Hypotension and Bradycardia after carotid artery stentingttw3.mmh.org.tw/neuroweb/pdf_files/20121205Hypotension and... · • ICA Siphon • Depth(mm)48 50 52 57 62 58 62 58 58 51

Hypotension and Bradycardiaafter carotid artery stenting

胡智銘醫師

• 72 year-old male 黃OO

• Chief Complaint

Acute onset of right limbs weakness when riding motorcycle in the morning on 101/03/15

• Present Illness

He didn’t have any discomfort yesterday evening except occasionally difficult to urinate.

He rode motorcycle to buy meat in the morning on

101/03/15. Then, he suffered from acute onset of

right limbs weakness when riding motorcycle.

He stopped immediately and got unstable gait

without falling down.

A passerby found something wrong from his facial

expression and patient didn’t say anything. The

someone call 911 for help.

He was sent to our ER by ambulance on 101/03/15.

• Past History/Social History

1.Herniated Intervertebral Disc, L4-5 with frequent backache

2.Left knee osteoarthritis

3.HTN ?

4.Tobacco: 1.5 PPD for 30 years

5.Alcohol: Social drinking

6.Betel nut: +, 20 years

• Physical Examination

TPR: 36/48/18 BP: 158/66 mmHg

Conjunctivae: not anemic

Neck: supple

Hear: RHB, no murmur

Chest: clear BS, no crackle/ wheezing

Abdomen: soft, no tenderness

Extremities: no pitting edema

• Neurological Examination

1.Alertness / Attention: Well

2.Language: (Mixed transcortical aphasia)

Comprehension: impairment

Fluency: impairment

Repetition: fair

3.Orientation/Memory: Unknown

• Neurologic examination

1. VA/VF: intact

2. Pupil:3 mm/ 3mm; Light reflex: +/+

3. Right central type facial palsy

4. Forced eye gazing to left

side

0

-3

0

-3 0

0 0

0

00 0 0

0

0

0

0

0

• Neurologic ExaminationMuscle power

Sensory:

4-

4- 55

4 5

54

++ ++

++ ++

++++++++

++++

• Neurologic Examination

Sensory: Unknown

Cerebellar sign: Unknown

• Urinary retention on Foley

• 101/03/15 08:55 • 血色素檢查(Hemaglobin) 15.6 g/dL 13.0 - 18.0• 血球比容值測定 44.7 % 40.0 - 54.0• (Hematocrite)• 白血球記數(W.B.C) 6.80 K/ul 4.00 - 10.00• 白血球分類記數 (WBC differential count)• 節狀中性球 64.2 % 55.0 - 75.0• (Segmented neutrophil)• 嗜伊紅性白血球 1.9 % 0.0 - 5.0• (Eosinophil)• Baso 0.4 % 0.0 - 1.0• 單核球(Monocyte) H 10.4 % 0.0 - 10.0• 淋巴球(Lymphocyte) 23.1 % 20.0 - 40.0• 血小板記數 161 K/uL 140 - 450• (Platelet count)

101/03/15 生化

• 飯前葡萄糖(Glucuse AC) H 113 mg/dL 70 - 99• 血清麩胺酸苯醋酸 25 IU/L 15 - 41• S-GOT• 血中尿素氮(BUN) 11 mg/dL 8 - 20• 肌肝(Creatinine) 1.1 mg/dL 0.4 - 1.2• GFR• Age 71 y/o• Estimated GFR(MDRD) 66.0 mL/min• 鉀(K) 4.1 mEq/L 3.5 - 5.1• 鈉(Na) 139 mEq/L 136 - 144• 肌酸磷化同? 80 IU/L 38 - 397• (CK isoenzyme)• CKMB 2.20 ng/mL 0.00 - 5.40• CKMB mass/Total CK HH 2.8 %• Troponin-I 0.05 ng/ml <0.50• Normal 99%: <0.04 ng/mL• AMI Cutoff: < 0.5 ng/mL

101/03/15

Chest X ray

Brain CT

• Impression

1.Cerebral Ischemic Infarction, Left

middle cerebral artery

2.HTN

3.Sinus bradycardia

4.HIVD

5.BPH

Admission--101/03/16 生化

• 飯前葡萄糖(Glucuse AC) 84 mg/dL 70 - 99• 白蛋白(Albumin) 3.6 g/dL 3.5 - 5.0• 直接膽紅素(Biliruin direct) 0.3 mg/dL 0.1 - 0.5• 膽紅素總量(Bilirubin total) 1.0 mg/dL 0.3 - 1.2• 鹼性磷酯 (Alkaline phosphatase) 79 IU/L 38 - 126• (S-GPT) 18 IU/L 14 - 40

