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Transcript
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 instability
· 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 stenosis
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 control
Michael Doumas, et al. Expert Opin. Ther. Targets. 2009
· Afferent fibres from carotid sinus baroreceptors join the
glossopharyngeal nerve and project to the nucleus tractus solitarii
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 hours
Delayed 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
Comparison of Significant Difference of Transient Sinus Reaction
<3hr SR(+)
<3hr SR(-)
Apical
7
49
Body
16
23
Lesion length
16.77
18.30
0.26
Length of maximum stenosis
from the ICA ostium*
7.74
12.79
0.004
Stenosis degree
75.87
74.04
0.968
Calcification (yes)
6
15
0.577
Balloon diameter (mm)
5.23
5.37
0.283
Balloon pressure (ATM)
8.00
8.29
0.464
Stent length
34.35
34.03
0.728
Residual stenosis
23.52
19.86
0.295
Lesion type
*
P-valve
0.001
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
<3h
12
8
0.914
3 - 24 h
7
5
1
1m
5
0
0.076
6m
0
1
0.411
Hyperperfusion
6
2
0.464
Restenosis
1
3
0.302
SBP>160
Event
Case 1
Age/sex
M/63
Location
right
Transient sinus reaction
+
Lesion type
Body
Length of maximum stenosis from
the ICA ostium* (mm)
2.24
Case 2
Age/sex
M/77
Location
right
Transient sinus reaction
-
Lesion type
Apical
Length of maximum stenosis from
the ICA ostium* (mm)
14.53
Case 3
Age/sex
M/85
Location
right
Transient sinus reaction
-
Lesion type
Apical
Length of maximum stenosis from
the ICA ostium* (mm)
16.67
Hyperperfusion
+
Summary and conclusion
1. 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