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Cardiac Arrest Induced by Carotid Sinus Reflex Activation During Flow-Diverter Stent Deployment
Case Report
Cardiac Arrest Induced by Carotid Sinus Reflex Activation During Flow-Diverter Stent Deployment Shunsaku Goto, Takashi Izumi, Masahiro Nishihori, Mamoru Ishida, Tetsuya Ishida, Masato Otawa, Tomoki Kawaguchi, Ryosuke Oshima, Asuka Kropp, Mizuka Ikezawa, Toshihiko Wakabayashi
Key words Carotid sinus reflex - Complication - Flow diverter stent -
Abbreviations and Acronyms CAS: Carotid artery stenting ICA: Internal carotid artery PED: Pipeline embolization device Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Japan To whom correspondence should be addressed: Takashi Izumi, M.D. [E-mail: [email protected]] Citation: World Neurosurg. (2019) 124:22-24. https://doi.org/10.1016/j.wneu.2018.12.136 Journal homepage: www.journals.elsevier.com/worldneurosurgery Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2019 Elsevier Inc. All rights reserved.
- BACKGROUND:
A 60-year-old female with multiple carotid aneurysms underwent endovascular treatment with a Pipeline Flex embolization device (PED) under local anesthesia via femoral puncture.
- CASE
DESCRIPTION: Cardiac arrest occurred when the delivery systems were pushed to promote adequate opening and apposition of the PED against the vessel wall and was recovered to sinus rhythm in approximately 30 seconds by pulling down the microcatheter. The carotid sinus reflex was suspected as the cause of this temporary asystole. Delivery of the PED was accompanied by application of forward pressure on the delivery system. This resulted in buckling of the delivery systems in the neck and likely excessive pressure on the carotid sinus. The procedure was continued and successfully completed with care not to excessively push the system and with the additional use of atropine.
- CONCLUSIONS:
Although it was a rare complication, the phenomenon and its mechanisms were known in the carotid artery stenting procedure. To the best of our knowledge, this is the first report of cardiac arrest induced by a carotid sinus reflex during PED deployment. It is important for an operator of PED deployment to recognize its possibility. Vital signs should be closely checked during PED deployment, particularly while pushing the catheter.
INTRODUCTION Flow diverting using the Pipeline embolization device (PED; Medtronic, Irvine, California, USA) is a well-established technique for the treatment of intracranial cerebral aneurysms, particularly for cases difficult to treat by conventional endovascular treatments (e.g., coiling and stent-assisted coiling). Its safety and efficacy have been demonstrated in previous clinical studies including the Pipeline for Uncoilable and Failed aneurySms (PUFS) trial and International Retrospective Study of the Pipeline Embolization Device (Intre PED).1,2 However, PED requires a high skill level to adequately deploy relative to conventional stents, such as system push and wire push when resheathing, opening the device, or promoting adequate opening and apposition against the vessel wall. Moreover, complications related to the procedure or devices have been reported.3,4 Of the possible complications, rupture of the aneurysm, parenchymal hemorrhage, and ischemic stroke, such as perforator infarction, are encountered.3,4
22
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Here we report on a rare but serious complication of PED deployment, in which cardiac arrest was induced by the carotid sinus reflex during PED deployment. CASE REPORT A 60-year-old woman was previously diagnosed with right multiple internal carotid artery (ICA) aneurysms, and her status was yearly monitored as an outpatient (Figure 1). A coil embolization had been performed for the anterior choroidal artery aneurysm; after 6 months, the residual ICA aneurysms were treated using PED deployment. She was started on double antiplatelet agents (clopidogrel 75 mg/day and aspirin 100 mg/day) beginning 14 days before intervention. PED deployment was performed under local anesthesia via femoral puncture. She was intravenously administered pentazocine (15 mg) and hydroxyzine pamoate (25 mg) before the femoral
puncture; afterward, she was administered dexmedetomidine hydrochloride 0.3 g (after an initial loading of 5 g for 5 minutes) for mild sedation. An 8-French Roadmaster (Goodman, Aichi, Japan) was placed in the right cervical ICA using a 6-French Envoy (Cerenovus, New Brunswick, New Jersey, USA) and 4-French HK inner catheter (Hanako, Saitama, Japan). The Marksman (Medtronic) was triaxially advanced through a 5-French Navien (Medtronic). The Navien was placed in the cavernous segment of the ICA, and the Marksman was then navigated to the second segment of the middle cerebral artery (Figure 2). The patient’s blood pressure and heart rate at that time were 110/70 mm Hg and 66 bpm, respectively. A Pipeline Flex (4 16 mm) was inserted and deployed from the proximal end of the ICAeposterior communicating artery bifurcation (Figure 3A). During the deployment, cardiac arrest occurred when the Navien
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2018.12.136
CASE REPORT SHUNSAKU GOTO ET AL.
