Introduction/purpose Bradycardia and hypotension are recognized complications after carotid artery angioplasty and stenting (CAS). Typically this is short-lived but may persist up to 1 week in cases with post stent angioplasty. We report the occurrence of prolonged bradycardia greater than 1 week after CAS without post stent angioplasty.
Results A 58 year old man with past medical history of hypertension, diabetes mellitus, gout and smoking presented with left-sided hemiplegia and dysphagia. MRI demonstrated infarction within the right basal ganglia and right frontoparietal white matter. CT Angiography demonstrated, 99% stenosis of right ICA with tandem occlusion of the right middle cerebral artery. Due to tandem occlusion with poor collaterals and age younger than 70 years CAS was elected. Pretreatment was with aspirin and ticagrelor as he was clopidogrel resistant. Conscious sedation with fentanyl 25 µg and anticoagulation with bivalirudin was used. Angiography confirmed ICA stenosis greater than 70% by NASCET criteria. A balance middleweight 0.014-inch wire was used to cross the stenosis and the spider filter embolic protection device, 5 mm, was deployed. Submaximal angioplasty was performed using a 4 mm viatrac balloon to 8 atms. At this point the patient began to experience significant bradycardia and was given atropine. The balloon was removed. A protégé 8–6 mm × 40 mm tapered stent was then deployed. Post-stenting angioplasty was not performed. The filter was retrieved. Final control angiogram internal carotid artery revealed less than 10% stenosis by NASCET criteria. Directly following the procedure, the patient’s BP was 84/53 with a HR of 63. A norepinephrine infusion was started and the patient was transferred to ICU. Hypotension persisted 20 hours. However, the patient also became profoundly bradycardic (heart rate equal 20–30 beats per minute). For the following 9 days, the patient continued to experience persistent bradycardia with intermittent asymptomatic decreases in BP (mean arterial pressure 40–60 mmHg) during periods of lowest heart rate. The bradycardia represented sinus bradycardia with sinus pauses without any heart block or junctional rhythms.
Discussion Angioplasty induce sinus hypersensitivity syndrome is a complication of carotid angioplasty and stenting. Previous studies suggested that bradycardia lasts for a mean of 26 hours and almost never longer than 48 hours. To our knowledge prior to our report, the longest period of persistent bradycardia after carotid stenting was 7 days. Unlike our case, this occurred in a patient who had post stenting angioplasty. Also of note, the patient in our report did not experience any bradycardia during the 2 days prior to carotid angioplasty and stenting while on ticagrelor.
Conclusion Rarely, prolonged bradycardia may occur and persist for greater than 1 week after carotid angioplasty and stenting even in cases without post stent angioplasty.
Disclosures D. Archer: None. J. Ferdous: None. Y. Alderazi: None.
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