SHM Converge Scientific Abstract ePoster Gallery-When Blood Pressure Drops, So Does My Patient's Recovery: Orthostatic Hypotension Post-Transcarotid Artery Revascularization

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This case describes a 68-year-old man with hypertension, prediabetes, and gout who presented with transient left-sided weakness and numbness. Imaging showed a small acute stroke, complete occlusion of the right internal carotid artery, and severe stenosis of the left internal carotid artery. He was initially discharged on anticoagulation and aspirin with a plan for outpatient carotid surgery, but he was readmitted within 24 hours because of recurrent weakness.<br /><br />As his symptoms worsened into crescendo TIAs and repeat MRI showed evolving stroke, vascular surgery proceeded with transcarotid artery revascularization (TCAR) of the left ICA. After the procedure, his hospital course became prolonged and complicated by persistent orthostatic hypotension. When his systolic blood pressure dropped below 160 mmHg, he developed recurrent left-sided weakness, dysarthria, and trouble walking. He required ICU care with phenylephrine infusion and blood pressure support.<br /><br />The discussion explains that TCAR and carotid endarterectomy can disrupt baroreceptors, causing hemodynamic instability such as hypotension, hypertension, or bradycardia. Post-TCAR hypotension is particularly concerning because it can reduce cerebral perfusion and trigger watershed infarcts, especially in patients with severe carotid disease. In this patient, right hemispheric blood flow depended heavily on collateral circulation from the left ICA, making him especially sensitive to blood pressure drops.<br /><br />He was eventually weaned off pressors and transitioned to oral midodrine, permissive hypertension, gradual ambulation, hydration, and compression stockings. He was discharged to rehab after 18 days in the hospital.<br /><br />The case highlights the importance of recognizing and aggressively managing post-TCAR orthostatic hypotension to prevent recurrent neurologic deficits and improve outcomes.

Asset Subtitle

Tirtha Sawant

Meta Tag

Author List Elizabeth Chandy, Gerald A. Nelson, Kunwardeep Arora, Soumya Yemme, Tirtha Sawant

Category Clinical Vignettes

Concept Transcarotid Artery Revascularization

Concept Hypotension

Concept Carotid Artery Disease

Concept Baroreceptor Dysfunction

Concept Orthostatic Hypotension

Distinguished Non-Finalist

Presenter Organization Texas Health Resources HEB/Denton

Presenting Author Tirtha Sawant

Track Adult

Keywords

transcarotid artery revascularization

TCAR

orthostatic hypotension

carotid artery stenosis

internal carotid artery occlusion

crescendo TIAs

ischemic stroke

baroreceptor dysfunction

phenylephrine infusion

cerebral hypoperfusion

Transcarotid Artery Revascularization

Hypotension

Carotid Artery Disease

Baroreceptor Dysfunction

Orthostatic Hypotension