• 總膽固醇 (Cholesterol,total) H 225 mg/dL 130 - 200• 三酸甘油酯 (Triglyceride) H 169 mg/dL 35 - 150• 尿酸(Uric acid) H 7.7 mg/dL 4.4 - 7.6• P 3.0 MG/DL 2.7 - 4.• 鈣(Ca) L 8.5 MG/DL 8.9 - 10.3• Mg 1.8 MG/DL 1.8 - 2.5• LDL-Cholesterol H 163 MG/DL <130•• HDL-Cholesterol L 31 MG/DL >50 -

Admission

• 101/03/16

Aphasia/Right central type facial palsy

Brain MRI

Heart echo

24 hours holter

Carotid doppler

1

1 55

1 5

51

Brain MRI

Brain MRI

HOLTER 101/03/17

• Conclusions

[1] Basically sinus rhythm with ventricular

rate, min 39 bpm, max 88 bpm, average 53

bpm;

[2] A few of PVCs, isolated;

[3] Persitent ST-T segment horizontal or

downsloped depression 0.5-2mV at channel

2 and 3;

[4] No SVT, VT, or long pause;

心超 101/03/16Conclusions

• [1] Aortic valve sclerosis, aortic root dilatation, LAE, LVH ;• [2] Preserved global LV systolic performance, but impaired

diastolic compliance ;• [3] Normal pulmonary pressure .

• Prosthetic value:AV MV St.Jude B-Shiley• P't Normal P't Normal• AO (H)41 (20-38) (mm) LVIDd 53 (37-53) (mm)• AV 22 (16-26) (mm) LVIDs 33 (24-36) (mm)• LA (H)49 (19-40) (mm) LVEDV 134 (80-180) (ml)• RV (L) ( 5-21) (mm) LVESV 43 (16-83) (ml)

• EF Slpoe (L)75 (80-150) (mm/sec) EF 68 (50-70) ( %)• IVS (H)14 ( 7-11) (mm) HR (L)52 (60-100)

(/m)• LVPW (H)14 ( 9-11) (mm) CO 4.75 (2.5-7.2) (L/m)• EPSS ( < 8) (mm) DT (160-220)(msec)• IVRT (70-90) (msec) E (cm/s)• A (cm/s)

Right :• TerminalCarotid• M C A ACA P 1 P 2 VA VA BA BA• ICA Siphon

Depth(mm)43 46 56 58 61 64 56 64 69 78 84• MV 31.6 32.1 36.9 44.4 65.4 33.6 33 62 61 44 40• PI 1.59 1.53 1.60 1.70 1.13 0.96 1.26 1.44 1.48 1.711.71

Left :• TerminalCarotid• M C A ACA P 1 P 2 VA VA BA BA• ICA Siphon• Depth(mm)40 48 54 56 62 66 64 62 68 51 71 75 80 88• MV 41.5 44.3 47.6 53.4 34.7 35 31.1 26 29.2 24.4 31.1 27.4 41 33• PI 1.27 1.10 1.12 1.21 1.28 1.31 1.08 1.57 1.50 1.78 1.76 1.99 1.751.55

CTA

Diagnosis

• Hyperlipidemia

• Left symptomatic carotid stenosis

Carotid endarterectomy

Carotid artery stenting

Admission

• 101/03/16-101/04/15

1

15

5

1

5

5

1

4-4-

5

5

4-

5

5

4

Admission• 101/03/17-101/04/01 Pneumonia (Sputum culture: Klebsiella pneumoniae) x 2

• 101/03/26 11:03 胡智銘廖秋珠(東) • [檢驗項目]: Sputum (痰液) - Routine culture（需氧）• ---------------------------------------------------------------• 1. Klebsiella pneumoniae ssp pneumoniae (moderate)• ------------------------- 1.MIC• Ampicillin R(>=32)• Amikin S(<=2)• Ceftazidime S(<=1)• Ciprofloxacin S(<=0.25)• Cefpirome S(<=1)• Cefotaxime S(<=1)• Cefuroxime S(<=1)• Cefazolin S(<=4)• Ertapenem S(<=0.5)• Flomoxef S(<=2)• Cefoxitin S(<=4)• Gentamicin S(<=1)• Imipenem S(<=1)• Meropenem S(<=0.25)

