title: Role of stent selection in the incidence of persisting hemodynamic depression after carotid artery stenting.
abstract: OBJECTIVE
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Heart and Vascular Center, Semmelweis University, Budapest, Hungary media@csobay.hu.
authors.forename: Csaba
authors.initials: C
authors.lastname: Csobay-Novák
authors.affiliation: Heart and Vascular Center, Semmelweis University, Budapest, Hungary.
authors.forename: Tamás
authors.initials: T
authors.lastname: Bárány
authors.affiliation: Heart and Vascular Center, Semmelweis University, Budapest, Hungary.
authors.forename: Endre
authors.initials: E
authors.lastname: Zima
authors.affiliation: Heart and Vascular Center, Semmelweis University, Budapest, Hungary.
authors.forename: Balázs
authors.initials: B
authors.lastname: Nemes
authors.affiliation: Heart and Vascular Center, Semmelweis University, Budapest, Hungary.
authors.forename: Péter
authors.initials: P
authors.lastname: Sótonyi
authors.affiliation: Heart and Vascular Center, Semmelweis University, Budapest, Hungary.
authors.forename: Béla
authors.initials: B
authors.lastname: Merkely
authors.affiliation: Heart and Vascular Center, Semmelweis University, Budapest, Hungary.
authors.forename: Kálmán
authors.initials: K
authors.lastname: Hüttl
mesh_terms: D000368:Aged; D000497:Alloys; D000800:Angioplasty, Balloon / Q000009:adverse effects; D015992:Body Mass Index; D001919:Bradycardia / Q000209:etiology; D017536:Carotid Artery, Common / Q000473:pathology*; D002343:Carotid Artery, Internal / Q000473:pathology; D016893:Carotid Stenosis / Q000453:epidemiology / Q000473:pathology* / Q000503:physiopathology / Q000628:therapy*; D005260:Female; D006439:Hemodynamics; D006801:Humans; D006973:Hypertension / Q000209:etiology; D015994:Incidence; D008297:Male; D008875:Middle Aged; D010975:Platelet Aggregation Inhibitors / Q000008:administration & dosage; D011182:Postoperative Care; D011300:Preoperative Care; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D015607:Stents / Q000009:adverse effects; D016896:Treatment Outcome
chemical_list: D000497:Alloys; D010975:Platelet Aggregation Inhibitors; C013616:nitinol
keywords: baroreceptor; bradycardia; carotid artery; carotid artery stenting; hypotension; nitinol stent; pacemaker; self-expanding stent