Post-stent balloon dilation is associated with postoperative hypotension after transcarotid artery revascularization.

Abstract

Postoperative hypotension following transcarotid artery revascularization (TCAR) is associated with greater intensive care unit (ICU) utilization, longer inpatient length of hospital stay (LOS), and increased in-hospital mortality. This study's aim was to identify key intraoperative and anatomic factors contributing to postoperative hypotension in the setting of TCAR for asymptomatic carotid stenosis. Identification and risk stratification of such high-risk patients is an important aspect of perioperative care to mitigate this occurrence and ensuing complications. This was a retrospective, single-institutional analysis of TCAR procedures performed in 94 patients with asymptomatic carotid stenosis. The primary endpoint was the development of postoperative hypotension. Secondary outcomes were rates of ICU utilization, LOS, and postoperative transient ischemic attack or stroke. Ninety-four patients met inclusion criteria for this study. Baseline demographics between the two groups were comparable. Postoperative hypotension was more common in the post-stent dilation (PSD) group (75.0% vs 34.8%; P < .001). Among patients with postoperative hypotension, there were greater rates of ICU utilization and incidence of prolonged inpatient LOS (>1 day). However, only 19.0% of patients with postoperative hypotension following PSD required vasopressors, with a median duration of 15.9 hours. Patients that experienced postoperative hypotension had a significantly higher measured calcium volume percent (17% vs 6.5%; P = .006). Median carotid bulb dilation index was similar across groups (1.30 vs 1.30; P = .577). On multivariate logistic regression, PSD was the only factor significantly associated with postoperative hypotension (odds ratio, 4.01; 95% confidence interval, 1.36-12.78; P = .014). Patients with increased vessel calcification required PSD more frequently to achieve adequate luminal gain. However, PSD was the sole intraoperative factor associated with postoperative hypotension when adjusting for covariates. This suggests that intraprocedural carotid bulb manipulation exerts increased transient distension on baroreceptors in instances of PSD, thus conferring a higher risk of this complication. The risks and benefits of post-stent balloon dilation for increased luminal gain and stent expansion should be carefully considered in these patients.