CARDIAC ARREST INDUCED BY CAROTID SINUS REFLEX ACTIVATION
Figure 1. Preoperative imaging findings. (A) 3-dimensional digital subtraction angiogram (DSA) revealed multiple internal carotid artery aneurysms. The arrowhead shows a ruptured anterior choroidal artery aneurysm, which was treated via coil embolization. The arrow shows aneurysms treated by flow diverter deployment. (B) Working angle of preoperative DSA. The anterior choroidal artery aneurysm was already embolized.
and Marksman were pushed farther to promote adequate opening and apposition of the PED against the vessel wall and increase the neck coverage by the device (Figure 3B). Immediately before the arrest, her blood pressure and heart rate were 90/50 mm Hg and 60 bpm, respectively. By pulling the delivery system back down and reducing tension to the carotid sinus, a normal sinus rhythm was immediately restored; the cardiac arrest lasted approximately 30
seconds (Figure 4). The procedure resumed after administration of intravenous atropine (0.5 mg), with care not to excessively push the system. Neither severe hypotension nor bradycardia were observed for the remainder of the procedure, and after successfully deploying the PED, a postoperative neurologic examination was negative (Figure 5). Because her modified Rankin Scale score was negatively affected, she was discharged on postoperative day 4.
DISCUSSION PED is a well-established technique for the treatment of intracranial cerebral an-
Figure 2. Digital subtraction angiogram before flow diverter deployment. The arrow shows the tip of the Marksman, and the arrowhead shows the tip of the 5-French Navien.
WORLD NEUROSURGERY 124: 22-24, APRIL 2019
eurysms and performs well in cases that are difficult to treat by conventional endovascular (e.g., coiling) treatments. However, numerous complications and several metaanalyses have also identified similar complication rates. For example, Geng et al3 reported a 17% overall complication rate, 2.8% mortality rate, and 4.5% neurologic morbidity rate in their metaanalysis of 60 studies that included 3125 patients. Brinjikji et al4 also reported a 4% mortality rate and 5% morbidity rate in their metaanalysis of 1451 patients. Commonly reported complications that may lead to morbidity or mortality include rupture of the aneurysm; parenchymal hemorrhage; ischemic stroke, such as perforator infarction; and parent artery stenosis.1-4 To our knowledge, this is the first report of cardiac arrest induced by the carotid sinus reflex as a complication of PED deployment. Activation of the carotid sinus reflex is well known as a complication of carotid artery stenting (CAS). Mylonas et al5 performed a metaanalysis of 27 studies and found that hemodynamic instability was observed in 39% of patients after CAS. One of the main triggers of the carotid sinus reflex in CAS is mechanical stretching of the carotid sinus baroreceptor during balloon inflation or when using a self-expanding stent. Reflex triggering by balloon inflation is usually transient and resolves quickly, whereas a self-expanding stent prolongs the reflex activation.6 Regarding PED deployment, the act of pushing the PED delivery system farther
Figure 3. Flow-diverting stent implantation. (A) The Pipeline Flex embolization device (PED; 4 16 mm) was deployed from the proximal aspect of the internal carotid arteryeposterior communicating artery bifurcation. (B) The delivery catheter system was forcefully pushed inward to attach the PED to the vessel wall when cardiac arrest occurred.
www.journals.elsevier.com/world-neurosurgery
23
CASE REPORT SHUNSAKU GOTO ET AL.
Figure 4. The vital-sign monitor during Pipeline embolization device deployment. Allows revealed the line of the electrocardiogram; arrest was observed for approximately 30 seconds.
in, whether to promote adequate opening and apposition of the PED against the vessel wall, can trigger the reflex. The tip of the guiding catheter placed in the carotid bifurcation or the side wall of the catheter system can be buckled in the neck by application of forward pressure on the delivery system; both parts may stimulate the carotid sinus baroreceptor excessively. In particular, cases with a tortuous access route or difficult deployment area of the vessel may require relatively highfrequency and/or stronger stimulation of the carotid sinus reflex to adequately deploy PED. The transient mechanical
Figure 5. Postoperative digital subtraction angiogram after PED deployment. Arrows identify the proximal and distal ends of the stent.
