title: Predictors and consequences of hemodynamic instability after carotid artery stenting.
abstract: BACKGROUND
  The purpose of this study was to determine the predictors and consequences of hemodynamic instability (HI) after carotid artery stenting (CAS).
  
  
  METHODS
  The records of all patients undergoing CAS in a single institution were reviewed. Patient demographics and risk factors were recorded. Indications for CAS, medications including statins, atropine, and beta blockers, anatomic risk factors, balloon and stent length and diameter, and degree of stenosis were noted. The presence of periprocedural hypertension (systolic blood pressure [SBP] >160), hypotension (SBP <90), and bradycardia (heart rate <60) lasting longer than 1 hr was documented, as was more transient HI. Rates of transient ischemic attack (TIA), stroke, myocardial infarction (MI), and death within 30 days of the procedure were calculated. Chi-squared analysis was used to determine the role of periprocedural factors in predicting the risk of HI and to determine if patients experiencing HI were more likely to experience major adverse events (MAEs) than those who did not.
  
  
  RESULTS
  Between 2005 and 2012, 199 CAS were performed in 191 patients. One hundred seventeen were men and 74 were women. Their ages ranged from 46 to 92 years (mean, 73.6 years). Eighty-seven percent had hypertension, 48.5% were smokers, 48% had coronary disease, and 38% were diabetic. CAS was performed for asymptomatic stenosis in 55% of patients, 24% had previous TIA, and 20% previous stroke. Sixty-three percent of patients were on statins, 41.4% on beta blockers, and 92% received atropine before balloon dilatation or stent placement. Overall, 130 (65.3%) patients experienced HI and 67 patients (33.7%) experienced HI lasting longer than 1 hr. Octogenarians were more likely to experience both transient and prolonged HI, whereas angina or contralateral occlusion was predictive of any HI, and female sex was predictive of prolonged HI. Transient HI was not predictive of MAE. Patients with HI persisting longer than 1 hr were more likely to experience a TIA than those who did not (P = 0.045), but they were no more likely to experience stroke, MI, or death (P > 0.35 for each).
  
  
  CONCLUSIONS
  Periprocedural HI occurs frequently during CAS even with prophylactic atropine administration. Although patients experiencing HI were more likely to experience a TIA, its presence is not associated with an increase in stroke, MI, or death.
authors.affiliation: Department of Graduate Medical Education, Huntington Hospital, Pasadena, CA.
authors.forename: Tiffany Y
authors.initials: TY
authors.lastname: Wu
authors.affiliation: Division of Vascular Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA.
authors.forename: Sung W
authors.initials: SW
authors.lastname: Ham
authors.affiliation: Division of Vascular Surgery, Keck School of Medicine, University of Southern California, Pasadena, CA. Electronic address: skatz@med.usc.edu.
authors.forename: Steven G
authors.initials: SG
authors.lastname: Katz
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000800:Angioplasty, Balloon / Q000009:adverse effects* / Q000295:instrumentation*; D001794:Blood Pressure; D001919:Bradycardia / Q000175:diagnosis / Q000209:etiology* / Q000401:mortality / Q000503:physiopathology; D002140:California; D016893:Carotid Stenosis / Q000175:diagnosis / Q000503:physiopathology / Q000628:therapy*; D016009:Chi-Square Distribution; D005260:Female; D006339:Heart Rate; D006439:Hemodynamics; D006801:Humans; D006973:Hypertension / Q000175:diagnosis / Q000209:etiology* / Q000401:mortality / Q000503:physiopathology; D007022:Hypotension / Q000175:diagnosis / Q000209:etiology* / Q000401:mortality / Q000503:physiopathology; D002546:Ischemic Attack, Transient / Q000209:etiology / Q000401:mortality / Q000503:physiopathology; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000209:etiology / Q000401:mortality / Q000503:physiopathology; D016017:Odds Ratio; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D012720:Severity of Illness Index; D015607:Stents; D020521:Stroke / Q000209:etiology / Q000401:mortality / Q000503:physiopathology; D013997:Time Factors; D016896:Treatment Outcome