Factors associated with postoperative hypertension complicating carotid endarterectomy

Summary Blood pressure lability following carotid endarterectomy is a commonly observed phenomenon. Distinct hypertensive and hypotensive responses exist. Unlike postoperative hypotension, the etiology of postoperative hypertension remains unclear. In order to examine factors associated with hypertension following carotid endarterectomy, 100 carotid endarterectomies were examined retrospectively. The variables evaluated included pre-and postoperative blood pressure, age, sex, race, the use of an indwelling shunt, and complications. Postoperative hypertension (defined as systolic blood pressure greater than or equal to 200 mm Hg, diastolic blood pressure greater than 100 mm Hg, or any BP requiring intravenous infusion of antihypertensive agents for control), was observed in 35% of all patients.Postoperative hypertension was significantly associated with both preoperative systolic and diastolic blood pressure elevation, as well as the use of indwelling shunts. Increased age and race (black) were also associated with an increased incidence of postoperative hypertension. No correlation existed with respect to postoperative complications.In view of an observed lack of correlation with postoperative complications, a cautious and conservative therapeutic approach must be undertaken for postoperative hypertension. It is suggested that, perhaps, the utilization of transcutaneous doppler evaluations may be useful for assessing the clinical significance of postoperative hypertension.     

Incidence of cranial nerve dysfunction following carotid endarterectomy

An analysis of postoperative injuries to the recurrent laryngeal, hypoglossal, marginal mandibular, and superior laryngeal nerves was undertaken in 517 patients who underwent 535 carotid endarterectomies between April 1978 and March 1981 at The Cleveland Clinic Foundation. A review of the literature is presented followed by the results of this analysis and a discussion of the findings. Suggestions for decreasing or avoiding such injuries are made. Conclusions are drawn to help the otolaryngologist identify the endarterectomized patient with an impaired upper aerodigestive tract.     

Arterial hypertension after carotid endarterectomy

Arterial hypertension as a consequence of carotid endarterectomy is a relatively frequent event and potentially dangerous because of the development of central postoperative neurological deficiency. The main pathogenetic theories are reviewed, with reference to hypotensive phenomena and preventive action also. Stress is laid on the importance of recognising potential risk factors, such as the use of anaesthetics which interfere with cerebral flow self-regulation mechanisms, diabetes and atherosclerosis.     

Risk of persistent cranial nerve injury after carotid endarterectomy

OBJECT: Cranial nerve injuries, particularly motor nerve injuries, following carotid endarterectomy (CEA) can be disabling and therefore patients should be given reliable information about the risks of sustaining such injuries. The reported frequency of cranial nerve injury in the published literature ranges from 3 to 23%, and there have been few series in which patients were routinely examined before and after surgery by a neurologist. METHODS: The authors investigated the risk of cranial nerve injuries in patients who underwent CEA in the European Carotid Surgery Trial (ECST), the largest series of patients undergoing CEA in which neurological assessment was performed before and after surgery. Cranial nerve injury was assessed and recorded in every patient and persisting deficits were identified on follow-up examination at 4 months and 1 year after randomization. Risk factors for cranial nerve injury were examined by performing univariate and multivariate analyses. There were 88 motor cranial nerve injuries among the 1739 patients undergoing CEA (5.1% of patients; 95% confidence interval [CI] 4.1-6.2). In 23 patients, the deficit had resolved by hospital discharge, leaving 3.7% of patients (95% CI 2.9-4.7) with a residual cranial nerve injury: 27 hypoglossal, 17 marginal mandibular, 17 recurrent laryngeal, one accessory nerve, and three Homer syndrome. In only nine patients (0.5%; 95% CI 0.24-0.98) the deficit was still present at the 4-month follow-up examination; however, none of the persisting deficits resolved during the subsequent follow up. Only duration of operation longer than 2 hours was independently associated with an increased risk of cranial nerve injury (hazard ratio 1.56, p < 0.0001). CONCLUSIONS: The risk of motor cranial nerve injury persisting beyond hospital discharge after CEA is approximately 4%. The vast majority of neurological deficits resolve over the next few months, however, and permanent deficits are rare. Nevertheless, the risk of cranial nerve injury should be communicated to patients before they undergo surgery.     

Control of hypertension following carotid endarterectomy

The role of carotid endarterectomy in the treatment of extracranial carotid artery disease has been well established. Postoperative hypertension is a significant prognostic factor and is associated with an increased incidence of both transient and permanent neurologic deficits. We studied 110 patients undergoing unilateral carotid endarterectomy to review the efficacy of the drug combination of hydralazine and propranolol to treat postoperative hypertension. All patients receiving hydralazine and propranolol had their blood pressure controlled postoperatively, and no patients developed hypotension, myocardial infarction, or postoperative neurologic deficits. There were no mortalities in the study group. We conclude that propranolol-hydralazine therapy is a safe and effective means to control hypertension associated with carotid endarterectomy.     