24
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CARDIAC ARREST INDUCED BY CAROTID SINUS REFLEX ACTIVATION
compression by the catheter during PED deployment is like the compression caused by the balloon in CAS. Therefore pulling down the catheter to reduce tension on the carotid sinus is the first choice for management of the carotid sinus reflex. In our case, the reflex was so strongly activated that it caused transient cardiac arrest but quickly resolved, which supports the hypothesis that cardiac arrest was induced by the activation of the carotid sinus reflex. There is no standardized approach to manage the perioperative carotid sinus reflux in CAS, but some reports have suggested the prophylactic use of atropine.7,8 Therefore in the present study, atropine was used. It may also be effective during PED deployment or early use when potential carotid sinus reflex activation is considered. This report has some limitations. First, it is possible that dexmedetomidine hydrochloride could have negatively affected circulation and caused the cardiac arrest as a side effect. Second, we used local anesthesia and sedation instead of general anesthesia when performing the procedure. However, it is common in carotid endarterectomy to use local anesthetics to block the carotid sinus reflex before dissecting a vessel. Therefore the carotid sinus reflex may be activated under general anesthesia. Further studies are necessary to completely understand the relationship between PED deployment and the carotid sinus reflex, as well as to improve the management of the carotid sinus reflex in PED deployment. This case demonstrated a rare but potentially serious complication of cardiac arrest induced by a carotid sinus reflux during PED deployment, which has not been previously reported. We suggest that clinicians should be more vigilant regarding patients’ vital signs during PED deployment and should pull back the catheter system for repositioning if the vital signs indicate that the carotid sinus reflex is being stimulated. CONCLUSIONS We report on a rare but serious complication of PED deployment, in which cardiac arrest was induced by carotid sinus
reflex during PED deployment, something that has not been previously reported. It is important for an operator of PED deployment to recognize its possibility. Clinicians should be more vigilant regarding patients’ vital signs during PED deployment and should pull back the catheter system for repositioning if they indicate that the carotid sinus reflex is being stimulated. REFERENCES 1. Becske T, Kallmes DF, Saatci I, et al. Pipeline for uncoilable or failed aneurysms: results from a multicenter clinical trial. Radiology. 2013;267: 858-868. 2. Kallmes DF, Hanel R, Lopes D, et al. International retrospective study of the pipeline embolization device: a multicenter aneurysm treatment study. Am J Neuroradiol. 2015;36:108-115. 3. Geng Z, Ming S, Yan LY, Li MH. Complications associated with the use of flow-diverting devices for cerebral aneurysms: asystematic review and meta analysis. Neurosurg Focus. 2017;42:E17. 4. Brinjikji W, Murad MH, Lanzino G, Cloft HJ, Kallmes DF. Endovascular treatment of intracranial aneurysms with flowdiverters: a meta-analysis. Stroke. 2013;44:442-447. 5. Mylonas SN, Moulakakis KG, Antonopoulos CN, Kakisis JD, Liapis CD. Carotid artery stentinginduced hemodynamic instability. J Endovasc Ther. 2013;20:48-60. 6. Marcin B, Erik S, Stephanie MM, et al. Dysautonomic responses during percutaneous carotid intervention: principles of physiology and management. Catheter Cardiovasc Interv. 2015;85:282-291. 7. Cayne NS, Faries PL, Trocciola SM, et al. Carotid angioplasty and stent-induced bradycardia and hypotension: impact of prophylactic atropine administration and prior carotid endarterectomy. J Vasc Surg. 2005;41:956-996. 8. Mas JL, Chatellier G, Beyssen B, et al. Endarterectomy versus stenting in patients with symptomatic severe carotid stenosis. N Engl J Med. 2006;355: 1660-1671.
Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Received 21 November 2018; accepted 18 December 2018 Citation: World Neurosurg. (2019) 124:22-24. https://doi.org/10.1016/j.wneu.2018.12.136 Journal homepage: www.journals.elsevier.com/worldneurosurgery Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2019 Elsevier Inc. All rights reserved.