• Moxifloxacin S(<=0.25)• Trimethoprim/Sulfamethoxa S(<=20)• Tigecycline S(<=0.5)

Medication

• Bokey 1# qd Combine Plavix 1# qd

• Dipyridamole 25mg 2# tidac

• Lipitor 40mg 1# qd

• Norvasc 1# qd

• Diovan 0.5# qd

• Hytrin 0.5# qhs

Admission

• 101/04/17---Carotid angiography and stenting

直徑: 8.4 mm

Carotid bulb

長度=44.8 mm

Admission

• 101/04/17---Carotid angiography and stenting

Heart rate down to 30 /min during Balloon dilatation atropine 1mg 1V IV st BP elevation (180/100 mmHg)

Nicardipine 10mg/10ml 1cc BP down to 120/70 mmHg Transfer to MICU

Carotid stent

Atropine 1mg

90/50 mmHg

80/50 mmHg

Challenge Poly starch 500ml

Atropine 1mg IV

MICU 607A

Atrpine0.25mg IV

Meptin 1# bid

Atropin 1mg IV

Theophylline 250mg 1# bid

EKG Transfer to CCU

On TPM (60 BPM)

DC meptin and theophylline

Dopamine premix 3mg/ml 200ml

run 8-10 ml/hr

Skin rash drug related ?

Recheck cardiac enzyme nomal

TPM and DopamineSkin rash

TPM and DopamineDC Plavix

Keep Bokey and Cilostazol

DC TPM and dopamine

Skin rash improving

Admission• 101/04/17-101/04/25

(During Hemodynamic Depression)

No Muscle power decrement, except conscious change

• Discharge on 101/05/03

Medication: (Allergy to Plavix)

Bokey 1# qd

Cilostazol 1# bid

Tamsulosin 1# qhs

Captopril 25mg 0.5# bid

Berotec 2.5mg 1# qd

Carotid Doppler

• 檢查日期 :101/08/14• 開單日期 : 61043• Case No : 11007 BW : BL : • Brachial BP : R't L't : Pulse • Right :• TerminalCarotid• M C A ACA P 1 P 2 VA VA BA BA• ICA Siphon• Depth(mm)49 51 54 59 62 58 62 63 55 60 53 65 78 87• MV 44 47 43 43 26 43 44 33 30 28 38 77 29 20• PI 1.46 1.57 1.86 1.02 1.23 1.48 0.92 1.87 1.12 1.25 1.15 1.10 1.610.98• Left :• TerminalCarotid• M C A ACA P 1 P 2 VA VA BA BA• ICA Siphon• Depth(mm)48 50 52 57 62 58 62 58 58 51 58 66 82 90• MV 29 26 28 29 29 28 37 48 36 29 27 58 34 15• PI 2.03 1.63 1.43 1.69 0.96 1.72 1.37 1.17 0.97 0.98 1.42 1.17 1.421.04

Discussion

• 為何會有 Hypotension and bradycardia after carotid artery stenting (CAS)?

Extension manipulation in the vicinity of the carotid sinus

Increased parasympathetic discharge (Bradycardia) and a reduction of systemic arterial smooth muscles tone (Hypotension)

Discussion--Definition

• Post-CAS Hypotension

Systolic BP <100 mmHg or

Blood pressure fall > 30mmHg

• Post-CAS Bradycardia

Heart rate < 60 beats or

A decreased of > 20 beats/min

Am J Cardiol 1998;82:1077-1081

Discussion—Hemodynamic change

• Predilatation/Stent delivery/Postdilatation

Predilatation: Initial balloon dilatation

until stent deployment

Stent delivery: Stent deployment until the

postdilatation balloon

inflation

Postdilatation: Remainder of the procedure

Am J Cardiol 1998;82:1077-1081

Discussion—Hemodynamic change

• Predilatation/Stent delivery/Postdilatation

Incidence of bradycardia:

No differing significantly from one period of the next Predilatation(32%) / Stent delivery(21%) / Postdilatation(32%)

Incidence of hypotension:

After stent delivery(23%) and after postdilatation(26%)

Am J Cardiol 1998;82:1077-1081

Discussion--發生率

Post-CAS Hypotension: 14%

Post-CAS Bradycardia: 27%

Combine Post-CAS hypotension and bradycardia: 5%

J Vas Surge 2007;46:846-54

Duration: Median 12 hours (range 1 to 96 hours)

J Am Coll Cardiol 2006;47:1538-43

Discussion

• Factors associated with hypotension and bradycardia after carotid artery stenting (CAS)?

