Risk Factors and Neurological Consequences of Syncopes Induced by Internal Carotid Artery Angioplasty

Abstract

Background and Purpose-Syncope and carotid sinus reactions (CSR) occur frequently in patients undergoing carotid angioplasty (CA). We investigated risk factors and the neurological consequences of carotid sinus syncope induced by CA. Methods-We examined 359 consecutive patients. Patients underwent assessment of cerebrovascular reserve before CA and continuous electroencephalographical monitoring during the procedure. We examined the impact of vascular risk factors, cerebral hemodynamics, characteristics of plaque, and procedural modality on the incidence of CSR and syncope. The effect of syncopes on periprocedural complication rates was also investigated. Results-CSR and syncope occurred in 62.7% and 18.0% of the procedures, respectively. The occurrence of CSR during angioplasty was significantly associated with the appearance of syncope. The incidence of syncope was significantly higher in longer plaques located in the carotid bifurcation, in the presence of contralateral carotid stenosis, or when protection devices were used. Although TIA during CA was more common in syncopal patients, stroke or death rates were similar in the 2 groups. Conclusions-Syncope occurs more frequently in patients with long plaques proximal to the carotid bifurcation, but it does not increase the periprocedural complications rate.

Effects of Carotid Endarterectomy or Stenting on Hemodynamic Complications in the International Carotid Stenting Study: A Randomized Comparison

“…In some uncontrolled studies of patients treated with CAS, periprocedural hemodynamic depression was associated with increased rates of stroke or death , but this was not confirmed by others . In the current study, we found no significant association between the occurrence of either hemodynamic compromise or hypertension requiring treatment and the risk of stroke, MI, or death within 30 days.…”

“…This difference may be explained by the use of different definitions for hypotension or hemodynamic depression as a composite measure. For example, most observational studies defined arterial hypotension as a SBP below a fixed value (3,11,23–25), or a specific fall in blood pressure (22,24), whereas in ICSS, hypotension was only reported if this required treatment and we therefore could have missed less severe episodes of hypotension. Recent large clinical trials did not report the development of early hypotension after CEA (15,17,18).…”

“…Previous studies have associated the presence of the stenosis at the carotid bifurcation and calcification of the plaque with hemodynamic depression (3,22,23,25), but these factors were not evaluated in ICSS. Increasing age (24) and contralateral carotid artery stenosis (25), which have also been related to the occurrence of hypotension and bradycardia were not found to be independent predictors of hemodynamic depression in ICSS. Higher SBP at baseline was the single most important and modifiable predictor of severe hypertension after CAS or CEA, and was also related to a lower risk of hemodynamic depression in CEA patients.…”

Periprocedural Hemodynamic Depression Is Associated With a Higher Number of New Ischemic Brain Lesions After Stenting in the International Carotid Stenting Study-MRI Substudy

“…[17][18][19][20] However, this association has not been found in every study. [21][22][23] In the current study, 12% of the patients treated by CAS had periprocedural hemodynamic depression requiring treatment, whereas uncontrolled series of patients treated by CAS have reported frequencies of arterial hypotension or hemodynamic depression ranging from 19% to 51%. 17,19,[24][25][26] This difference may be explained by ascertainment bias because the assessment of hemodynamic depression was a primary aim of some of the observational studies but not of ICSS.…”