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2018.12.136
Cardiac Arrest Induced by Carotid Sinus Reflex Activation During Flow-Diverter Stent Deployment Shunsaku Goto, Takashi Izumi, Masahiro Nishihori, Mamoru Ishida, Tetsuya Ishida, Masato Otawa, Tomoki Kawaguchi, Ryosuke Oshima, Asuka Kropp, Mizuka Ikezawa, Toshihiko Wakabayashi
Key words Carotid sinus reflex - Complication - Flow diverter stent -
Abbreviations and Acronyms CAS: Carotid artery stenting ICA: Internal carotid artery PED: Pipeline embolization device Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Japan To whom correspondence should be addressed: Takashi Izumi, M.D. [E-mail: [email protected]] Citation: World Neurosurg. (2019) 124:22-24. https://doi.org/10.1016/j.wneu.2018.12.136 Journal homepage: www.journals.elsevier.com/worldneurosurgery Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2019 Elsevier Inc. All rights reserved.
- BACKGROUND:
A 60-year-old female with multiple carotid aneurysms underwent endovascular treatment with a Pipeline Flex embolization device (PED) under local anesthesia via femoral puncture.
- CASE
DESCRIPTION: Cardiac arrest occurred when the delivery systems were pushed to promote adequate opening and apposition of the PED against the vessel wall and was recovered to sinus rhythm in approximately 30 seconds by pulling down the microcatheter. The carotid sinus reflex was suspected as the cause of this temporary asystole. Delivery of the PED was accompanied by application of forward pressure on the delivery system. This resulted in buckling of the delivery systems in the neck and likely excessive pressure on the carotid sinus. The procedure was continued and successfully completed with care not to excessively push the system and with the additional use of atropine.
- CONCLUSIONS:
Although it was a rare complication, the phenomenon and its mechanisms were known in the carotid artery stenting procedure. To the best of our knowledge, this is the first report of cardiac arrest induced by a carotid sinus reflex during PED deployment. It is important for an operator of PED deployment to recognize its possibility. Vital signs should be closely checked during PED deployment, particularly while pushing the catheter.
INTRODUCTION Flow diverting using the Pipeline embolization device (PED; Medtronic, Irvine, California, USA) is a well-established technique for the treatment of intracranial cerebral aneurysms, particularly for cases difficult to treat by conventional endovascular treatments (e.g., coiling and stent-assisted coiling). Its safety and efficacy have been demonstrated in previous clinical studies including the Pipeline for Uncoilable and Failed aneurySms (PUFS) trial and International Retrospective Study of the Pipeline Embolization Device (Intre PED).1,2 However, PED requires a high skill level to adequately deploy relative to conventional stents, such as system push and wire push when resheathing, opening the device, or promoting adequate opening and apposition against the vessel wall. Moreover, complications related to the procedure or devices have been reported.3,4 Of the possible complications, rupture of the aneurysm, parenchymal hemorrhage, and ischemic stroke, such as perforator infarction, are encountered.3,4
22
www.SCIENCEDIRECT.com
Here we report on a rare but serious complication of PED deployment, in which cardiac arrest was induced by the carotid sinus reflex during PED deployment. CASE REPORT A 60-year-old woman was previously diagnosed with right multiple internal carotid artery (ICA) aneurysms, and her status was yearly monitored as an outpatient (Figure 1). A coil embolization had been performed for the anterior choroidal artery aneurysm; after 6 months, the residual ICA aneurysms were treated using PED deployment. She was started on double antiplatelet agents (clopidogrel 75 mg/day and aspirin 100 mg/day) beginning 14 days before intervention. PED deployment was performed under local anesthesia via femoral puncture. She was intravenously administered pentazocine (15 mg) and hydroxyzine pamoate (25 mg) before the femoral
puncture; afterward, she was administered dexmedetomidine hydrochloride 0.3 g (after an initial loading of 5 g for 5 minutes) for mild sedation. An 8-French Roadmaster (Goodman, Aichi, Japan) was placed in the right cervical ICA using a 6-French Envoy (Cerenovus, New Brunswick, New Jersey, USA) and 4-French HK inner catheter (Hanako, Saitama, Japan). The Marksman (Medtronic) was triaxially advanced through a 5-French Navien (Medtronic). The Navien was placed in the cavernous segment of the ICA, and the Marksman was then navigated to the second segment of the middle cerebral artery (Figure 2). The patient’s blood pressure and heart rate at that time were 110/70 mm Hg and 66 bpm, respectively. A Pipeline Flex (4 16 mm) was inserted and deployed from the proximal end of the ICAeposterior communicating artery bifurcation (Figure 3A). During the deployment, cardiac arrest occurred when the Navien
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2018.12.136
CASE REPORT SHUNSAKU GOTO ET AL.