1.Age

2.History of coronary artery disease

3.Larger balloon diameters

4.Elevated SBP > 180mmHg before the procedure

5.Lesions involving carotid bulb or heavy calcification and ulceration

VASCULAR DISEASE MANAGEMENT 2012;9(2):E17–E19

Discussion—Age/CAD

J Endovasc Ther 2003;10:851-859

Age

CAD


J Endovasc Ther 2003;10:851-859


J Vasc Surg 2007;46:846-54


J Vasc Surg 2007;46:846-54

Low EFPrior ipsilateral CEA


J Vas Surg 2007;46:846-54


Elderly patients / coronary artery disease / low ejection fraction

depressed cardiac output state and diastolic ventricular dysfunction

Carotid baroreceptor stimulation by balloon angioplasty or stent placement

Not have a full cerebral autoregulatory response or impairment of myocardial function to bradycardia or hypotension

J Vas Surg 2007;46:846-54

Discussion—Prior ipsilateral CEA

• Carotid bulb was been divided or interrupted surgically

• Unable to send impulse to the medulla when triggered by balloon dilatation

J Vas Surg 2007;46:846-54

Discussion—Larger Balloon Diameter

Radiology 2000; 215:677-683

Balloon-expandable stent placement

VSSelf-expanding

stent placement


Radiology 2000; 215:677-683


Radiology 2000; 215:677-683


• Hemodynamic change:

Statistically significant association between the insertion of large stents

(≧10 mm in diameter or ≧ 40 mm in length)

Am J Cardiol 1998;82:1077-1081

Discussion—Elevated SBP > 180mmHg before the procedure




Discussion-Lesions involving carotid bulb or heavy calcification and ulceration

Patients with calcified

plaque

in the carotid bulbe







Therapy

• Isotonic Fluid

• Atropine

• Intravenous vasopressor therapy

(Dopamine average 7.8±2.9μg/kg/min

0.6-0.3mg/kg/hr) Am J Cardiol 1998;82:1077-1081

• Pacemaker (暫時性 or 永久性 ?)

Conclusion

• Large stent

• Balloon-expandable stent placement

• Sinus bradycardia

• Carotid sinus

• Smoking

THANK FOR YOUR ATTENTION!!

DISCUSSION

心超 101/03/16

• Conclusions• [1] Aortic valve sclerosis, aortic root dilatation, LAE, LVH ;• [2] Preserved global LV systolic performance, but impaired diastolic compliance ;• [3] Normal pulmonary pressure .

• Prosthetic value:AV MV St.Jude B-Shiley• P't Normal P't Normal• AO (H)41 (20-38) (mm) LVIDd 53 (37-53) (mm)• AV 22 (16-26) (mm) LVIDs 33 (24-36) (mm)• LA (H)49 (19-40) (mm) LVEDV 134 (80-180) (ml)• RV (L) ( 5-21) (mm) LVESV 43 (16-83) (ml)• EF Slpoe (L)75 (80-150) (mm/sec) EF 68 (50-70) ( %)• IVS (H)14 ( 7-11) (mm) HR (L)52 (60-100) (/m)• LVPW (H)14 ( 9-11) (mm) CO 4.75 (2.5-7.2) (L/m)• EPSS ( < 8) (mm) DT (160-220)(msec)• IVRT (70-90) (msec) E (cm/s)• A (cm/s)

• FINDINGS : • (V) LAE ( ) LVE (V) LVH ( ) RAE ( ) RVE ( ) ASH• AR : ( ) Trivial ( ) Mild ( ) Moderate ( ) Severe AS:PG9.5 mmHg• MR : ( ) Trivial ( ) Mild ( ) Moderate ( ) Severe MS:PG mmHg• PR : ( ) Trivial ( ) Mild ( ) Moderate ( ) Severe PS:PG mmHg• TR : ( ) Trivial ( ) Mild ( ) Moderate ( ) Severe TS:PG17.2 mmHg• PAP : mmHg ; AVA : c㎡ ; MVA : c㎡ ; • [1] No regional wall motion abnormality ;• [2] Reversed E/A ratio ;• [3] ECG -- sinus bradycardia ;

Hypotension and Bradycardia after carotid artery stentingttw3.mmh.org.tw/neuroweb/pdf_files/20121205Hypotension and... · • ICA Siphon • Depth(mm)48 50 52 57 62 58 62 58 58 51

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