sinus reaction during carotid stenting according to the carotid lesion type
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Sinus reaction during carotid stenting according to the carotid lesion type. Jong Lim Kim , Dae Chul Suh, Jin-Ho Shin, Dong Ho Hyun, Ha Young Lee, Deok Hee Lee, Choong Gon Choi, Sang Joon Kim, Jong Sung Kim Departments of Radiology and Research Institute of Radiology , Department of - PowerPoint PPT PresentationTRANSCRIPT
Sinus reaction during carotid stenting according to the carotid
lesion type
Jong Lim Kim, Dae Chul Suh, Jin-Ho Shin, Dong Ho Hyun, Ha Young Lee, Deok Hee Lee, Choong Gon Choi, Sang Joon Kim, Jong Sung Kim
Departments of Radiology and Research Institute of Radiology,
Department of Neurology, University of Ulsan, College of Medicine,
Asan Medical Center, Korea
Carotid sinus reaction or hemodynamic in-stability
· Carotid sinus reaction Post- and peri-procedural hypotension (SBP <90 mmHg) Bradycardia (HR <50 beats/sec) Heart rate fluctuation (>20 beats/sec)
* Asystole (≥ 3 sec) and hypotension (SBP ≤ 90 mm Hg)
Leisch F, et al. Catheter Cardiovasc Interv. 2003
* Hypotension (SBP < 90 mm Hg) or bradycardia (HR < 60 beats/min)
Gupta R, et al. J Am Coll Cardiol. 2006
Carotid sinus reaction during carotid artery stenting
Carotid sinus reaction occurs frequently (40%) during carotid sinus stent
Bifurcation location of stenosis is the most important predictor of carotid sinus reaction
* Carotid sinus reaction Asystole (≥ 3 sec) Hypotension (SBP ≤ 90 mmHg)
* Carotid stenosis location Bifurcation Ostial Isolated ICA
Leisch F, et al. Catheter Cardiovasc Interv. 2003
Carotid sinus reaction during carotid artery stenting
Hemodynamic disturbances was not related to carotid steno-sis location
* Hemodynamic disturbances Hypotension (SBP < 90 mmHg) Bradycardia (HR < 50 beats/min) Heart rate fluctuation (> 20 beats/min) Hypertension (SBP > 160 mmHg)
* Carotid stenosis location Apical Body
Park ST, et al. Am J Neuroradiol. 2010
I like to show that carotid sinus reaction can be associated with stenosis location
Apical type stenosis in the left carotid bulb
No carotid sinus reaction
Body type stenosis in the right carotid bulb
Marked carotid sinus reaction
Carotid sinus (anatomy & physiology)
· Ill-defined dilatation at the origin of the internal carotid artery D Heath. Thorax. 1983
· Monitoring and regulation of blood pressure Michael Doumas, et al. Expert Opin. Ther. Targets. 2009
Carotid sinus (Embryology)
Common carotid artery and proximal part of internal carotid artery
- Formed by remodeling of the third arch artery (yellow)
Baroreceptors (arrow) of the glossopharyngeal nerve - Distributed in proximal portion of internal carotid artery (carotid sinus)
Yoko Kameda. Cell Tissue Res. 2009
Carotid sinus nerve· Originating from the glossopharyngeal (IX) nerve
· Located in loose tissue close to the ICA wall Run parallel to or together with vagus nerve
· Ended in both carotid sinus & carotid body Toorop RJ, et al. J Vasc Surg. 2009
IX, glossopharyngeal nerve
X, vagus nerve
P, pharyngeal branches
S, sympathetic trunk
Baroreflex· Major contributor to the homeostatic system of blood pressure con-
trol Michael Doumas, et al. Expert Opin. Ther. Targets. 2009
· Afferent fibres from carotid sinus baroreceptors join the glos-sopharyngeal nerve and project to the nucleus tractus soli-tarii in the dorsal medulla, and in turn projects to efferent cardiovascular neurones in the medulla and spinal cord
Timmers HJ et al. J Physiol. 2003
Arterial baroreflex loops Carotid sinus baroreceptors → glossopharyngeal nerve → medullary centres (nucleus tractus solitarii) → sympathetic and parasympathetic fibres to heart and blood vessels
Materials and Methods Prospective analysis
2007.01 ~ 2009.6
95 patients who underwent carotid stenting M : F = 82 : 12 Mean age : 69 years (38-89 years) Symptomatic carotid stenosis ≥ 50% (NASCET criteria)
Materials and Methods Transient sinus reaction : <3 hoursDelayed sinus reaction : 3~24 hours
Analyzed angiographic or neurointerventional findings - Location of plaque : apical vs. body - Length of maximum stenosis from the ICA ostium - Lesion length - Stenosis degree - Calcification - Balloon diameter - Balloon pressure - Stent length - Residual stenosis - Hyperperfusion - Restenosis
Results
<3hr SR(+) <3hr SR(-) P-valve
Lesion typeApical 7 49
0.001Body 16 23
Lesion length 16.77 18.30 0.26Length of maximum steno-
sis from the ICA ostium* 7.74 12.79 0.004
Stenosis degree 75.87 74.04 0.968Calcification (yes) 6 15 0.577
Balloon diameter (mm) 5.23 5.37 0.283Balloon pressure (ATM) 8.00 8.29 0.464
Stent length 34.35 34.03 0.728Residual stenosis 23.52 19.86 0.295
Comparison of Significant Difference of Transient Sinus Reac-tion
* Stepwise logistic regression to eliminate confounding factor reveals that length is true independent factor (P = 0.002)
Results
Apical (n=56) Body (n=39) P-valve
SBP>160< 3 h 12 8 0.914
3 - 24 h 7 5 1
Event1m 5 0 0.076
6m 0 1 0.411
Hyperperfusion 6 2 0.464
Restenosis 1 3 0.302
Case 1Age/sex M/63Location right
Transient sinus reaction +Lesion type Body
Length of maximum stenosis from the ICA ostium* (mm) 2.24
Case 2
Age/sex M/77Location right
Transient sinus reaction -Lesion type Apical
Length of maximum stenosis from the ICA ostium* (mm) 14.53
Case 3
Age/sex M/85Location right
Transient sinus reaction -Lesion type Apical
Length of maximum stenosis from the ICA ostium* (mm) 16.67
Hyperperfusion +
Summary and conclusion1. Sinus reaction in carotid stenting is different in two distinct locations, body and apical portion of carotid bulb
2. Body lesion type was more vulnerable to sinus reaction than apical
lesion type ① Related to anatomical baroreceptor disposition in carotid sinus * Baroreceptors are located in the carotid sinus of carotid bulb Such embryological implication appeared to affect carotid bulb lesion type ② Induced preventive effect for high blood pressure which might contribute
to hyperperfusion syndrome → Less common to hyperperfusion syndrome
3. Apical lesion type had higher event rate than body lesion type
① Associated with more common periprocedural hypertension → Needs more careful management of blood pressure control for apical
lesion type after carotid stenting