CARDIAC ARREST INDUCED BY CAROTID SINUS REFLEX ACTIVATION
Figure 1. Preoperative imaging findings. (A) 3-dimensional digital subtraction angiogram (DSA) revealed multiple internal carotid artery aneurysms. The arrowhead shows a ruptured anterior choroidal artery aneurysm, which was treated via coil embolization. The arrow shows aneurysms treated by flow diverter deployment. (B) Working angle of preoperative DSA. The anterior choroidal artery aneurysm was already embolized.
and Marksman were pushed farther to promote adequate opening and apposition of the PED against the vessel wall and increase the neck coverage by the device (Figure 3B). Immediately before the arrest, her blood pressure and heart rate were 90/50 mm Hg and 60 bpm, respectively. By pulling the delivery system back down and reducing tension to the carotid sinus, a normal sinus rhythm was immediately restored; the cardiac arrest lasted approximately 30
seconds (Figure 4). The procedure resumed after administration of intravenous atropine (0.5 mg), with care not to excessively push the system. Neither severe hypotension nor bradycardia were observed for the remainder of the procedure, and after successfully deploying the PED, a postoperative neurologic examination was negative (Figure 5). Because her modified Rankin Scale score was negatively affected, she was discharged on postoperative day 4.
DISCUSSION PED is a well-established technique for the treatment of intracranial cerebral an-
Figure 2. Digital subtraction angiogram before flow diverter deployment. The arrow shows the tip of the Marksman, and the arrowhead shows the tip of the 5-French Navien.
WORLD NEUROSURGERY 124: 22-24, APRIL 2019
eurysms and performs well in cases that are difficult to treat by conventional endovascular (e.g., coiling) treatments. However, numerous complications and several metaanalyses have also identified similar complication rates. For example, Geng et al3 reported a 17% overall complication rate, 2.8% mortality rate, and 4.5% neurologic morbidity rate in their metaanalysis of 60 studies that included 3125 patients. Brinjikji et al4 also reported a 4% mortality rate and 5% morbidity rate in their metaanalysis of 1451 patients. Commonly reported complications that may lead to morbidity or mortality include rupture of the aneurysm; parenchymal hemorrhage; ischemic stroke, such as perforator infarction; and parent artery stenosis.1-4 To our knowledge, this is the first report of cardiac arrest induced by the carotid sinus reflex as a complication of PED deployment. Activation of the carotid sinus reflex is well known as a complication of carotid artery stenting (CAS). Mylonas et al5 performed a metaanalysis of 27 studies and found that hemodynamic instability was observed in 39% of patients after CAS. One of the main triggers of the carotid sinus reflex in CAS is mechanical stretching of the carotid sinus baroreceptor during balloon inflation or when using a self-expanding stent. Reflex triggering by balloon inflation is usually transient and resolves quickly, whereas a self-expanding stent prolongs the reflex activation.6 Regarding PED deployment, the act of pushing the PED delivery system farther
Figure 3. Flow-diverting stent implantation. (A) The Pipeline Flex embolization device (PED; 4 16 mm) was deployed from the proximal aspect of the internal carotid arteryeposterior communicating artery bifurcation. (B) The delivery catheter system was forcefully pushed inward to attach the PED to the vessel wall when cardiac arrest occurred.
www.journals.elsevier.com/world-neurosurgery
23
CASE REPORT SHUNSAKU GOTO ET AL.
Figure 4. The vital-sign monitor during Pipeline embolization device deployment. Allows revealed the line of the electrocardiogram; arrest was observed for approximately 30 seconds.
in, whether to promote adequate opening and apposition of the PED against the vessel wall, can trigger the reflex. The tip of the guiding catheter placed in the carotid bifurcation or the side wall of the catheter system can be buckled in the neck by application of forward pressure on the delivery system; both parts may stimulate the carotid sinus baroreceptor excessively. In particular, cases with a tortuous access route or difficult deployment area of the vessel may require relatively highfrequency and/or stronger stimulation of the carotid sinus reflex to adequately deploy PED. The transient mechanical
Figure 5. Postoperative digital subtraction angiogram after PED deployment. Arrows identify the proximal and distal ends of the stent.
