation may be performed under local or general anaesthesia. The advantages and disadvantages of both are explored in this review. Carotid shunting may offer a degree of cerebral protection, but carries its own risks and has not been proved to reduce morbidity and mortality. The use of carotid shunts is based on clinical judgement, awake neurological monitoring, and the use of monitors of cerebral perfusion. There is no ideal monitor of cerebral perfusion in the patient receiving general anaesthesia. Both the intraoperative and postoperative periods may be witness to dramatic haemodynamic changes that may compromise the cerebral or myocardial circulations. In particular, postoperative hypotension may compromise both myocardial and cerebral perfusion, and severe hypertension can cause cerebral hyperperfusion. There is as yet limited evidence to guide the management of these problems. In summary, CEA can yield significant benefit, but those with the most to gain from the operation also present the greatest challenge to the anaesthetist.
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Affiliation(s)
- S J Howell
- Academic Unit of Anaesthesia, The General Infirmary at Leeds, Great George Street, Leeds LS1 3EX, UK.
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