Hypotension During Carotid Artery Stenting with Severe Aortic Stenosis: The Intra-Aortic Balloon Pump Option

ABSTRACT: This case highlights the importance of intra-aortic balloon pump (IABP) during carotid artery stenting (CAS) in patients with severe aortic stenosis. We report the case of a patient with severe carotid artery disease and aortic stenosis who first underwent CAS using IABP and subsequently underwent aortic valve replacement. We conclude that IABP could be helpful in the staged treatment of patients with concomitant severe carotid artery disease and aortic valve disease.

J INVASIVE CARDIOL 2011;23:E202–E204

Key words: intra-aortic balloon pump, aortic stenosis, carotid stenting

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Carotid artery stenting (CAS) is rapidly evolving as a treatment alternative to carotid endarterectomy in patients with carotid artery stenosis.^1,2 Although recent randomized trials have shown the safety and efficacy of CAS, procedural complication rates are an ongoing concern.^3,4 Hemodynamic depression (HD) is a well-described peri- and postprocedural complication and has been correlated to major adverse cardiac and neurologic events.^5,6 Pre-treating high-risk patients with vasopressors may prevent persistent HD and subsequently reduce the risk of adverse vascular events.⁷ Unfortunately, the use of dopamine in patients with severe aortic stenosis (AS) may lead to potential complications, including angina, arrhythmias, and syncope, and therefore is contraindicated.⁸ The intra-aortic balloon pump (IABP) has been previously employed to treat patients with severe symptomatic carotid and coronary artery disease (CAD).⁹ Hennen et al reported a case with IABP during CAS in a patient with severe depression of left ventricular function and CAD.¹⁰ We recently treated a patient with severe aortic stenosis who first underwent CAS using IABP and subsequently underwent aortic valve replacement.

Case Report. A 72-year-old male presented with a history of syncope secondary to physical effort. The patient had a previous  episode of syncope secondary to physical effort. Risk factors included hypertension and a past history of smoking. Physical examination revealed an intense systolic murmur on the aortic site that was well-transmitted both along the carotid vessels and to the apex. Medical treatment was 100 mg/day aspirin and 10 mg/day enalapril. Electrocardiogram showed signs of left ventricular hypertrophy with normal sinus rhythm. Doppler echocardiography showed normal systolic function with severe stenosis of the aortic valve (anatomic area < 0.8 cm² and left ventricular-aortic pressure gradient of 90 mmHg). Coronary angiography was normal. Duplex ultrasound of the carotid arteries showed severe right internal carotid stenosis. Digital angiography revealed an ulcerated plaque with high-grade stenosis (95%) of the right internal carotid artery (ICA) (Figure 1) and mild stenosis of the left ICA. Computed tomography of the brain showed an old ischemic lesion of the right anterior frontal region. We decided to perform CAS first with prophylactic IABP, followed by aortic valve replacement at 1 month.

The patient was pretreated with dual-antiplatelet therapy. Three days pre-CAS, the ACE inhibitor was discontinued and fluid infusion was started at 120 ml/hour. Blood pressure was 140/80 mmHg at the time of the procedure. Two large-bore peripheral intravenous catheters were placed (one for normal saline infusion). Systemic heparin (70 U/Kg) was given. A 90 cm, 6 Fr Destination sheath (Terumo, Somerset, New Jersey) was placed just below the right common carotid artery (CCA) bifurcation. The lesion was crossed with the Embolshield embolic protection device (Abbott Vascular, Abbott Park, Illinois) and primary stenting using a 9 x 30 mm Carotid Wallstent (Boston Scientific, Natick, Massachusetts) was performed with prophylactic administration of 1 mg atropine. IABP was then carried out. The stent was postdilated with a 5.5 x 20 mm balloon to nominal inflation pressure, resulting in an excellent final angiographic result (Figure 2). With prophylactic IABP support maintained for 72 hours (Figure 3), the patient remained hemodynamically stable (systolic blood pressure, 120 mmHg; heart rate, 75 bpm), although a short period of hypotension was observed (about 2 minutes with systolic blood pressure at 90 mmHg). The  patient was discharged on day 5 without any adverse clinical event. One month later, biologic aortic valve replacement was performed without neurological and cardiac complications.

Discussion. HD, reported in up to 68% of CAS cases, may increase the risk of periprocedural complications, especially when patients have severe comorbidities.^5,6,11 HD in response to CAS implantation has been previously associated with various clinical and angiographic factors, such as age, left ventricular function, severity of carotid calcification, length and diameter of the stent.^5,6,12 Additionally, the deployment of balloon-expandable (as compared with self-expanding) stents has been associated with increased rates of persistent HD due to increased radial forces exerted near the carotid sinus.⁵

In our experience, pretreating patients with vasopressors such as dopamine may prevent persistent HD and subsequently reduce the risk of adverse cardiovascular events.⁷ Unfortunately, dopamine administration in severe aortic valve stenosis is contraindicated.⁸ To date, the optimal treatment of patients with symptomatic carotid and surgical heart disease remains controversial. Simultaneous carotid endarterectomy and heart surgery has not been demonstrated to reduce overall stroke and death rate compared with staged procedures.^13,14

To reduce the risk of periprocedural cerebral and cardiac complications, we decided to administer fluid at 120 ml/hour (about 7 liters in 72 hours) and to position IABP with the intention of periprocedural hemodynamic stabilization. On the other hand, hypovolemia together with hyperdynamic state resulting from catecholamine administration may yield dynamic left ventricular outflow tract obstruction even if baseline cardiac evaluation is unremarkable.⁸

IABP mainly provides two beneficial hemodynamic effects: a reduction of left ventricular afterload and an increase in mean diastolic pressure, improving coronary perfusion.¹⁵

The first evidence of potentially positive effects of IABP in cerebrovascular disease patients was provided by Myers⁹ in 5 patients with severe symptomatic carotid and coronary artery disease. Patients with subocclusive carotid stenosis and triple-vessel CAD underwent carotid surgery twice: first with IABP protection and then coronary artery bypass grafting 24 hours later. Both operations were uneventful without neurological or cardiac complications. Hennen reported the beneficial effects of prophylactic IABP placement during CAS in a patient with severely depressed left ventricular function from CAD.¹⁰

In the present case, the patient demonstrated marked hemodynamic stability with IABP implantation. More experience is necessary to determine if this is an acceptable and effective mode of treatment to perform CAS in patients with severe AS.

References

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Editor’s Comments: While IABP is routinely used in high risk PCIs, its use is infrequent during carotid stenting; even high-risk. This case illustrate a thoughtful approach of prophylactic IABP use for carotid stenting, in high risk cases to decrease procedural hemodynamic compromise and its attendant consequences. – Samin K. Sharma, MD, Mount Sinai Medical Center, New York, New York.

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From the Department of Clinical and Interventional Cardiology, Istituto Clinico Città Studi, Milano, Italy.
The authors report no conflicts of interest regarding the content herein.
Manuscript submitted November 5, 2010, final version accepted November 22, 2010.
Address for correspondence: Angelo Anzuini, MD, FESC, Department of Interventional Cardiology, Istituto Clinico Città Studi, Via Ampère 47, 20131 Milano, Italy. Email: Anzangelo@yahoo.com