Monitoring Of Hemodynamics Associated With Carotid Surgery (MOHAWCS)
Thomas A. Kania, MD1, Aaquib Noorani, MD1, Amandeep Juneja, MD1, Kuldeep Singh, MD1, Jonathan S. Deitch, MD1, Yana Etkin, MD2, Gregg S. Landis, MD2, Jonathan Schor, MD1.
1Staten Island University Hospital, Staten Island, NY, USA, 2Long Island Jewish Hospital, Long Island, NY, USA.
Monitoring of Hemodynamics Associated With Carotid Surgery (MOHAWCS)
OBJECTIVE - Transcarotid artery revascularization (TCAR) is an increasingly accepted approach to the management of carotid artery occlusive disease. This study aims to demonstrate that postoperative hemodynamic control is key to improved outcomes.
METHODS - We performed a retrospective review of all TCARs done at two tertiary academic medical centers within a single hospital system from 2017 to 2020. Demographics, comorbidities, procedural details, and postoperative data were collected. Patients were assessed over 24 hours postoperatively for stroke, death, MI, and hemodynamic instability at 3, 6, 9, 12, and 24 hours. Hemodynamic instability was defined as any vital sign abnormality that was managed with continuous infusion of antihypertensive, vasopressor, and/or anti-arrhythmic agents. The relationship between postoperative complications and hemodynamic instability was analyzed.
RESULTS - During the study period, 84 patients underwent 89 TCAR procedures.
| Table 1: Demographic Data | ||||
| # | % | |||
| Gender | Male | 48 | 57 | |
| Female | 36 | 43 | ||
| Race | White | 69 | 82 | |
| Black | 4 | 5 | ||
| Asian | 7 | 8 | ||
| Hispanic | 3 | 4 | ||
| Risk Factors | Symptomatic PAD | 20 | 24 | |
| HTN | 72 | 86 | ||
| DM | 29 | 35 | ||
| HLD | 77 | 92 | ||
| Smoking | Active | 11 | 13 | |
| Former | 41 | 49 | ||
| Not Documented | 32 | 38 | ||
| Median Age | 73 years | |||
| Median MAP | 95 mmHg | |||
| *PAD: Peripheral Arterial Disease, HTN: Hypertension, DM: Diabetes Mellitus, HLD: Hyperlipidemia, MAP: Mean Arterial Pressure | ||||
Preoperatively, 58 (65%) were prescribed 2 or more antihypertensive home medications; 52 (58%) were on a beta-blocker. Postoperatively, 14 (16%) required drips within 3 hours. Thereafter, 4 patients were started on drips between the 3-6 hour interval and none were started between 6-9 or 9-12 hours. Only one patient was started on a drip after 12 hours; this patient had already been receiving fluid boluses for borderline hypotension since post-operative hour 1. Six (7%) patients experienced a symptomatic neurologic event, of which 3 (3%) had stroke confirmed on CT. Among those with positive imaging findings, 1 was on a vasopressor drip. Of the 3 patients with negative CT findings, 1 was hypotensive receiving neosynephrine, 1 was hypertensive on a clevedipine drip and 1 was bradycardic. Average time to neurologic event was 4.1 hours. No patients experienced MI or death. Average length of stay was 2.28 days.
CONCLUSIONS - Our data suggests that quick evaluation and correction of hemodynamic instability can help prevent global hypoperfusion and improve outcomes after TCAR.
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