Avoidance of postcarotid endarterectomy hypertension.

To minimize extreme blood pressure changes after carotid endarterectomy, dissection methods were developed to preserve the intercarotid neural bundle supplying the carotid baroreceptors and applied to our last 90 consecutive carotid endarterectomies. Hypertension was defined as a rise in systolic blood pressure greater than 40 mmHg and hypotension as a drop of 40 mmHg in those with preoperative hypertension or a systolic blood pressure of less than 100 mmGh. There were 46 cases hypertensive before operation, and the remaining 44 were normotensive before operation. When the series was analyzed, half the patients undergoing nerve-sparing dissection became hypotensive, irrespective of pre-existing hypertension extent and bilaterality of stenoses, and preoperative neurologic deficits. Hypotension was a transient and benign process and easily controlled by catheter instillation of 2% xylocaine in the postoperative period. Hypertension, which occurred in ten patients, was equally benign; only five required treatment. There were no deaths or neurologic deficits. Nerve-sparing carotid dissection and catheter placement for block of the carotid sinus nerves are valuable methods to minimize extreme blood pressure changes after carotid endarterectomy.     

Clinical outcomes of postcarotid endarterectomy hypertension

ObjectiveThe objective of this study was to determine the clinical relevance of postcarotid endarterectomy hypertension (PEH) by investigating the effect of PEH on hospital length of stay (LOS) and by investigating short-term and long-term complications of PEH. In addition, risk factors for PEH were determined.MethodsA single-center retrospective cohort study was performed. Demographic, preoperative, intraoperative, and postoperative outcomes of 192 patients undergoing carotid endarterectomy were evaluated. Outcomes were compared between patients with PEH and patients without PEH. PEH was defined as an acute systolic blood pressure (SBP) rise >170 mm Hg or persistent SBP >150 mm Hg on the ward and leading to the consultation of an internist. The overall survival and event-free survival were compared using a Kaplan-Meier analysis and a Cox regression analysis. A multivariate logistic regression analysis was performed to determine risk factors for PEH.ResultsPEH developed in 44 of 192 patients (25%). Preoperative hypertension (SBP >150 mm Hg) was determined to be a risk factor for PEH (odds ratio, 3.3; 95% confidence interval [CI], 1.6-6.9). Hospital LOS was prolonged in patients with PEH compared with patients without PEH (median LOS of 5 days vs 3 days, respectively; P < .001). No difference in the occurrence of ischemic neurologic events or rebleeding during hospitalization was observed (P = .58 and P = .72, respectively). Cardiovascular and ischemic neurologic events during follow-up did not occur more often in patients with PEH than in patients without PEH (P = .46). There was no difference in mortality between the PEH and non-PEH groups (hazard ratio, 1.6; 95% CI, 0.6-4.3). The same applies to the event-free survival (hazard ratio, 0.77; 95% CI, 0.4-1.7). Combined event-free survival for stroke and myocardial infarction was 92% (95% CI, 87%-97%) at 2 years for patients without PEH and 86% (95% CI, 74%-98%) at 2 years for patients with PEH (P = .25). Event-free survival for mortality was 90% (95% CI, 85%-96%) at 2 years for patients without PEH and 94% (95% CI, 86%-100%) at 2 years for patients with PEH (P = .36).ConclusionsPatients with PEH had a significant increase in hospital LOS. However, adverse short-term and long-term events did not occur more often in patients with PEH. High preoperative SBP was identified as a risk factor for PEH; no other demographic and clinical variables were associated with PEH.     

Incidence and mechanism of post-carotid endarterectomy hypertension

Hypertension following carotid endarterectomy occurs frequently but is poorly understood. Its occurrence has been correlated with an increased incidence of neurologic complication. We identified those factors that correlate with an increased incidence of post-carotid endarterectomy hypertension. The records of 100 patients who underwent carotid endarterectomy at UCLA Medical Center from November 1981 to September 1983 were examined. One hundred fifty variables were surveyed to determine those factors associated with this problem. Fifty-eight percent of the study patients developed post-carotid endarterectomy hypertension (an increase in systolic blood pressure greater than 35 mm Hg over baseline, and/or blood pressure requiring treatment with sodium nitroprusside). Of patients who developed this problem, 93% had diabetes mellitus, 75% received isoflurane anesthesia, 71% had peripheral vascular occlusive disease, 71% underwent ipsilateral transient ischemic attacks, and 65% had high-grade ipsilateral carotid stenosis. These variables have in common the loss of or interference with cerebral autoregulation. Central dysautoregulation may set the stage for a positive feedback mechanism that results in increased blood pressure. Anesthetic agents that do not interfere with cerebral autoregulation may reduce the incidence of this complication, and an aggressive treatment program may prevent neurologic complications.     

