Intra-Operative Hypotension is a Risk Factor for Post-operative Silent Brain Ischaemia in Patients With Pre-operative Hypertension Undergoing Carotid Endarterectomy
Rots, Marjolijn L; Fassaert, Leonie M M; Kappelle, L Jaap; de Groot, Mark C H; Haitjema, Saskia; Bonati, Leo H; van Klei, Wilton A; de Borst, Gert J
(2020) European Journal of Vascular and Endovascular Surgery, volume 59, issue 4, pp. 526 - 534
(Article)
Abstract
Objective: Intra-operative haemodynamic instability during carotid endarterectomy (CEA) has been associated with an increased risk of procedural stroke. Diffusion weighted imaging (DWI) lesions have been proposed as a surrogate marker for peri-operative silent cerebral ischaemia. This study aimed to investigate the relationship between peri-operative blood pressure (BP) and presence of
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post-operative DWI lesions in patients undergoing CEA. Methods: A retrospective analysis was performed based on patients with symptomatic CEA included in the MRI substudy of the International Carotid Stenting Study. Relative intra-operative hypotension was defined as a decrease of intra-operative systolic BP ≥ 20% compared with pre-operative (‘baseline’) BP, absolute hypotension was defined as a drop in systolic BP < 80 mmHg. The primary endpoint was the presence of any new DWI lesions on post-operative MRI (DWI positive). The occurrence and duration of intra-operative hypotension was compared between DWI positive and DWI negative patients as was the magnitude of the difference between pre- and intra-operative BP. Results: Fifty-five patients with symptomatic CEA were included, of whom eight were DWI positive. DWI positive patients had a significantly higher baseline systolic (186 ± 31 vs. 158 ± 27 mmHg, p = .011) and diastolic BP (95 ± 15 vs. 84 ± 13 mmHg, p = .046) compared with DWI negative patients. Other pre-operative characteristics did not differ. Relative intra-operative hypotension compared with baseline occurred in 53/55 patients (median duration 34 min; range 0–174). Duration of hypotension did not differ significantly between the groups (p = .088). Mean systolic intra-operative BP compared with baseline revealed a larger drop in BP (−37 ± 29 mmHg) in DWI positive compared with DWI negative patients (−14 ± 26 mmHg, p = .024). Absolute intra-operative systolic BP values did not differ between the groups. Conclusion: In this exploratory study, high pre-operative BP and a larger drop of intra-operative BP were associated with peri-procedural cerebral ischaemia as documented with DWI. These results call for confirmation in an adequately sized prospective study, as they suggest important consequences for peri-operative haemodynamic management in carotid revascularisation.
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Keywords: Blood pressure, Carotid endarterectomy, Diffusion weighted imaging, Intra-operative monitoring, Ischaemic brain lesions, Prospective Studies, Humans, Intraoperative Complications/diagnosis, Middle Aged, Carotid Stenosis/complications, Hypertension/complications, Male, Endarterectomy, Carotid/adverse effects, Asymptomatic Diseases/epidemiology, Female, Retrospective Studies, Hypotension/diagnosis, Risk Factors, Postoperative Complications/diagnostic imaging, Treatment Outcome, Brain/blood supply, Blood Pressure Determination/statistics & numerical data, Brain Infarction/diagnostic imaging, Diffusion Magnetic Resonance Imaging, Aged, Preoperative Period, Cardiology and Cardiovascular Medicine, Surgery, Journal Article
ISSN: 1078-5884
Publisher: W.B. Saunders Ltd
Note: Publisher Copyright: © 2020 European Society for Vascular Surgery Copyright: Copyright 2020 Elsevier B.V., All rights reserved.
(Peer reviewed)