Reevaluation of temporary transvenous cardiac pacemaker usage during carotid angioplasty and stenting: a safe and valuable adjunct.

Although many current series document the safety of carotid angioplasty and stenting procedures (CAS), several acknowledge clinically significant hemodynamic disturbances in 25-71% of patients. We report herein the safety and efficacy of prophylactic percutaneous temporary transvenous cardiac pacemaker insertion during CAS for the prevention of hemodynamic changes. At a community-based institution, 48 patients undergoing 51 attempted CAS procedures from March 1999 to August 2002 for carotid artery occlusive disease were retrospectively reviewed. Thirty-one percent of patients had procedures performed for either recurrent disease or a history of neck radiation; 62.5% had significant coronary disease. Temporary transvenous pacemakers were inserted as an adjunctive procedure in the authors' CAS protocol. The pacers were set to capture a heart rate decrease below 60 beats per minute. Demographics, cardiac risk, and outcomes were analyzed. CAS was successfully performed in 96% (49 lesions). In the intent-to-treat group, the patients had a mean age of 71 +/-9 years and angiographic stenoses of 88 +/-8%, with 29% having symptomatic lesions. Significant bradycardia or asystole to trigger ventricular pacing occurred in 11 (22%) procedures, thus, triggering ventricular pacing. Pharmacologic support for concomitant hypotension was temporarily necessary in only 4 (8%) cases. No patient required prolonged pacing or medication therapy following CAS. Neither presence of carotid-related symptoms nor disease etiology was related to need for intraprocedural pacing. Furthermore, there was no occurrence of pacemaker failure or other complication secondary to venous catheterization. Hemodynamic changes may occur during mechanical dilation of the carotid artery and bulb, with reports in the literature of the need for prolonged pharmacologic support. In selected patients, the prophylactic placement of a transvenous pacemaker is a safe, feasible, and expeditious method to treat periprocedural hemodynamic changes with a decrease in additional pharmacologic support during CAS.

Carotid artery stenting in a community setting: experience outside of a clinical trial.

Carotid artery angioplasty and stenting (CAS) currently represents a less invasive percutaneous alternative to conventional endarterectomy for the treatment of carotid occlusive disease. We report here the results and complication rates of CAS performed by a team of interventionalists at a non-clinical trial center utilizing a standardized CAS protocol. CAS was attempted in 51 arteries in 48 patients (mean age 71 +/- 9 years, range 53-90). Fifteen (29%) of 48 patients were symptomatic. Indications for CAS were previous ipsilateral endarterectomy (15/51, 29%), previous neck radiation therapy (1/51, 2%), or significant coronary artery disease (30/51, 59%). SMART((R)) stents were deployed via percutaneous femoral artery access, with anticoagulation (heparin, abciximab, aspirin, clopidogrel) and temporary transvenous cardiac pacemakers employed in all patients. Neuroprotection was not used. Neurological examination and duplex scans were performed in follow-up. CAS was successfully performed in 96% of cases (49 lesions/46 patients) with angiographic stenoses of 88 +/- 8%. Neurological complications included one (2%) minor stroke that occurred 12 hr after CAS. There were no periprocedural mortalities. Clinically significant bradycardia or asystole occurred in 11/49 (22%) procedures, necessitating short-term ventricular pacing. All stented vessels remained patent during 12.2 +/- 10.1 (range 1-37) months follow-up period. One asymptomatic restenosis (>70%) occurred at 3 months, which was successfully reangioplastied; we thus had 1-year angiographic restenosis rate of 2%. Patients selected for CAS may represent a subset of patients with carotid disease who have considerable comorbidities or unfavorable anatomy compared to those undergoing conventional endarterectomy. CAS may be performed safely outside of a clinical trial with results similar to those of published series from trial centers using a standardized protocol.