Hemodynamic instability in the immediate postoperative setting after transcarotid artery revascularization

Abstract

Objective Transcarotid artery revascularization (TCAR) is a relatively recent development in the management of carotid artery occlusive disease, the utilization of which is becoming more prevalent. This study aims to evaluate the timing, prevalence, and types of hemodynamic instability after TCAR. Methods We performed a retrospective review of all TCAR procedures performed at two tertiary care academic medical centers within a single hospital system from 2017 through 2019. Demographics, comorbidities, preoperative patient factors, procedural details, and postoperative data were collected. Patients were assessed over 24 hours postoperatively for stroke, death, myocardial infarction (MI), and hemodynamic instability at 3, 6, 9, 12, and 24 hour intervals. Hemodynamic instability was defined as any vital sign abnormality which required pharmacological intervention with antihypertensive, vasopressor, and/or anti-arrhythmic agents. The incidence and timing of postoperative complications and hemodynamic instability were recorded. Results During the study period, 76 patients 80 TCAR procedures. Out of 80 procedures, 64 (80.0%) were receiving home antihypertensive medication and 28 (35.0%) were symptomatic lesions preoperatively. Intraoperatively, one patient (1.3%) received atropine, 26 (32.5%) received glycopyrrolate, 76 (95%) underwent predilatation, and 16 (20.0%) underwent postdilatation. Postoperatively, a total of 22 cases (27.5%) required medication for acute control of blood pressure or heart rate, which reached a peak of 19 patients (23.8%) within the first 3 hours, and tapered to nine patients (11.3%) by the 24 hour mark. A total of three patients (3.75%) required initiation of pharmacological management after the three-hour mark. Six patients (7.5%) underwent stroke code workup, 4 (5.0%) of whom were confirmed to have stroke on CT. Average time to neurologic event was 3.9 hours. No patients experienced MI or death. Median ICU and hospital days for unstable patients were two and three, respectively, compared to one and one for stable patients. Conclusions Hemodynamic instability is common after TCAR and reliably presents at or before postoperative hour 3. Hypo- followed by hyper-tension were the most common manifestations of hemodynamic instability. Regardless, unstable patients and stroke patients were more likely to require longer periods of time in the ICU and in the hospital overall. This may have implications for postoperative ICU resource management when deciding to transfer patients out of a monitored setting. Further study is required to establish relationships between pre- and intra-operative risk factors and outcomes such as hemodynamic instability and/or stroke. At present, one should proceed with careful evaluation of preoperative medications, strict management of postoperative hemodynamics, and clear communication among team members should all be employed to optimize outcomes.

Transcarotid Revascularization Timing and Early Postoperative Outcomes in Symptomatic Patients

“…If revascularization were performed too soon after neurological symptoms, unstable plaque could break off and embolize, 12 or the sudden hyperperfusion caused by restoration of blood flow combined with previously dilated blood vessel could result in cerebral hemorrhage. 13,14 If intervention were delayed, the continued presence of the offending unstable arterial plaque could worsen symptoms as further embolization occurs. 15 Guidelines on the timing of revascularization surgery are not in accordance with each other.…”

What Is the Role of Transcarotid Artery Revascularization?

“…Severe hypotension and bradycardia during the procedure is managed by aggressive volume expansion and intravenous atropine (0.4-1 mg). Moreover, phenylephrine and dopamine should be readily available to be used when necessary [18,78]. In our experience, avoiding poststent ballooning reduces the risk of hemodynamic instability.…”

“…Following an uneventful TCAR, patients should be monitored for 24 hours, as an embolic stroke, hypotension with or without bradycardia or hypertension can occur during this early postoperative period [71,78]. It should be ascertained that the postoperative neurologic assessment continues to be normal or at baseline.…”