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Uncontrolled Hypertension Associated With Intravenous Vasodilator Requirement After Carotid Endarterectomy
Charles DeCarlo, MD, Young Kim, MD, Samuel Jessula, MD, Anahita Dua, MBChB MBA MSc, Jahan Mohebali, MD MPH, Abhishek Mohapatra, MD.
Massachusetts General Hospital, Boston, MA, USA.

Background: Few studies have evaluated degree of blood pressure (BP) control as a predictor of adverse events after carotid endarterectomy (CEA). This study sought to elucidate the effect of Uncontrolled hypertension (uHTN) on the need for postoperative intravenous vasodilators (IVD) after CEA and determine the consequences IVD after CEA
Methods: VQI CEA data from 5/2020-6/2021 were gathered. uHTN was defined as a BP>130/80 on more than two occasions, preoperatively. The primary outcome was IVD requirement, postoperatively. The association between uHTN and IVD was evaluated with logistic regression.
Results: Among 17,135 CEA, 5,114 (29.5%) had uHTN, 10,427 (60.9%) had controlled hypertension (cHTN), and 1,594 (9.3%) were normotensive. Mean age of the cohort was 70.99.3; 61.5% were male. Patients with cHTN were less likely to be symptomatic (cHTN: 33.0% vs. uHTN: 42.6% and normotensive: 41.1%; p<0.001) and more likely to have an ICA stenosis>70% than those with uHTN (cHTN: 83.1%% vs. uHTN: 81.8% vs. normotension: 81.3%; p=0.044). Patients with uHTN were significantly more likely to require IVD postoperatively (uHTN: 26.8% vs. cHTN: 17.3% vs. normotension: 12.7%; p<0.001). In the multivariable model, uHTN was the most significant predictor of postoperative IVD (OR:2.23; 95%CI:1.89-2.63; p<0.001; reference: normotension; Table). After adjustment for symptom status and stenosis>70%, patients requiring IVD, postoperatively, had higher odds of stroke (OR: 3.28; 95%CI: 2.42-4.44; p<0.001), 30-day mortality (OR:1.98; 95%CI: 1.25-3.15; p=0.004), return to OR (OR: 2.23; 95%CI: 1.74-2.86; p<0.001), and postoperative length of stay (+0.78 days; 95%CI: +0.67 to +0.89 days; p<0.001).
Conclusion: Patients with uHTN are more likely to require postoperative IVD; postoperative IVD was associated with higher rates of adverse events and longer lengths of stay. uHTN is associated with significant resource allocation postoperatively and may represent a quality improvement target for patients undergoing CEA.

Table: Multivariable Model for Postoperative Intravenous Vasodilators after Carotid Endarterectomy
OR95% CIP-value
Hypertension (Reference: Normotension)
Controlled Hypertension1.291.101.510.002
Uncontrolled Hypertension2.231.892.63<0.001
Female Sex1.131.041.220.002
White Race0.730.660.82<0.001
Private Insurance0.910.830.990.034
COPD0.900.810.990.025
Diabetes1.221.131.32<0.001
Current Smoker0.890.810.980.015
Prior CEA1.100.981.230.103
Creatinine>1.5 mg/dl1.270.961.680.088
Preoperative Aspirin0.840.760.930.001
Increasing ASA Classification1.211.121.30<0.001
General Anesthesia1.651.371.99<0.001
Symptomatic1.101.021.200.017
Protamine0.860.780.940.001
Eversion CEA1.491.331.67<0.001
Postoperative Dextran Infusion1.411.181.70<0.001
Intraoperative Carotid Re-exploration1.621.152.280.005
Preoperative Beta-Blocker
Day-of-Surgery Only1.801.512.14<0.001
1-30 days Preoperatively1.601.262.02<0.001
Chronic use1.191.091.29<0.001


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