Renovascular hypertension complicated with VATER association

We report herein a case of a girl with renovascular hypertension associated with VATER association. Her plasma renin activity and aldosterone were high. The ultrasonic echogram and renogram revealed a right hypoplastic kidney without function and a normal-sized left kidney with normal function. Renal angiography revealed a small diameter right main renal artery and a normal left main renal artery with segmental stenosis of left branching renal arteries in the middle segment. Selective renal vein sampling indicated that renin secretion was primarily from the left kidney. This is the first report of renovascular hypertension complicated with VATER association.     

Systematic review and meta-analysis of postcarotid endarterectomy hypertension after eversion versus conventional carotid endarterectomy

Objective

Blood pressure (BP) instability after carotid endarterectomy (CEA) is a risk factor for cerebrovascular and cardiovascular complications. The role of the operative technique in the development of post-CEA hemodynamic instability is unclear. The primary goal of this study was to systematically review the literature to determine whether hypertension in the early postoperative period is dependent on the surgical technique used.

Potential adverse effects of norepinephrine on cortical somatosensory-evoked potentials during carotid endarterectomy: a case report

The cerebral metabolic and vascular effects of intravenous norepinephrine have been shown in an animal model using somatosensory-evoked potentials (SSEPs). A case of intravenous norepinephrine resulting in a decrease in SSEP amplitude (of greater than 50%) despite no significant change in blood pressure, prior to cross-clamping during a carotid endarterectomy is presented. This finding may have implications for the use of norepinephrine in the critical care unit as well as the operating room.     

White-coat and masked hypertension in children: association with target-organ damage

White-coat hypertension (WCH) and masked hypertension have been associated with increased cardiovascular risk in adults. In the current study, we investigated: (a) the prevalence of WCH and masked hypertension in pediatric patients and (b) the association of these conditions with target organ damage. A total of 85 children underwent office blood pressure measurements, 24-h ambulatory blood pressure monitoring, echocardiography and ultrasonography of the carotid arteries. Subjects with both office and ambulatory normotension or hypertension were characterized as confirmed normotensives or hypertensives, respectively; WCH was defined as office hypertension with ambulatory normotension and masked hypertension as office normotension and ambulatory hypertension. WCH was found in 12.9% and masked hypertension in 9.4% of the subjects. WCH was significantly more prevalent in obese subjects, while masked hypertension was only present in non-obese ones. Confirmed and masked hypertensives had significantly higher left ventricular mass index than confirmed normotensives (34.0±5.8 g/m^2.7, 31.9±2.9 g/m^2.7 and 25.3±5.6 g/m^2.7, respectively, P<0.05). White-coat hypertensives tended to have higher left ventricular mass index than confirmed normotensives, but the difference was not statistically significant (27.8±5.1 g/m^2.7 versus 25.3±5.6 g/m^2.7). No significant differences were found in the intima-media thickness of the carotid arteries between confirmed normotensives, white-coat hypertensives, masked hypertensives and confirmed hypertensives. WCH and masked hypertension are common conditions in children. Confirmed and masked hypertension in pediatric patients are accompanied by increased left ventricular mass index.     

Transaortic endarterectomy of renal visceral artery lesions in association with infrarenal aortic surgery

The complexity of infrarenal aortic reconstruction increases when bypass grafts to revascularize associated renal and visceral arteries are needed. Lesions in these vessels, however, are usually limited to their aortic orifices and therefore are amenable to retroperitoneal transaortic endarterectomy. A combined infrarenal aortic reconstruction and transaortic endarterectomy of the renal/visceral vessels was used in 18 (16%) of 120 patients undergoing elective infrarenal aortic reconstruction over a 2-year-period. Transaortic endarterectomy was performed primarily for renal preservation in 11 patients with bilateral, high-grade renal artery stenoses and abnormal renal function (serum creatinine greater than or equal to 1.9 mg/dl). In seven patients transaortic endarterectomy was performed as a secondary procedure during the course of complex reconstruction of aneurysmal or occlusive aortic disease. Mean serum creatinine, which was elevated preoperatively in 14 (78%) patients (3.3 mg/dl), decreased significantly after the operation (2.0 mg/dl, p less than 0.01). A single death occurred in the 18 patients undergoing transaortic endarterectomy. Renal function preservation can be achieved by renal revascularization in patients with bilateral renal artery stenoses and decreased renal function. The retroperitoneal approach to aortic reconstruction and the use of transaortic endarterectomy allows correction of most renal/visceral vessel involvement in complex aortic revascularization procedures.     

Angioscopic video-assisted pulmonary endarterectomy for post-embolic pulmonary hypertension.

