Risk Factors for Postoperative Hypotension and Hypertension following Carotid Endarterectomy.

BACKGROUND: Patients undergoing carotid endarterectomy (CEA) often experience postoperative hemodynamic changes that require intravenous medications for hypo- and hypertension. Prior studies have found these changes to be associated with increased risks of 30-day mortality, stroke, myocardial infarction (MI), and length of stay (LOS). Our aim is to investigate preoperative risk factors associated with the need for postoperative intravenous medications for blood pressure control. METHODS: A retrospective review of an internally maintained prospective database of patients undergoing carotid interventions between January 2014 and March 2019 was performed. Demographic data, clinical history, and perioperative data were recorded. Carotid artery stents and reinterventions were excluded. Our primary end points were the need to intervene with intravenous medication for either postoperative hypotension [systolic blood pressure (SBP) <100 mm Hg] or postoperative hypertension (SBP >160 mm Hg). RESULTS: A total of 221 patients were included in the study after excluding those with a prior ipsilateral CEA or carotid artery stent. The mean age was 72.3 (±8.9) years, 157 (71%) patients were male, and 78 (35.3%) were Caucasian. Following CEA, 151 (68.3%) patients were normotensive, while 33 (14.9%) and 37 (16.7%) required medication for hypotension and hypertension, respectively. A univariate logistic regression identified 5 variables as being associated with postoperative blood pressure including race, history of MI, prior percutaneous transluminal coronary angioplasty (PTCA), statin use, and angiotensin-converting enzyme-inhibitor/angiotensin-receptor blocker (ARB) use. A stepwise regression selection found race, prior MI, and statin use to be associated with our primary end points. The hypertensive group was more likely to have a history of MI compared to the hypotensive and normotensive groups (40.5% vs. 27.3% vs. 18.5%, P = 0.02), PTCA (43.2% vs. 39.4% vs. 23.8%, P = 0.03), and statin use (94.6% vs. 93.9% vs. 78.8%, P = 0.01). Mean LOS was also the highest for the hypertensive group, followed by hypotensive and normotensive patients [2.0 (±1.6) vs. 1.8 (±2.4) vs. 1.3 (±0.8), P = 0.002]. Multivariable logistic regression demonstrated that non-Caucasian patients [odds ratio (OR) 2.72, 95% confidence interval (CI) 1.26-5.86, P = 0.01] and those with a history of MI (OR 2.98, 95% CI 1.33-6.67) were more likely to have postoperative hypertension compared to patients who were Caucasian or had no history of MI. CONCLUSIONS: Postoperative hypertension is associated with non-Caucasian race and a history of MI. Given the potential implications for adverse perioperative outcomes including MI, mortality, and LOS, it is important to continue to elucidate potential risk factors in order to further tailor the perioperative management of patients undergoing CEA.

Various Approaches to Open Removal of Inferior Vena Cava Filters.

BACKGROUND: Inferior vena cava (IVC) filters may lead to complications of IVC filter placement including strut migration and caval erosion into adjacent organs. While percutaneous techniques for removal are preferred, in certain cases, this is not possible, and open retrieval is necessary. We present outcomes of 4 different approaches to 6 cases of open IVC filter retrieval. METHODS: We included 6 patients who underwent open IVC filter retrieval at our institution from 2013 to 2018. CASE REPORTS: Of the 6 patients, only one patient had a prior retrieval attempt that was unsuccessful. Four patients presented with abdominal pain alone due to erosion into the duodenum. One patient presented with back pain due to strut erosion into the vertebral body. One patient presented with abdominal and back pain due to erosion into the duodenum, aorta, and vertebral body, and one patient presented with chest pain due to strut migration and perforation of the left ventricular wall with development of pericardial tamponade. Five patients underwent computed tomography scans and were deemed irretrievable percutaneously. One patient had an attempted but failed percutaneous attempt. Various approaches were used to remove the filters. All patients underwent either a midline or subcostal incision for exposure of the IVC. In 3 patients, after the IVC was clamped and the filter was removed, the cavotomy was repaired primarily. In one patient, the IVC was repaired using a bovine pericardial patch because it was scarred down and primary repair would have narrowed the lumen. In one patient, without clamping the IVC, the struts were cut at the point that protruded out of the IVC into the adjacent organs and sutured in place on the IVC wall. In one patient, the hook of the IVC filter protruded out of the IVC, and a snare was used to capture the filter, whereas a purse string suture was applied to repair the venotomy. One patient required sternotomy and retrieval of a strut from the left ventricle with primary repair, as well as an open retrieval of the IVC filter, which were performed separately. All patients had resolution of symptoms after removal with no morbidity or mortality. CONCLUSIONS: While open IVC filter retrieval is rarely required, various approaches can be successfully and safely used for retrieval with low morbidity.