The need for treatment of hemodynamic instability following carotid endarterectomy is associated with increased perioperative and 1-year morbidity and mortality

Abstract

Objective The objective of this study was to evaluate the outcomes of patients after carotid endarterectomy (CEA) who developed postoperative hypertension or hypotension requiring the administration of intravenous vasoactive medication (IVMED). Methods We examined consecutive, primary elective CEA performed by 128 surgeons within the Vascular Study Group of New England (VSGNE) database (2003-2010) and compared outcomes of patients who required postoperative IVMED to treat hyper- or hypotension with those who did not. Outcomes included perioperative death, stroke, myocardial infarction (MI), congestive heart failure (CHF), hospital length of stay, and 1-year stroke or death. Propensity score matching was performed to facilitate risk-adjusted comparisons. Multivariable regression models were used to compare the association between IVMED and outcomes in unmatched and matched samples. Factors associated with use of IVMED in postoperative hypertension and hypotension were evaluated, and predictive performance of multivariable models was examined using receiver operating characteristic (ROC) curves. Results Of 7677 elective CEAs identified, 23% received IVMED for treatment of either postoperative hypertension (11%) or hypotension (12%). Preoperative neurological symptomatic status (20%) was similar across cohorts. In the crude sample, the use of IVMED to treat postoperative hypertension was associated with increased 30-day mortality (0.7% vs 0.1%; P < .001), stroke (1.9% vs 1%; P = .018), MI (2.4% vs 0.5%; P < .001), and CHF (1.9% vs 0.5%; P < .001). The use of IVMED to treat postoperative hypotension was also associated with increased perioperative mortality (0.8% vs 0.1%; P < .001), stroke (3.2% vs 1.0%; P < .001), MI (2.7% vs 0.5%; P < .001), and CHF (1.7% vs 0.5%; P < .001), as well as 1-year death (5.1% vs 2.9%; P < .001) or stroke (4.2% vs 2.1%; P < .001). Hospital length of stay was significantly longer among patients who needed IVMED for postoperative hypertension (2.8 ± 4.7 days vs 1.7 ± 5.5 days; P < .001) and hypotension (2.8 ± 5.9 days vs 1.7 ± 5.5 days; P < .001). In multivariable analysis, IVMED for postoperative hyper-tension was associated with increased MI, stroke, or death (odds ratio, 2.6; 95% confidence interval [CI], 1.6-4.1; P < .001). Similarly, IVMED for postoperative hypotension was associated with increased MI, stroke, or death (odds ratio, 3.2; 95% CI, 2.1-5.0; P < .001), as well as increased 1-year stroke or death (hazard ratio, 1.6; 95% CI, 1.2-2.2; P = .003). Smoking, coronary artery disease, and clopidogrel (ROC, 0.59) were associated with postoperative hypertension requiring IVMED, whereas conventional endarterectomy and general anesthesia were associated with postoperative hypotension requiring IVMED (ROC, 0.58). The unitization of IVMED varied between 11% and 38% across VSGNE, and center effect did not affect outcomes. Conclusions Postoperative hypertension requiring IVMED after CEA is associated with increased perioperative mortality, stroke, and cardiac complications, whereas...

Insight into the cerebral hyperperfusion syndrome following carotid endarterectomy from the national Vascular Quality Initiative

“…22 Indeed, both postoperative hypertension and hypotension have been associated with cardiac complications in a VQI study using a regional data set. 23 In sum, these findings justify close monitoring of CEA patients in the postoperative period.…”

Modifiable Factors Leading to Increased Length of Stay after Carotid Endarterectomy

“…[25] Post-operative hemodynamic instability after CEA is a well-described phenomenon presenting a major barrier to post-operative day one discharge. [6, 7, 26-28] In our CEA population, post-operative hypertension or hypotension affects over 25% and 10% of our patients requiring prolonged LOS respectively. This is a major target for improvement as we have advancements in intraoperative monitoring and anesthetic techniques.…”

Upper Extremity Blood Pressure Difference in Patients Undergoing Carotid Revascularisation

“…A recent analysis showed that adequate implementation of 2014 hypertension guidelines could potentially prevent 37,400 strokes annually in the U.S. 1 Haemodynamic instability is observed in 13% -23% of patients undergoing carotid endarterectomy (CEA) 2,3,4, and is associated with poor perioperative outcomes as well as an increased 1-year stroke or death rate. 3,4 Peri-procedural haemodynamic depression in patients treated by carotid artery stenting (CAS), is associated with an excess of new ischaemic brain lesions. In general, patients undergoing carotid intervention under general anaesthesia are more likely to be exposed to intra-procedural hypotension and post-procedural hypertension.…”