24
www.SCIENCEDIRECT.com
CARDIAC ARREST INDUCED BY CAROTID SINUS REFLEX ACTIVATION
compression by the catheter during PED deployment is like the compression caused by the balloon in CAS. Therefore pulling down the catheter to reduce tension on the carotid sinus is the first choice for management of the carotid sinus reflex. In our case, the reflex was so strongly activated that it caused transient cardiac arrest but quickly resolved, which supports the hypothesis that cardiac arrest was induced by the activation of the carotid sinus reflex. There is no standardized approach to manage the perioperative carotid sinus reflux in CAS, but some reports have suggested the prophylactic use of atropine.7,8 Therefore in the present study, atropine was used. It may also be effective during PED deployment or early use when potential carotid sinus reflex activation is considered. This report has some limitations. First, it is possible that dexmedetomidine hydrochloride could have negatively affected circulation and caused the cardiac arrest as a side effect. Second, we used local anesthesia and sedation instead of general anesthesia when performing the procedure. However, it is common in carotid endarterectomy to use local anesthetics to block the carotid sinus reflex before dissecting a vessel. Therefore the carotid sinus reflex may be activated under general anesthesia. Further studies are necessary to completely understand the relationship between PED deployment and the carotid sinus reflex, as well as to improve the management of the carotid sinus reflex in PED deployment. This case demonstrated a rare but potentially serious complication of cardiac arrest induced by a carotid sinus reflux during PED deployment, which has not been previously reported. We suggest that clinicians should be more vigilant regarding patients’ vital signs during PED deployment and should pull back the catheter system for repositioning if the vital signs indicate that the carotid sinus reflex is being stimulated. CONCLUSIONS We report on a rare but serious complication of PED deployment, in which cardiac arrest was induced by carotid sinus
reflex during PED deployment, something that has not been previously reported. It is important for an operator of PED deployment to recognize its possibility. Clinicians should be more vigilant regarding patients’ vital signs during PED deployment and should pull back the catheter system for repositioning if they indicate that the carotid sinus reflex is being stimulated. REFERENCES 1. Becske T, Kallmes DF, Saatci I, et al. Pipeline for uncoilable or failed aneurysms: results from a multicenter clinical trial. Radiology. 2013;267: 858-868. 2. Kallmes DF, Hanel R, Lopes D, et al. International retrospective study of the pipeline embolization device: a multicenter aneurysm treatment study. Am J Neuroradiol. 2015;36:108-115. 3. Geng Z, Ming S, Yan LY, Li MH. Complications associated with the use of flow-diverting devices for cerebral aneurysms: asystematic review and meta analysis. Neurosurg Focus. 2017;42:E17. 4. Brinjikji W, Murad MH, Lanzino G, Cloft HJ, Kallmes DF. Endovascular treatment of intracranial aneurysms with flowdiverters: a meta-analysis. Stroke. 2013;44:442-447. 5. Mylonas SN, Moulakakis KG, Antonopoulos CN, Kakisis JD, Liapis CD. Carotid artery stentinginduced hemodynamic instability. J Endovasc Ther. 2013;20:48-60. 6. Marcin B, Erik S, Stephanie MM, et al. Dysautonomic responses during percutaneous carotid intervention: principles of physiology and management. Catheter Cardiovasc Interv. 2015;85:282-291. 7. Cayne NS, Faries PL, Trocciola SM, et al. Carotid angioplasty and stent-induced bradycardia and hypotension: impact of prophylactic atropine administration and prior carotid endarterectomy. J Vasc Surg. 2005;41:956-996. 8. Mas JL, Chatellier G, Beyssen B, et al. Endarterectomy versus stenting in patients with symptomatic severe carotid stenosis. N Engl J Med. 2006;355: 1660-1671.
Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Received 21 November 2018; accepted 18 December 2018 Citation: World Neurosurg. (2019) 124:22-24. https://doi.org/10.1016/j.wneu.2018.12.136 Journal homepage: www.journals.elsevier.com/worldneurosurgery Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2019 Elsevier Inc. All rights reserved.
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2018.12.136