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