OBJECTIVES: To assess whether the use of video-assisted angioscopy would increase the outcome of pulmonary thromboendarterectomy (PTE). METHODS: PTE included a median sternotomy, intrapericardial dissection of the superior vena cava, institution of cardiopulmonary bypass, deep hypothermia and sequential circulatory arrest periods. It was always performed through two separate arteriotomies on both main intrapericardial pulmonary arteries, into which a rigid 5 mm angioscope connected to a video camera was introduced to increase the visibility and endarterectomies. RESULTS: From January 1996 to July 1998, 68 consecutive patients (35 males and 33 females) aged 54.3 +/- 13.5 years underwent PTE. Patients were in New York Heart Association (NYHA) class II (n = 2), III (n = 43) or IV (n = 23) with the following hemodynamics: mean pulmonary arterial pressure (PAP) 54 +/- 13 mmHg; cardiac output (CO): 3.8 +/- 0.8 l/min, and total pulmonary resistance (TPR): 1207 +/- 416 dyne x s x cm(-5). The cumulated circulatory arrest time was 23 +/- 12 min and postoperative length of ventilatory support 10 +/- 12 days. Nine patients died, for an overall in-hospital mortality of 13.2%. The functional outcome in surviving patients was significantly improved (P < 0.0001) both clinically (NYHA class 3.2 +/- 0.5 vs. 1.3 +/- 0.6) and hemodynamically (PAP (mmHg) 53.1 +/- 13 vs. 30.2 +/- 11.8, CI (l/min per m2) 2.1 +/- 0.5 vs. 2.8 +/- 0.6, TPR (dyne x s x cm(-5)) 1174 +/- 416 vs. 519 +/- 250). CONCLUSIONS: Video-assisted angioscopy improves the quality and degree of pulmonary endarterectomy expanding the indications to include patients with previously inaccessible distal disease.     

Nicardipine versus nitroprusside for breakthrough hypertension following carotid endarterectomy

STUDY OBJECTIVE: To evaluate the effectiveness of nicardipine and nitroprusside for breakthrough hypertension following carotid endarterectomy. DESIGN: Prospective, randomized, double-blind, controlled effectiveness trial. SETTING: University-based surgical intensive care unit. PATIENTS: 60 ASA physical status I, II, III, and IV patients experiencing breakthrough hypertension at the time of admission to the intensive care unit (ICU). INTERVENTIONS: Patients received either nicardipine (n = 29) and placebo or nitroprusside (n = 31) and placebo for up to 6 hours postoperatively. Loading doses of nicardipine were provided, but placebo was used as a load for patients randomized to nitroprusside. MEASUREMENTS AND MAIN RESULTS: Rapidity and variability of blood pressure (BP) control were assessed. During the first 10 minutes, 83% of nicardipine patients compared to 23% of nitroprusside-treated patients, achieved BP control (p < 0.01). Following initial control, 12 nicardipine- and 24 nitroprusside-treated patients required additional titration of their infusions to maintain blood pressure within the targeted range (p < 0.05). No patient suffered a stroke, myocardial infarction, or was returned to the operating room (OR) for bleeding. CONCLUSIONS: Nicardipine administration produced more rapid BP control, most likely related to the administration of a loading dose. In addition to more rapid control, nicardipine-treated patients had less variability in BP and required significantly fewer additional interventions. Although no patient suffered a major event during this study, this study was not powered sufficiently to assess safety.     

Recurrence of a metastatic tumour in association with a cranial fixation device

Summary We present a case of recurrent metastatic brain tumour spread across a cranial fixation device.     

Pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension: is deep hypothermia required?

OBJECTIVE: To investigate whether deep (<20 degrees C) hypothermia is necessary in patients undergoing pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension. METHODS: Between January 2004 and February 2005, 30 patients (New York Heart Association (NYHA) class III or IV) were randomly assigned to increasing (1 degrees C) levels of moderate (28-32 degrees C) hypothermic cardiopulmonary bypass (CPB), each study group including six patients. Primary study endpoint was adverse neurological outcome. Overall preoperative total pulmonary vascular resistance was 1110+/-192 dynes cm(-5). RESULTS: Mean CPB and cross-clamp times, and core temperature at the time of circulatory arrests were 129+/-39 min and 92+/-24 min, and 30.1+/-1.5 degrees C, respectively. Circulatory arrest was induced 2+/-0.7 times and its mean total duration was 10.3+/-5.2 min (range, 2-19 min). Postoperatively, three patients (10%) belonging to the 31 degrees C (n=1) and 32 degrees C (n=2) groups suffered from temporary neurological dysfunction. Postoperative mechanical ventilatory support and ICU stay were 26.3+/-18.9 h and 6.6+/-8.5 days, respectively, and uninfluenced by degree of hypothermia. There were no lung reperfusion injuries or any other major complications. All patients had a significant hemodynamic improvement. CONCLUSION: Results suggest that pulmonary endarterectomy can be safely performed with moderate hypothermia and short periods of circulatory arrests without the need of profound hypothermia.