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Outcomes & Risk Factors For Postoperative Hypertension Following Carotid Revascularization
Samia D. Ellias, MD
1, Randall A. Bloch, MD
1, Elisa Caron, MD
2, Scott G. Prushik, MD
1, Katie E. Shean, MD
1, Marc L. Schermerhorn, MD
2, Mark F. Conrad, MD, MMSc
1.
1St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA,
2Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
Objectives: Hypertension(HTN) after carotid revascularization is concerning due to its association with hyperperfusion syndrome and subsequent intracerebral hemorrhage. This study aimed to identify risk factors for postoperative HTN that may guide perioperative risk assessment and management.
Methods: All procedures from the carotid artery stent(CAS) and carotid endarterectomy(CEA) registries of the Vascular Quality Initiative(VQI) database performed between 2014 and 2023 were identified. Postoperative hypertension was defined as the need for intravenous(IV) antihypertensive medications, and patients were excluded if this information was not available. Risk factors for IV antihypertensive requirements and the association between IV antihypertensive requirement and hyperperfusion syndrome were assessed.
Results: Among 259,197 patients, 169,987 underwent carotid endarterectomy(CEA), 33,295 had transfemoral carotid stenting(TFCAS), and 53,351 received transcarotid artery revascularization(TCAR). TFCAS had a significantly higher rate of hyperperfusion syndrome(1.37%) compared to TCAR(0.25%) and CEA(0.16%). 46,365 patients(17.89%) had postoperative hypertension which was associated with a higher rate of hyperperfusion syndrome (0.94% vs. 0.21%; OR 4.46; 95% CI 3.81-5.22; P<0.0005), longer postoperative hospital stays (3.95 vs 2.53 days; OR 1.3; 95% CI 1.27-1.34; P<0.0005), higher rate of postoperative myocardial infarction (0.76% vs 0.23%; OR 3.36; 95% CI 2.90-3.90; P<0.0005) and a lower 30 day survival rate (98.0% vs 99.0%; P<0.0005). Significant Risk factors for postoperative HTN are listed in multivariable model below (Table 1).
Conclusions: Post-operative hypertension is associated with the development of hyperperfusion syndrome after carotid intervention. Close blood pressure monitoring among patients with urgent indications for carotid revascularization and preoperative optimization of blood pressure among patients with pre-existing HTN may reduce the need for postoperative IV antihypertensives and thus reduce the risk for CHS. Table 1. Multivariable logistic regression for postoperative hypertension
| Multivariable model | OR | 95% CI | P |
| Demographics | | | |
| Male | 0.877 | 0.857-0.897 | <0.0005 |
| Caucasian | 0.702 | 0.678-0.726 | <0.0005 |
| OSH transfer | 1.216 | 1.162-1.272 | <0.0005 |
| smoker | 0.914 | 0.890-0.939 | <0.0005 |
| Medical Comorbidities | | | |
| HTN | 1.379 | 1.321-1.440 | <0.0005 |
| DM | 1.151 | 1.125-1.179 | <0.0005 |
| CAD | 0.897 | 0.874-0.922 | <0.0005 |
| COPD | 0.949 | 0.924-0.976 | <0.0005 |
| increasing ASA class | 1.186 | 1.160-1.213 | <0.0005 |
| Pre op Medications | | | |
| aspirin | 0.904 | 0.876-0.933 | <0.0005 |
| P2Y12 | 0.860 | 0.841-0.881 | <0.0005 |
| statin | 0.934 | 0.905-0.965 | <0.0005 |
| Beta blockers (BB) (<1 day) | 1.723 | 1.627-1.824 | <0.0005 |
| BB(<30 days) | 1.223 | 1.144-1.309 | <0.0005 |
| BB (>30 days) | 1.205 | 1.176-1.235 | <0.0005 |
| pre op ACE | 1.088 | 1.063-1.113 | <0.0005 |
| pre op AC | 0.919 | 0.885-0.954 | <0.0005 |
| Surgical history | | | |
| symptomatic | 1.085 | 1.059-1.113 | <0.0005 |
| urgent | 1.143 | 1.105-1.183 | <0.0005 |
| prior CEA | 1.127 | 1.06-1.197 | <0.0005 |
| Intra op | | | |
| completion eval | 0.878 | 0.857-0.901 | <0.0005 |
| total procedure time | 1.003 | 1.002-1.003 | <0.0005 |
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